Essentials of Nursing Leadership and Management

f i f t h e d i t i o n

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Essentials of

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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F. A. Davis Company

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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

Index 267

Bonus Chapters on DavisPlus


Triaxial of Action: Policy, Politics, and Nursing

Canadian Nursing Practice and the Law


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1 unit

Professional Considerations

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?

Leadership Defined


Followership Defined

Becoming a Better Follower

What Makes a Person a Leader?

Leadership Theories

Trait Theories

Behavioral Theories

Task Versus Relationship

Motivating Theories

Emotional Intelligence

Situational Theories

Transformational Leadership

Moral Leadership

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 discussed.


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 Defined

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 &

Campbell, 2004).

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

new policy.


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 Defined

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

your work.

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?

Leadership Theories

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).

Trait Theories

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

Behavioral Theories

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.

Motivating Theories

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,

table 1-1

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

autocratic style

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.

Emotional Intelligence

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

this done?

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).

Situational Theories

People and leadership situations are far more complex

than the early theories recognized. In addition, situa-

tions can change rapidly, requiring more complex

table 1-2

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, &

Cummings, 2001).

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.

Transformational Leadership

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).

Moral Leadership

The corporate scandals of recent years have redi-

rected attention to the values and ethics that

underlie the practice of leadership as well as that of

client care (Dantley, 2005). Caring about the peo-

ple who work for you as people as well as employ-

ees (Spears & Lawrence, 2004) is part of moral

leadership. This can be a great challenge in times of

limited financial resources.

Molly Benedict was a team leader on the acute geriatric unit (AGU) when a question of moral leadership arose. Faced with large budget cuts in the middle of the year and feeling a little desperate to f igure out how to run the AGU with fewer staff, her nurse manager suggested that reducing the time that unlicensed assistive personnel (UAP) spent ambulating the clients would enable him to increase UAP workload from 10 to 15 clients. “George,” responded Molly, “you know that inac- tivity has many harmful effects, from emboli to disorientation in our very elderly population. Instead, let’s try to f igure out how to encourage more self-care or even family involvement in care so the UAP can still walk clients and prevent their becoming nonambulatory.” Molly based her response on important values, particularly those of prevention.

Qualities of an Effective Leader

If leadership is seen as the ability to influence, what

qualities must the leader possess in order to be able

to do that? Integrity, courage, attitude, initiative,

energy, optimism, perseverance, balance, ability to

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chapter 1 | Leadership and Followership 9

handle stress, and self-awareness are some of the

qualities of effective leaders in nursing (Fig. 1.1):

■ Integrity. Integrity is expected of health-care professionals. Clients, colleagues, and employers

all expect nurses to be honest, law-abiding, and

trustworthy. Adherence to both a code of per-

sonal ethics and a code of professional ethics

(Appendix 1, American Nurses Association

Code for Nurses) is expected of every nurse.

Would-be leaders who do not exhibit these

characteristics cannot expect them of their

followers. This is an essential component of

moral leadership.

■ Courage. Sometimes, being a leader means taking some risks. In the story of Billie Blair

Thomas, for example, Billie needed some

courage to speak to her nurse manager about a

problem she had observed.

■ Attitude. A good attitude goes a long way in making a good leader. In fact, many outstanding

leaders cite attitude as the single greatest reason

for not hiring someone (Maxwell, 1993, p. 98).

A leader’s attitude is noticed by the followers

more quickly than are the actions.

■ Initiative. Good ideas are not enough. To be a leader, you must act on those good ideas. This

requires initiative on your part.

■ Energy. Leadership requires energy. Both lead- ership and followership are hard but satisfying

endeavors that require effort. It is also important

that the energy be used wisely.

■ Optimism. When the work is difficult and one crisis seems to follow another in rapid succession,

it is easy to become discouraged. It is important

not to let discouragement keep you and your

coworkers from seeking ways to resolve the prob-

lems. In fact, the ability to see a problem as an

opportunity is part of the optimism that makes a

person an effective leader. Like energy, optimism

is “catching.” Holman (1995) called this being a

winner instead of a whiner (Table 1-3). ■ Perseverance. Effective leaders do not give up

easily. Instead, they persist, continuing their

efforts when others are tempted to stop trying.

This persistence often pays off.

■ Balance. In the effort to become the best nurses they can be, people may forget that other aspects

of life are equally important. As important as

clients and colleagues are, family and friends are

important, too. Although school and work are

meaningful activities, cultural, social, recreational,

and spiritual activities also have meaning. People

need to find a balance between work and play.

■ Ability to handle stress. There is some stress in almost every job. Coping with stress in as posi-

tive and healthy a manner as possible helps to

conserve energy and can be a model for others.

Maintaining balance and handling stress are

reviewed in Chapter 10.

■ Self-awareness. How is your emotional intelli- gence? People who do not understand them-

selves are limited in their ability to understand

the motivations of others. They are far more

likely to fool themselves than are self-aware peo-

ple. For example, it is much easier to be fair with

a coworker you like than with one you do not










Ability to handle stress


Think critically

Solve problems

Communicate skillfully

Set goals, share vision

Develop self and others

Figure 1.1 Keys to effective leadership.

table 1-3

Winner or Whiner—Which Are You? A winner says: A whiner says:

“We have a real “This is really a problem.”

challenge here.”

“I’ll give it my best.” “Do I have to?”

“That’s great!” “That’s nice, I guess.”

“We can do it!” “That will never succeed.”

“Yes!” “Maybe....”

Adapted from Holman, L. (1995). Eleven Lessons in Self-leadership:

Insights for Personal and Professional Success. Lexington, Ky.: A Lessons

in Leadership Book.

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10 unit 1 | Professional Considerations

like. Recognizing that you like some people more

than others is the first step in avoiding unfair

treatment based on personal likes and dislikes.

Behaviors of an Effective Leader

Leadership requires action. The effective leader

chooses the action carefully. Important leadership

behaviors include setting specific goals, thinking

critically, solving problems, respecting people, com-

municating skillfully, communicating a vision for

the future, and developing oneself and others.

■ Setting priorities. Whether planning care for a group of clients or setting the strategic plan

for an organization, priorities continually

shift and demand attention. As a leader you

will need to remember the three “E’s” of

prioritization: evaluate, eliminate, and esti-

mate. Continually evaluate what you need to

do, eliminate tasks that someone else can do,

and estimate how long your top priorities

will take you to complete.

■ Thinking critically. Critical thinking is the care- ful, deliberate use of reasoned analysis to reach a

decision about what to believe or what to do

(Feldman, 2002). The essence of critical think-

ing is a willingness to ask questions and to be

open to new ideas, new ways to do things. To

avoid falling prey to assumptions and biases of

your own and those of others, ask yourself

frequently, “Do I have the information I need?

Is it accurate? Am I prejudging a situation?”

( Jackson, Ignatavicius, & Case, 2004).

■ Solving problems. Client problems, paperwork problems, staff problems: these and others occur

frequently and need to be solved. The effective

leader helps people to identify problems and to

work through the problem-solving process to

find a reasonable solution.

■ Respecting the individual. Although people have much in common, each individual has dif-

ferent wants and needs and has had different

life experiences. For example, some people really

value the psychological rewards of helping

others; other people are more concerned about

earning a decent salary. There is nothing wrong

with either of these points of view; they are

simply different. The effective leader recognizes

these differences in people and helps them

find the rewards in their work that mean the

most to them.

■ Skillful communication. This includes listening to others, encouraging exchange of information,

and providing feedback:

1. Listening to others. Listening is separate from talking with other people: listening emphasizes

that communication involves both giving and

receiving information. The only way to find

out people’s individual wants and needs is to

watch what they do and to listen to what they

say. It is amazing how often leaders fail simply

because they did not listen to what other

people were trying to tell them.

2. Encouraging exchange of information. Many misunderstandings and mistakes occur because

people fail to share enough information with

each other. The leader’s role is to make sure

that the channels of communication remain

open and that people use them.

3. Providing feedback. Everyone needs some infor- mation about the effectiveness of his or her

performance. Frequent feedback, both positive

and negative, is needed so people can continu-

ally improve their performance. Some nurse

leaders find it difficult to give negative feedback

because they fear that they will upset the other

person. How else can the person know where

improvement is needed? Negative feedback can

be given in a manner that is neither hurtful nor

resented by the individual receiving it. In fact,

it is often appreciated. Other nurse leaders,

however, fail to give positive feedback, assum-

ing that coworkers will know when they are

doing a good job. This is also a mistake because

everyone appreciates positive feedback. In fact,

for some people, it is the most important

reward they get from their jobs.

■ Communicating a vision for the future. The effective leader has a vision for the future.

Communicating this vision to the group and

involving everyone in working toward that

vision create the inspiration that keeps people

going when things become difficult. Even better,

involving people in creating the vision is not

only more satisfying for employees but also has

the potential for the most creative and innova-

tive outcomes (Kerfott, 2000). It is this vision

that helps make work meaningful.

■ Developing oneself and others. Learning does not end on leaving school. In fact, experienced

nurses say that school is just the beginning, that

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chapter 1 | Leadership and Followership 11

school only prepares you to continue learning

throughout your career. As new and better ways

to care for clients are discovered, it is your

responsibility as a professional to critically

analyze these new approaches and decide

whether they would be better for your clients

than current approaches to care. Effective lead-

ers not only continue to learn but also encour-

age others to do the same. Sometimes, leaders

function as teachers. At other times, their role

is primarily to encourage and guide others

to seek more knowledge. Observant, reflective,

analytical practitioners know that learning

takes place every day if people are open to it

(Kagan, 1999).


Leadership ability determines a person’s level of

effectiveness. To be an effective nurse, you must be an

effective leader. Your patients, your peers, and your

organization are depending on you to influence oth-

ers. Leadership develops daily. True leaders never

stop learning and growing. John Maxwell (1998), one

of America’s experts on leadership, states “who we are

is who we attract” (p. xi). To attract leaders, people

need to start leading and never stop learning to lead.

The key elements of leadership and followership

have been discussed in this chapter. Many of the

leadership qualities and behaviors mentioned here

are discussed in more detail in later chapters.

Study Questions

1. Why is it important for nurses to be good leaders? What qualities have you observed from nurses

on the units that exemplify effective leadership in action? How do you think these behaviors might

have improved the outcomes of their patients?

2. Why are effective followers as important as effective leaders?

3. Review the various leadership theories discussed in the chapter. Which ones might apply to leading

in today’s health-care environment? Support your answer with specific examples.

4. Select an individual whose leadership skills you particularly admire. What are some qualities and

behaviors that this individual displays? How do these relate to the leadership theories discussed in

this chapter? In what ways could you emulate this person?

5. As a new graduate, what leadership and followership skills will you work on developing or enhanc-

ing during the first 3 months of your first nursing position? Why?

Case Study to Promote Critical Reasoning

Two new associate-degree graduates were hired for the pediatric unit. Both worked three 12-hour

shifts a week, Jan in the day-to-evening shift and Ronnie at night. Whenever their shifts connected,

they would compare notes on their experience. Jan felt she was learning rapidly, gaining clinical

skills and beginning to feel at ease with her colleagues.

Ronnie, however, still felt unsure of herself and often isolated. “There have been times,” she told

Jan, “that I am the only registered nurse on the unit all night. The aides and LPNs are really expe-

rienced, but that’s not enough. I wish I could work with an experienced nurse as you are doing.”

“Ronnie, you are not even finished with your 3-month orientation program,” said Jan. “You

should never be left alone with all these sick children. Neither of us is ready for that kind of

responsibility. And how will you get the experience you need with no experienced nurses to help

you? You must speak to our nurse manager about this.”

“I know I should, but she’s so hard to reach. I’ve called several times, and she’s never available.

She leaves all the shift assignments to her assistant. I’m not sure she even reviews the schedule

before it’s posted.”

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12 unit 1 | Professional Considerations

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Chrispeels, J.H. (2004). Learning to Lead Together. Thousand Oaks, Calif.: Sage Publications.

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Deutschman, A. (2005). Is your boss a psychopath? Making Change. Fast Company, 96, 43–51.

Feldman, D.A. (2002). Critical Thinking: Strategies for Decision Making. Menlo Park, Calif.: Crisp Publications.

Goleman, D., Boyatzes, R., & McKee, A. (2002). Primal Leadership: Realizing the Power of Emotional Intelligence. Boston: Harvard Business School Press.

Grossman, S., & Valiga, T.M. (2000). The New Leadership Challenge: Creating the Future of Nursing. Philadelphia: FA Davis.

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Jackson, M., Ignatavicius, D., & Case, B. (eds.). (2004). Conversations in Critical Thinking and Clinical Judgement. Pensacola, Fla.: Pohl.

Kagan, S.S. (1999). Leadership Games: Experiential Learning for Organizational Development. Thousand Oaks, Calif.: Sage Publications.

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Korn, M. (2004). Toxic Cleanup: How to Deal With a Dangerous Leader. Fast Company, 88, 17.

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Maxwell, J.C. (1993). Developing the Leader Within You. Tenn.: Thomas Nelson Inc.

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Spears, L.C., & Lawrence, M. (2004). Practicing Servant-Leadership. New York: Jossey-Bass.

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Tappen, R.M. (2001). Nursing Leadership and Management: Concepts and Practice. Philadelphia: FA Davis.

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“You will have to try harder to reach her. Maybe you could stay past the end of your shift one

morning and meet with her,” suggested Jan. “If something happens when you are the only nurse on

the unit, you will be held responsible.”

1. In your own words, summarize the problem that Jan and Ronnie are discussing. To what extent is

this problem due to a failure to lead? Who has failed to act?

2. What style of leadership was displayed by Ronnie and the nurse manager? How effective was their

leadership? Did Jan’s leadership differ from that of Ronnie and the nurse manager? In what way?

3. In what ways has Ronnie been an effective follower? In what ways has Ronnie not been so effective

as a follower?

4. If an emergency occurred and was not handled well while Ronnie was the only nurse on the unit,

who would be responsible? Explain why this person or persons would be responsible.

5. If you found yourself in Ronnie’s situation, what steps would you take to resolve the problem? Show

how the leader characteristics and behaviors found in this chapter support your solution to the problem.

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chapter 2 Manager

OBJECTIVES After reading this chapter, the student should be able to: ■ Define the term management.

■ Distinguish scientific management and human relations–based management.

■ Explain servant leadership.

■ Discuss the qualities and behaviors that contribute to effective management.



Are You Ready to Be a Manager?

What Is Management?

Management Theories

Scientific Management

Human Relations–Based Management

Servant Leadership

Qualities of an Effective Manager

Behaviors of an Effective Manager

Interpersonal Activities

Decisional Activities

Informational Activities



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14 unit 1 | Professional Considerations

Every nurse should be a good leader and a good

follower. Not everyone should be a manager, how-

ever. In fact, new graduates simply are not ready to

take on management responsibilities. Once you

have had time to develop your clinical and leader-

ship skills, you can begin to think about taking on

management responsibilities (Table 2-1).


Are You Ready to Be a Manager?

For most new nurses, the answer is no, you should not accept managerial responsibility. The breadth

and depth of your experience are still undeveloped.

You need to direct your energies to building your

own skills before you begin supervising other people.

What Is Management?

The essence of management is getting work done

through others. The classic definition of manage-

ment is Henri Fayol’s 1916 list of managerial tasks:

planning, organizing, commanding, coordinating,

and controlling the work of a group of employees

(Wren, 1972). But Mintzberg (1989) argued that

managers really do whatever is needed to make sure

that employees do their work and do it well.

Lombardi (2001) points out that two-thirds of a

manager’s time is spent on people problems. The

rest is taken up by budget work, going to meetings,

preparing reports, and other administrative tasks.

Management Theories

There are two major but opposing schools of

thought in management: scientific management

and the human relations–based approach. As its

name implies, the human-relations approach

emphasizes the interpersonal aspects of managing

people, whereas scientific management emphasizes

the task aspects.

Scientific Management

Almost 100 years ago, Frederick Taylor argued

that most jobs could be done more efficiently if

they were analyzed thoroughly (Lee, 1980; Locke,

1982). With a well-designed task and enough

incentive to get the work done, workers could be

more productive. For example, Taylor promoted

the concept of paying people by the piece instead

of by the hour. In health care, the equivalent

would be by the number of patients bathed or vis-

ited at home rather than by the number of hours

worked. This would create an incentive to get the

most work done in the least amount of time.

Taylorism stresses that there is a best way to do a

job. Usually, this is also the fastest way to do the

job (Dantley, 2005).

The work is analyzed to improve efficiency. In

health care, for example, there has been much dis-

cussion about the time it takes to bring patients to

radiology or to physical therapy versus bringing the

technician or therapist to the patient. Eliminating

excess staff or increasing the productivity of remain-

ing employees is also based on this kind of thinking.

Nurse managers who use the principles of scien-

tific management will pay particular attention to

the type of assessments and treatments done on the

unit, the equipment needed to do this efficiently,

and the strategies that would facilitate efficient

accomplishment of these tasks. Typically, these

nurse managers keep careful records of the amount

of work accomplished and reward those who

accomplish the most.

Human Relations–Based Management

McGregor’s theories X and Y provide a good

example of the difference between scientific man-

agement and human relations–based management.

Theory X, said McGregor (1960), reflects a com-

mon attitude among managers that most people do

not want to work very hard and that the manager’s

job is to make sure that they do work hard. To

accomplish this, according to Theory X, a manager

needs to employ strict rules, constant supervision,

and the threat of punishment (reprimands, withheld

raises, and threats of job loss) to create industrious,

conscientious workers.

table 2-1

Differences Between Leadership and Management

Leadership Management

Based on influence Based on authority

and shared meaning

An informal role A formally designated role

An achieved position As assigned position

Part of every nurse’s Usually responsible for budgets,

responsibility hiring, and firing people

Requires initiative and Improved by the use of

independent thinking effective leadership skills

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chapter 2 | Manager 15

Theory Y, which McGregor preferred, is the

opposite viewpoint. Theory Y managers believe

that the work itself can be motivating and that peo-

ple will work hard if their managers provide a sup-

portive environment. A Theory Y manager empha-

sizes guidance rather than control, development

rather than close supervision, and reward rather

than punishment (Fig. 2.1). A Theory Y nurse

manager is concerned with keeping employee

morale as high as possible, assuming that satisfied,

motivated employees will do the best work.

Employees’ attitudes, opinions, hopes, and fears

are important to this type of nurse manager.

Considerable effort is expended to work out con-

flicts and promote mutual understanding to pro-

vide an environment in which people can do their

best work.

Servant Leadership

The emphasis on people and interpersonal rela-

tionships is taken one step further by Greenleaf

(2004), who wrote an essay in 1970 that began the

servant leadership movement. Like transforma-

tional leadership, servant leadership has a special

appeal to nurses and other health-care profession-

als. Despite its name, servant leadership applies

more to people in supervisory or administrative

positions than to people in staff positions.

The servant leader–style staff manager believes

that people have value as people, not just as workers

(Spears & Lawrence, 2004).The manager is commit-

ted to improving the way each employee is treated at

work. The attitude is “employee first,” not “manager

first.” So the manager sees himself or herself as being

there for the employee. Here is an example:

Hope Marshall is a relatively new staff nurse at Jefferson County Hospital. When she was invited to be the staff nurse representative on the search com- mittee for a new vice-president for nursing, she was very excited about being on a committee with so many managerial and administrative people. As the interviews of candidates began, she focused on what they had to say. They had very impressive résumés and spoke conf idently about their accomplishments. Hope was impressed but did not yet prefer one over the other. Then the f inal candidate spoke to the com- mittee. “My primary job,” he said, “is to make it pos- sible for each nurse to do the very best job he or she can do. I am here to make their work easier, to remove barriers, and to provide them with whatev- er they need to provide the best patient care possible.” Hope had never heard the term servant leadership, but she knew immediately that this candidate, who articulated the essence of servant leadership, was the one she would support for this important position.


Two-thirds of people who leave their jobs say the

main reason was an ineffective or incompetent

manager (Hunter, 2004). A survey of 3266 newly

licensed nurses found that lack of support from

their manager was the primary reason for leaving

their position, followed by a stressful work environ-

ment as the second reason. Following are some of

the indicators of their stressful work environment:

■ 25% reported at least one needle stick in their

first year.

■ 39% reported at least one strain or sprain.

■ 62% reported experiencing verbal abuse.

■ 25% reported a shortage of supplies needed to

do their work.

These results underscore the importance of having

effective nurse managers who can create an envi-

ronment in which new nurses thrive (Kovner,

Brewer, Fairchild, et al., 2007)


Work is something to be avoided

People want to do as little as possible

Use control-supervision-punishment


The work itself can be motivating

People really want to do their job well

Use guidance-development-reward

Figure 2.1 Theory X versus Theory Y.

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16 unit 1 | Professional Considerations

The effective nurse manager possesses a combi-

nation of qualities: leadership, clinical expertise, and

business sense. None of these alone is enough; it is

the combination that prepares an individual for the

complex task of managing a unit or team of health-

care providers. Consider each of these briefly:

■ Leadership. All of the people skills of the leader are essential to the effective manager. They are

skills needed to function as a manager. ■ Clinical expertise. It is very difficult to help

others develop their skills and evaluate how well

they have done so without possessing clinical

expertise oneself. It is probably not necessary

(or even possible) to know everything all other

professionals on the team know, but it is impor-

tant to be able to assess the effectiveness of their

work in terms of patient outcomes.

■ Business sense. Nurse managers also need to be concerned with the “bottom line,” with the

cost of providing the care that is given, especially in comparison with the benefit received

from that care and the funding available to

pay for it, whether from insurance, Medicare,

Medicaid, or out of the patient’s own pocket.

This is a complex task that requires knowledge

of budgeting, staffing, and measurement of

patient outcomes.

There is some controversy over the amount of

clinical expertise versus business sense that is

needed to be an effective nurse manager. Some

argue that a person can be a “generic” manager,

that the job of managing people is the same no

matter what tasks he or she performs. Others

argue that managers must understand the tasks

themselves, better than anyone else in the work

group. Our position is that equal amounts of clin-

ical skill and business acumen are needed, along

with excellent leadership skills.


Mintzberg (1989) divided a manager’s activities

into three categories: interpersonal, decisional,

and informational. We use these categories and

have added some activities suggested by other

authors (Dunham-Taylor, 1995; Montebello,

1994) and by our own observations of nurse man-

agers (Fig. 2.2).

Interpersonal Activities

The interpersonal category is one in which leaders

and managers have overlapping concerns. However,

the manager has some additional responsibilities

that are seldom given to leaders. These include the


■ Networking. Nurse managers are in pivotal positions, especially in inpatient settings where

they have contact with virtually every service of

the institution as well as with most people above

and below them in the organizational hierarchy.

This provides them with many opportunities to

influence the status and treatment of staff nurses

and the quality of the care provided to their

patients. It is important that they “maintain the

line of sight,” or connection, between what they

do as managers, patient care, and the mission

of the organization (Mackoff & Triolo, 2008,

p. 123). In other words, they need to keep in

mind how their interactions with both their

staff members and with administration affects

the care provided to the patients for whom they

are responsible.



Representing employees

Representing the organization

Public relations monitoring


Conflict negotiation and resolution

Employee development and coaching

Rewards and punishment

Decisional Employee evaluation Resource allocation Hiring and firing employees Planning Job analysis and redesign

Figure 2.2 Keys to effective management.

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chapter 2 | Manager 17

■ Conflict negotiation and resolution. Managers often find themselves resolving conflicts among

employees, patients, and administration. The

ineffective manager either lets people go

unmanaged emotionally or mismanages feelings

in the workplace (Welch & Welch, 2008).

■ Employee development. Providing for the continuing learning and upgrading of the skills

of employees is a managerial responsibility.

■ Coaching. It is often said that employees are the organization’s most valuable asset (Shirey,

2007). This is one of the ways in which nurse

managers can share their experience and exper-

tise with the rest of the staff. The goal is to

nurture the growth and development of the

employee (the “coachee”) to do a better job

through learning (McCauley & Van Velson,

2004; Shirey, 2007).

Some managers use a directive approach: “This is

how it’s done. Watch me.” or “Let me show you

how to do this.” Others prefer a nondirective

approach: “Let’s try to figure out what’s wrong

here” (Hart & Waisman, 2005). “How do you think

we can improve our outcomes?”

You can probably see the parallel with demo-

cratic and autocratic leadership styles described in

Chapter 1. The decision whether to be directive

(e.g., in an emergency) or nondirective (e.g., when

developing a long-term plan to improve infection

control) will depend on the situation.

■ Rewards and punishments. Managers are in a position to provide specific (e.g., salary increases,

time off ) and general (e.g., praise, recognition)

rewards as well as punishments.

Decisional Activities

Nurse managers are responsible for making many


■ Employee evaluation. Managers are responsible for conducting formal performance appraisals of

their staff members. Effective managers regularly

tell their staff how well they are doing and where

they need improvement (Welch & Welch, 2008).

■ Resource allocation. In decentralized organiza- tions, nurse managers are often given a set amount

of money to run their units or departments and

must allocate these resources wisely. This can be

difficult when resources are very limited.

■ Hiring and firing employees. Nurse managers decide either independently or participate in employ-

ment and termination decisions for their units.

■ Planning for the future. The day-to-day opera- tion of most units is complex and time-consum-

ing, and nurse managers must also look ahead in

order to prepare themselves and their units for

future changes in budgets, organizational priori-

ties, and patient populations. They need to look

beyond the four walls of their own organization to

become aware of what is happening to their com-

petition and to the health-care system (Kelly &

Nadler, 2007).

■ Job analysis and redesign. In a time of extreme cost sensitivity, nurse managers are often

required to analyze and redesign the work of

their units to make them as efficient as possible.

Informational Activities

Nurse managers often find themselves in positions

within the organizational hierarchy in which they

acquire much information that is not available to

their staff. They also have much information about

their staff that is not readily available to the admin-

istration, placing them in a strategic position with-

in the information web of any organization. The

effective manager uses this position for the benefit

of both the staff and the organization. The follow-

ing are some examples:

■ Spokesperson. Nurse managers often speak for administration when relaying information to

their staff members. Likewise, they often speak

for staff members when relaying information to

administration. You could think of them as

clearinghouses, acting as gatherers and dissemi-

nators of information to people above and below

them in the organizational hierarchy (Shirey,

Ebright, & McDaniel, 2008, p. 126).

■ Monitoring. Nurse managers are also expert “sensors,” picking up early signs of problems

before they grow too big (Shirey, Ebright, &

McDaniel, 2008). They are expected to moni-

tor the many and various activities of their

units or departments, including the number of

patients seen, average length of stay, infection

rates, fall rates, and so forth. They also monitor

the staff (e.g., absentee rates, tardiness, unpro-

ductive time), the budget (e.g., money spent,

money left to spend in comparison with money

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18 unit 1 | Professional Considerations

needed to operate the unit), and the costs of

procedures and services provided, especially

those that are variable such as medical supplies

(Dowless, 2007).

■ Public Relations. Nurse managers share infor- mation with their patients, staff members, and

employers. This information may be related to

the results of their monitoring efforts, new

developments in health care, policy changes, and

so forth. Review Table 2-2, “Bad Management

Styles,” to compare what you have just read

about effective nurse managers with descriptions

of some of the most common ineffective

approaches to being a manager.


Nurse managers have complex, responsible posi-

tions in health-care organizations. Ineffective man-

agers may do harm to their employees, their

patients, and to the organization, and effective

managers can help their staff members grow and

develop as health-care professionals while provid-

ing the highest quality care to their patients.

table 2-2

Bad Management Styles These are the types of managers you do not want to be and for whom you do not want to work:

Know-it-all Self-appointed experts on everything, these managers do not listen to anyone else.

Emotionally remote Isolated from the staff and the work going on, these managers do not know what is going on in

the workplace and cannot inspire others.

Pure mean Mean, nasty, dictatorial, these managers look for problems and reasons to criticize.

Overnice Desperate to please everyone, these managers agree to every idea and request, causing confusion

and spending too much money on useless projects.

Afraid to decide In the name of fairness, these managers do not distinguish between competent and incompetent,

hard-working and unproductive employees, thus creating an unfair reward system.

Based on Welch, J. & Welch, S. (2007, July 23). Bosses who get it all wrong. BusinessWeek, p. 88.

Study Questions

1. Why should new graduates decline nursing management positions? At what point do you think a

nurse is ready to assume managerial responsibilities?

2. Which theory, scientific management or human relations, do you believe is most useful to nurse

managers? Explain your choice.

3. Compare servant leadership with scientific management. Which approach do you prefer? Why?

4. Describe your ideal nurse manger in terms of the person for whom you would most like to work.

Then describe the worst nurse manager you can imagine, and explain why this person would be

very difficult.

5. List 10 behaviors of nurse managers, then rank them from least to most important. What rationale(s)

did you use in ranking them?

Case Study to Promote Critical Reasoning

Joe Garcia has been an operating room nurse for 5 years. He was often on call on Saturday and

Sunday, but he enjoyed his work and knew that he was good at it.

Joe was called to come in on a busy Saturday afternoon just as his 5-year-old daughter’s birthday

party was about to begin. “Can you find someone else just this once?” he asked the nurse manager

who called him. “I should have let you know in advance that we have an important family event

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chapter 2 | Manager 19

References Dantley, M.E. (2005). Moral leadership: Shifting the manage-

ment paradigm. In English, F.W. The Sage Handbook of Educational Leadership (pp. 34–46). Thousand Oaks, Calif.: Sage Publications.

Dowless, R.M. (2007). Your guide to costing methods and terminology. Nursing Management, 38(4), 52–57.

Dunham-Taylor, J. (1995). Identifying the best in nurse executive leadership. Journal of Nursing Administration, 25(7/8), 24–31.

Greenleaf, R.K. (2004). Who is the servant-leader? In Spears, L.C., & Lawrence, M. Practicing Servant-Leadership. New York: Jossey-Bass.

Hart, L.B., & Waisman, C.S. (2005). The Leadership Training Activity Book. New York: AMACOM.

Hunter, J.C. (2004). The World’s Most Powerful Leadership Principle. New York: Crown Business.

Kelly, J., & Nadler, S. (2007, March 3–4). Leading from below. Wall Street Journal, p. R4.

Kovner, C.T., Brewer, C.S., Fairchild, S., et al. (2007). Newly licensed RNs’ characteristics, work attitudes, and intentions to work. American Journal of Nursing, 107(9), 58–70.

Lee, J.A. (1980). The Gold and the Garbage in Management Theories and Prescriptions. Athens, Ohio: Ohio University Press.

Locke, E.A. (1982). The ideas of Frederick Taylor: An evaluation. Academy of Management Review, 7(1), 14.

Lombardi, D.N. (2001). Handbook for the New Health Care Manager. San Francisco: Jossey-Bass/AHA Press.

Mackoff, B.L., & Triolo, P.K. (2008). Why do nurse managers stay? Building a model engagement. Part I: Dimensions of engagement. Journal of Nursing Administration, 38(3), 118–124.

McCauley, C.D., & Van Velson, E. (eds.). (2004). The Center for Creative Leadership Handbook of Leadership Development. New York: Jossey-Bass.

McGregor, D. (1960). The Human Side of Enterprise. New York: McGraw-Hill.

Mintzberg, H. (1989). Mintzberg on Management: Inside Our Strange World of Organizations. New York: Free Press.

Montebello, A. (1994). Work Teams That Work. Minneapolis: Best Sellers Publishing.

Shirey, M.R. (2007). Competencies and tips for effective leader- ship. Journal of Nursing Administration, 37(4), 167–170.

Shirey, M.R., Ebright, P.R., & McDaniel, A.M. (2008). Sleepless in America: Nurse managers cope with stress and complexity. Journal of Nursing Administration, 38(3), 125–131.

Spears, L.C., & Lawrence, M. (2004). Practicing Servant-Leadership. New York: Jossey-Bass.

Welch, J., & Welch, S. (2007, July 23). Bosses who get it all wrong. BusinessWeek, p. 88.

Welch, J., & Welch, S. (2008, July 28). Emotional mismanage- ment. BusinessWeek, p. 84.

Wren, D.A. (1972). The Evolution of Management Thought. New York: Ronald Press.

today, but I just forgot. If you can’t find someone else, call me back, and I’ll come right in.” Joe’s

manager was furious. “I don’t have time to make a dozen calls. If you knew that you wouldn’t want

to come in today, you should not have accepted on-call duty. We pay you to be on-call, and I expect

you to be here in 30 minutes, not one minute later, or there will be consequences.”

Joe decided that he no longer wanted to work in the institution. With his 5 years of operating

room experience, he quickly found another position in an organization that was more supportive of

its staff.

1. What style of leadership and school of management thought seemed to be preferred by Joe Garcia’s


2. What style of leadership and school of management were preferred by Joe?

3. Which of the listed qualities of leaders and managers did the nurse manager display? Which

behaviors? Which ones did the nurse manager not display?

4. If you were Joe, what would you have done? If you were the nurse manager, what would you have

done? Why?

5. Who do you think was right, Joe or the nurse manager? Why?

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chapter 3 Nursing Practice and the Law

OBJECTIVES After reading this chapter, the student should be able to: ■ Identify three major sources of laws.

■ Explain the differences between various types of laws.

■ Differentiate between negligence and malpractice.

■ Explain the difference between an intentional and an unintentional tort.

■ Explain how standards of care are used in determining negligence and malpractice.

■ Describe how nurse practice acts guide nursing practice.

■ Explain the purpose of licensure.

■ Discuss issues of licensure.

■ Explain the difference between internal standards and external standards.

■ Discuss advance directives and how they pertain to clients’ rights.

■ Discuss the legal implications of the Health Insurance Portability and Accountability Act (HIPAA)


General Principles

Meaning of Law

Sources of Law

The Constitution


Administrative Law

Types of Laws

Criminal Law

Civil Law


Quasi-Intentional Tort



Other Laws Relevant to Nursing Practice

Good Samaritan Laws


Slander and Libel

False Imprisonment

Assault and Battery

Standards of Practice

Use of Standards in Nursing Negligence Malpractice Actions

Patient’s Bill of Rights

Informed Consent

Staying Out of Court


Appropriate Documentation

Common Actions Leading to Malpractice Suits

If a Problem Arises

Professional Liability Insurance

End-of-Life Decisions and the Law

Do Not Resuscitate Orders

Advance Directives

Living Will and Durable Power of Attorney for Health Care (Health-Care Surrogate)

Nursing Implications

Legal Implications of Mandatory Overtime


Qualifications for Licensure

Licensure by Examination


Preparing for the NCLEX-RN

Licensure Through Endorsement

Multistate Licensure

Disciplinary Action



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22 unit 1 | Professional Considerations

The courtroom seemed cold and sterile. Scanning her surroundings with nervous eyes, Germaine decided she knew how Alice must have felt when the Queen of Hearts screamed for her head. The image of the White Rabbit running through the woods, looking at his watch, yelling, “I’m late! I’m late!” flashed before her eyes. For a few moments, she indulged herself in thoughts of being able to turn back the clock and rewrite the past. The future certainly looked grim at that moment. The calling of her name broke her reverie. Mr. Ellison, the attorney for the plaintiff, wanted her undivided attention regarding the fateful day when she committed a fatal medication error. That day, the client died following a cardiac arrest because Germaine failed to check the appropriate dosage and route for the medication. She had administered 40 mEq of potas- sium chloride by intravenous push. Her 15 years of nursing experience meant little to the court. Because she had not followed hospital protocol and had vio- lated an important standard of practice, Germaine stood alone. She was being sued for malpractice.

As client advocates, nurses have a responsibility to

deliver safe care to their clients. This expectation

requires that nurses have professional knowledge at

their expected level of practice and be proficient in

technological skills. A working knowledge of the

legal system, client rights, and behaviors that may

result in lawsuits helps nurses to act as client advo-

cates. As long as nurses practice according to estab-

lished standards of care, they will be able to avoid

the kind of day in court that Germaine experienced.

General Principles

Meaning of Law

The word law has several meanings. For the pur- poses of this chapter, law means those rules that prescribe and control social conduct in a formal and

legally binding manner (Bernzweig, 1996). Laws

are created in one of three ways:

1. Statutory laws are created by various legislative bodies, such as state legislatures or Congress.

Some examples of federal statutes include the

Patient Self-Determination Act of 1990 and

the Americans With Disabilities Act. State

statutes include the state nurse practice acts,

the state boards of nursing, and the Good

Samaritan Act. Laws that govern nursing

practice are statutory laws.

2. Common law develops within the court system as judicial decisions are made in various cases

and precedents for future cases are set. In this

way, a decision made in one case can affect

decisions made in later cases of a similar nature.

This feature of American law is based on the

English tradition of case law: “judge-made law”

(Black, 2004). Many times a judge in a subse-

quent case will follow the reasoning of a judge

in a previous case. Therefore, one case sets a

precedent for another.

3. Administrative law is established through the authority given to government agencies, such

as state boards of nursing, by a legislative body.

These governing boards have the duty to meet

the intent of laws or statutes.

Sources of Law

The Constitution

The U.S. Constitution is the foundation of

American law. The Bill of Rights, comprising the

first 10 amendments to the Constitution, is the

basis for protection of individual rights. These laws

define and limit the power of the government and

protect citizens’ freedom of speech, assembly, reli-

gion, and the press and freedom from unwarranted

intrusion by government into personal choices.

State constitutions can expand individual rights but

cannot deprive people of rights guaranteed by the

U.S. Constitution.

Constitutional law evolves. As individuals or

groups bring suit to challenge interpretations of the

Constitution, decisions are made concerning appli-

cation of the law to that particular event. An exam-

ple is the protection of freedom of speech. Are

obscenities protected? Can one person threaten or

criticize another person? The freedom to criticize is

protected; threats are not protected. The definition

of what constitutes obscenity is often debated and

has not been fully clarified by the courts.


Localities, state legislatures, and the U.S. Congress

create statutes. These can be found in multivolume

sets of books and databases.

At the federal level, conference committees

comprising representatives of both houses of

Congress negotiate the resolution of any differ-

ences on wording of a bill before it becomes law. If

the bill does not meet with the approval of the

executive branch of government, the president can

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chapter 3 | Nursing Practice and the Law 23

veto it. If that occurs, the legislative branch must

have enough votes to override the veto or the bill

will not become law.

Nurses have an opportunity to influence the

development of statutory law both as citizens and

as health-care providers. Writing to or meeting

with state legislators or members of Congress is a

way to demonstrate interest in such issues and their

outcomes in terms of the laws passed. Passage of a

new law is often a long process that includes some

compromise of all interested individuals.

Administrative Law

The Department of Health and Human Services,

the Department of Labor, and the Department of

Education are the federal agencies that administer

health-care–related laws. At the state level are

departments of health and mental health and

licensing boards.

Administrative agencies are staffed with profes-

sionals who develop the specific rules and regulations

that direct the implementation of statutory law.

These rules must be reasonable and consistent with

existing statutory law and the intent of the legislature.

Usually, the rules go into effect only after review and

comment by affected persons or groups. For example,

specific statutory laws give state nursing boards the

authority to issue and revoke licenses, which means

that each board of nursing has the responsibility to

oversee the professional nurse’s competence.

Types of Laws

Another way to look at the legal system is to divide

it into two categories: criminal law and civil law.

Criminal Law

Criminal laws were developed to protect society

from actions that threaten its existence. Criminal

acts, although directed toward individuals, are con-

sidered offenses against the state. The perpetrator

of the act is punished, and the victim receives no

compensation for injury or damages. There are

three categories of criminal law:

1. Felony: the most serious category, including such acts as homicide, grand larceny, and nurse

practice act violation

2. Misdemeanor: includes lesser offenses such as traffic violations or shoplifting of a small dollar


3. Juvenile: crimes carried out by individuals younger than 18 years; specific age varies by

state and crime

There are occasions when a nurse breaks a law and

is tried in criminal court. A nurse who distributes

controlled substances illegally, either for personal

use or for the use of others, is violating the law.

Falsification of records of controlled substances is a

criminal action. In some states, altering a patient

record may be a misdemeanor (Northrop & Kelly,

1987). For example:

Nurse V needed to administer a blood transfusion. Because she was in a hurry, she did not check the paperwork properly and therefore did not follow the standard of practice established for blood adminis- tration. The client was transfused with incompati- ble blood, suffered from a transfusion reaction, and died. Nurse V attempted to conceal her conduct and falsif ied the records. She was found guilty of manslaughter (Northrop & Kelly, 1987).

Civil Law

Civil laws usually involve the violation of one per-

son’s rights by another person. Areas of civil law

that particularly affect nurses are tort law, contract

law, antitrust law, employment discrimination, and

labor laws.


The remainder of this chapter focuses primarily on

tort law. A tort is a legal or civil wrong carried out

by one person against the person or property of

another (Black, 2004). Tort law recognizes that

individuals in their relationships with each other

have a general duty not to harm each other

(Cushing, 1999). For example, as drivers of auto-

mobiles, everyone has a duty to drive safely so that

others will not be harmed. A roofer has a duty to

install a roof properly so that it will not collapse

and injure individuals inside the structure. Nurses

have a duty to deliver care in such a manner that

the consumers of care are not harmed. These legal

duties of care may be violated intentionally or


Quasi-Intentional Tort

A quasi-intentional tort has its basis in speech. These

are voluntary acts that directly cause injury or anguish

without meaning to harm or to cause distress. The

elements of cause and desire are present, but the

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24 unit 1 | Professional Considerations

element of intent is missing. Quasi-intentional torts

usually involve problems in communication that

result in damage to a person’s reputation, violation of

personal privacy, or infringement of an individual’s

civil rights. These include defamation of character,

invasion of privacy, and breach of confidentiality

(Aiken, 2004, p. 139).


Negligence is the unintentional tort of acting or

failing to act as an ordinary, reasonable, prudent

person, resulting in harm to the person to whom the

duty of care is owed (Black, 2004). The legal ele-

ments of negligence consist of duty, breach of duty,

causation, and harm or injury (Cushing, 1999). All

four elements must be present in the determination.

For example, if a nurse administers the wrong med-

ication to a client, but the client is not injured, then

the element of harm has not been met. However, if

a nurse administers appropriate pain medication but

fails to put up the side rails, and the client falls and

breaks a hip, all four elements have been satisfied.

The duty of care is the standard of care. The law

defines standard of care as that which a reasonable,

prudent practitioner with similar education and

experience would do or not do in similar circum-

stances (Prosser & Keeton, 1984).


Malpractice is the term used for professional negli- gence. When fulfillment of duties requires special-

ized education, the term malpractice is used. In

most malpractice suits, the facilities employing the

nurses who cared for a client are named as defen-

dants in the suit. Vicarious liability is the legal

principle cited in these cases. Respondeat superior, the borrowed servant doctrine, and the captain of

the ship doctrine fall under vicarious liability.

An important principle in understanding negli-

gence is respondeat superior (“let the master answer”) (Aiken, 2004, p. 279). This doctrine holds

employers liable for any negligence by their

employees when the employees were acting within

the realm of employment and when the alleged

negligent acts happened during employment

(Aiken, 2004).

Consider the following scenario:

A nursing instructor on a clinical unit in a busy metropolitan hospital instructed his students not to administer any medications unless he was present.

Marcos, a second-level student, was unable to f ind his instructor, so he decided to administer digoxin to his client without supervision. The dose was 0.125 mg. The unit dose came as digoxin 0.5 mg/mL. Marcos administered the entire amount without checking the digoxin dose or the client’s blood and potassium levels. The client became toxic, developed a dys- rhythmia, and was transferred to the intensive care unit. The family sued the hospital and the nursing school for malpractice. The nursing instructor was also sued under the principle of respondeat superior, even though specif ic instructions to the contrary had been given to the students.

Other Laws Relevant to Nursing Practice

Good Samaritan Laws

Fear of being sued has often prevented trained

professionals from assisting during an emergency.

To encourage physicians and nurses to respond to

emergencies, many states developed what are now

known as the Good Samaritan laws. When admin-

istering emergency care, nurses and physicians are

protected from civil liability by Good Samaritan

laws as long as they behave in the same manner as

an ordinary, reasonable, and prudent professional in

the same or similar circumstances (Prosser &

Keeton, 1984). In other words, when assisting dur-

ing an emergency, nurses must still observe profes-

sional standards of care. However, if a payment is

received for the care given, the Good Samaritan

laws do not hold.


It is possible for nurses to be involved in lawsuits

other than those involving negligence. For exam-

ple, clients have the right to confidentiality, and it

is the duty of the professional nurse to ensure this

right. This assures the client that information

obtained by a nurse while providing care will not be

communicated to anyone who does not have a need

to know. This includes giving information by tele-

phone to individuals claiming to be related to a

client, giving information without a client’s signed

release, or removing documents from a health-care

provider with a client’s name or other information.

The Health Insurance Portability and

Accountability Act (HIPAA) of 1996 was passed

as an effort to preserve confidentiality and protect

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chapter 3 | Nursing Practice and the Law 25

the privacy of health information and improve the

portability and continuation of health-care cover-

age. The HIPAA gave Congress until August 1999

to pass this legislation. Congress failed to act, and

the Department of Health and Human Services

took over developing the appropriate regulations

(Charters, 2003). The latest version of this privacy

act was published in the Federal Register in 2002

(Charters, 2003).

The increased use of electronic sources of docu-

mentation and transfer of client information pre-

sents many confidentiality issues. It is important for

nurses to be aware of the guidelines protecting the

sharing and transfer of information through elec-

tronic sources. Most health-care institutions have

internal procedures to protect client confidentiality.

Take the following example:

Bill was admitted for pneumonia. With Bill ’s per- mission, an HIV test was performed, and the result was positive. This information was available on the computerized laboratory result printout. A nurse inadvertently left the laboratory results on the com- puter screen that was partially facing the hallway. One of Bill ’s coworkers, who had come to visit him, saw the report on the screen. This individual reported the test results to Bill ’s supervisor. When Bill returned to work, he was f ired for “poor job perfor- mance,” although he had had superior job evalua- tions. In the process of f iling a discrimination suit against his employer, Bill discovered that the infor- mation on his health status had come from this source. A lawsuit was f iled against the hospital and the nurse involved based on a breach of conf identiality.

Slander and Libel

Slander and libel are categorized as quasi-intentional

torts. Nurses rarely think of themselves as being

guilty of slander or libel. The term slander refers to the spoken word, and libel refers to the written word. Making a false statement about a client’s con-

dition that may result in an injury to that client is

considered slander. Making a written false state-

ment is libel. For example, stating that a client who

had blood drawn for drug testing has a substance

abuse problem, when in fact the client does not

carry that diagnosis, could be considered a slander-

ous statement.

Slander and libel also refer to statements made

about coworkers or other individuals whom you

may encounter in both your professional and

educational life. Think before you speak and write.

Sometimes what may appear to be harmless to you,

such as a complaint, may contain statements that

damage another person’s credibility personally and

professionally. Consider this example:

Several nurses on a unit were having diff iculty with the nurse manager. Rather than approach the manager or follow the chain of command, they decided to send a written statement to the chief exec- utive off icer (CEO) of the hospital. In this letter, they embellished some of the incidents that occurred and took statements out of context that the nurse manager had made, changing the meanings of the remarks. The nurse manager was called to the CEO’s off ice and reprimanded for these events and statements, which in fact had not occurred. The nurse manager sued the nurses for slander and libel based on the premise that her personal and profes- sional reputation had been tainted.

False Imprisonment

False imprisonment is confining an individual

against his or her will by either physical (restrain-

ing) or verbal (detaining) means. The following are


■ Using restraints on individuals without the

appropriate written consent

■ Restraining mentally handicapped individuals

who do not represent a threat to themselves or


■ Detaining unwilling clients in an institution

when they desire to leave

■ Keeping persons who are medically cleared for

discharge for an unreasonable amount of time

■ Removing the clothing of clients to prevent

them from leaving the institution

■ Threatening clients with some form of physical,

emotional, or legal action if they insist on leaving

Sometimes clients are a danger to themselves and

to others. Nurses need to decide on the appropri-

ateness of restraints as a protective measure. Nurses

should try to obtain the cooperation of the client

before applying any type of restraints. The first step

is to attempt to identify a reason for the risky

behavior and resolve the problem. If this fails, doc-

ument the need for restraints, consult with the

physician, and carefully follow the institution’s

policies and standards of practice. Failure to follow

these guidelines may result in greater harm to the

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26 unit 1 | Professional Considerations

client and possibly a lawsuit for the staff. Consider

the following:

Mr. Harrison, who is 87 years old, was admitted through the emergency department with severe lower abdominal pain of 3 days’ duration. Physical assessment revealed severe dehydration and acute distress. A surgeon was called, and an abdominal laparotomy was performed, revealing a ruptured appendix. Surgery was successful, and the client was sent to the intensive care unit for 24 hours. On transfer to the surgical floor the next day, Mr. Harrison was in stable condition. Later that night, he became confused, irritable, and anxious. He attempted to climb out of bed and pulled out his indwelling urinary catheter. The nurse restrained him. The next day, his irritability and confusion continued. Mr. Harrison’s nurse placed him in a chair, tying him in and restraining his hands. Three hours later he was found in cardiopulmonary arrest. A lawsuit of wrongful death and false imprison- ment was brought against the nurse manager, the nurses caring for Mr. Harrison, and the institution. During discovery, it was determined that the primary cause of Mr. Harrison’s behavior was hypoxemia. A violation of law occurred with the failure of the nursing staff to notify the physician of the client’s condition and to follow the institution’s standard of practice on the use of restraints.

To protect themselves against charges of negli-

gence or false imprisonment in such cases, nurses

should discuss safety needs with clients, their fam-

ilies, or other members of the health-care team.

Careful assessment and documentation of client

status are also imperative; confusion, irritability,

and anxiety often have metabolic causes that need

correction, not restraint.

There are statutes and case laws specific to the

admission of clients to psychiatric institutions. Most

states have guidelines for emergency involuntary

hospitalization for a specific period. Involuntary

admission is considered necessary when clients are a

danger to themselves or others. Specific procedures

must be followed. A determination by a judge or

administrative agency or certification by a specified

number of physicians that a person’s mental health

justifies the person’s detention and treatment may be

required. Once admitted, these clients may not be

restrained unless the guidelines established by state

law and the institution’s policies provide. Clients

who voluntarily admit themselves to psychiatric

institutions are also protected against false imprison-

ment. Nurses need to find out the policies of their

state and employing institution.

Assault and Battery

Assault is threatening to do harm. Battery is touch-

ing another person without his or her consent. The

significance of an assault is in the threat: “If you

don’t stop pushing that call bell, I’ll give you this

injection with the biggest needle I can find” is con-

sidered an assaultive statement. Battery would

occur if the injection were given when it was

refused, even if medical personnel deemed it was

for the “client’s good.” With few exceptions, clients

have a right to refuse treatment. Holding down a

violent client against his or her will and injecting a

sedative is battery. Most medical treatments, par-

ticularly surgery, would be battery if it were not for

informed consent from the client.

Standards of Practice

Concern for the quality of care is a major part of

nursing’s responsibility to the public. Therefore,

the nursing profession is accountable to the con-

sumer for the quality of its services. One of the

defining characteristics of a profession is the abil-

ity to set its own standards. Nursing standards

were established as guidelines for the profession

to ensure acceptable quality of care (Beckman,

1995). Standards of practice are also used as crite-

ria to determine whether appropriate care has been

delivered. In practice, they represent the minimum

acceptable level of care. Nurses are judged on gen-

erally accepted standards of practice for their level

of education, experience, position, and specialty

area. Standards take many forms. Some are

written and appear as criteria of professional

organizations, job descriptions, agency policies

and procedures, and textbooks. Others, which may

be intrinsic to the custom of practice, are not

found in writing (Beckman, 1995).

State boards of nursing and professional orga-

nizations vary by role and responsibility in relation

to standards of development and implementation

(ANA, 1998; 2004). Statutes, professional organi-

zations, and health-care institutions establish stan-

dards of practice. The nurse practice acts of indi-

vidual states define the boundaries of nursing prac-

tice within the state. In Canada, the provincial and

territorial associations define practice.

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chapter 3 | Nursing Practice and the Law 27

The courts have upheld the authority of boards

of nursing to regulate standards. The boards

accomplish this through direct or delegated statu-

tory language (ANA, 1998; 2004). The American

Nurses Association (ANA) also has specific stan-

dards of practice in general and in several clinical

areas (see Appendix 2). In Canada, the colleges of

registered nurses and the registered nurses associa-

tions of the various provinces and territories have

developed published practice standards. These may

be found at cna-aiic.ca

Institutions develop internal standards of practice.

The standards are usually explained in a specific insti-

tutional policy (for example, guidelines for the appro-

priate administration of a specific chemotherapeutic

agent), and the institution includes these standards in

policy and procedure manuals. The guidelines are

based on current literature and research. It is the

nurse’s responsibility to meet the institution’s stan-

dards of practice. It is the institution’s responsibility to

notify the health-care personnel of any changes and

instruct the personnel about the changes. Institutions

may accomplish this task through written memos or

meetings and in-service education.

With the expansion of advanced nursing prac-

tice, it has become particularly important to clarify

the legal distinction between nursing and medical

practice. It is important to be aware of the bound-

aries between these professional domains because

crossing them can result in legal consequences and

disciplinary action. The nurse practice act and

related regulations developed by most state legisla-

tures and state boards of nursing help to clarify

nursing roles at the various levels of practice.

Use of Standards in Nursing Negligence Malpractice Actions

When omission of prudent care or acts committed

by a nurse or those under his or her supervision

cause harm to a client, standards of nursing practice

are among the elements used to determine whether

malpractice or negligence exists. Other criteria may

include but are not limited to (ANA, 1998):

■ State, local, or national standards

■ Institutional policies that alter or adhere to the

nursing standards of care

■ Expert opinions on the appropriate standard of

care at the time

■ Available literature and research that substanti-

ates a standard of care or changes in the standard

Patient’s Bill of Rights

In 1973 the American Hospital Association

approved a statement called the Patient’s Bill of

Rights. These were revised in October 1992. Patient

rights were developed with the belief that hospitals

and health-care institutions would support these

rights with the goal of delivering effective client

care. In 2003 the Patient’s Bill of Rights was

replaced by the Patient Care Partnership. These

standards were derived from the ethical principle of

autonomy. This document may be found at


Informed Consent

Without consent, many of the procedures per-

formed on clients in a health-care setting may be

considered battery or unwarranted touching. When

clients consent to treatment, they give health-care

personnel the right to deliver care and perform spe-

cific treatments without fear of prosecution.

Although physicians are responsible for obtaining

informed consent, nurses often find themselves

involved in the process. It is the physician’s respon-

sibility to give information to a client about a

specific treatment or medical intervention (Giese v. Stice, 1997). The individual institution is not responsible for obtaining the informed consent

unless (1) the physician or practitioner is employed

by the institution or (2) the institution was aware or

should have been aware of the lack of informed

consent and did not act on this fact (Guido, 2001).

Some institutions require the physician or inde-

pendent practitioner to obtain his or her own

informed consent by obtaining the client’s signature

at the time the explanation for treatment is given.

The informed consent form should contain all

the possible negative outcomes as well as the posi-

tive ones. Nurses may be asked to obtain the signa-

tures on this form. The following are some criteria

to help ensure that a client has given an informed

consent (Guido, 2001; Kozier, Erb, Blais, et al.,


■ A mentally competent adult has voluntarily

given the consent.

■ The client understands exactly to what he or she

is consenting.

■ The consent includes the risks involved in the

procedure, alternative treatments that may be

available, and the possible result if the treatment

is refused.

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28 unit 1 | Professional Considerations

■ The consent is written.

■ A minor’s parent or guardian usually gives

consent for treatment.

Ideally, a nurse should be present when the physi-

cian is explaining the treatment to the client.

Before obtaining the client’s signature, the nurse

asks the client to recall exactly what the physician

has told him or her about the treatment. If at any

point the nurse thinks that the client does not

understand the treatment or the expected outcome,

the nurse must notify the physician of this fact.

To be able to give informed consent, the client

must be fully informed fully. Clients have the right

to refuse treatment, and nurses must respect this

right. If a client refuses the recommended treat-

ment, a client must be informed of the possible

consequences of this decision.

Implied consent occurs when consent is

assumed. This may be an issue in an emergency

when an individual is unable to give consent, as in

the following scenario:

An elderly woman is involved in a car accident on a major highway. The paramedics called to the scene f ind her unresponsive and in acute respiratory dis- tress; her vital signs are unstable. The paramedics immediately intubate her and begin treating her cardiac dysrhythmias. Because she is unconscious and unable to give verbal consent, there is an implied consent for treatment.

Staying Out of Court


Unfortunately, the public’s trust in the medical pro-

fession has declined over recent years. Consumers

are better informed and more assertive in their

approach to health care. They demand good and

responsible care. If clients and their families believe

that behaviors are uncaring or that attitudes are

impersonal, they are more likely to sue for what

they view as errors in treatment. The same applies

to nurses. If nurses demonstrate an interest in and

caring behaviors toward clients, a relationship

develops. Individuals do not sue those they view as

“caring friends.” The potential to change the atti-

tudes of health-care consumers is within the power

of health-care personnel. Demonstrating care and

concern and making clients and families aware of

choices and methods can help decrease liability.

Nurses who involve clients and their families in

decisions about care reduce the likelihood of a law-

suit. Tips to prevent legal problems are listed in

Box 3-1.

All health-care personnel are accountable for

their own actions and adherence to the accepted

standards of health care. Most negligence and mal-

practice cases arise from a violation of the accepted

standards of practice and the policies of the

employing institution. Common causes of negli-

gence are listed in Table 3-1. Expert witnesses

are called to cite the accepted standards and assist

attorneys in formulating the legal strategies per-

taining to those standards. For example, most med-

ication errors can be traced to a violation of the

accepted standard of medication administration,

originally referred to as the Five Rights (Kozier

et al., 1995; Taylor, Lillis, & LeMone, 2008), which

have been amended to Seven Rights (Balas, Scott,

& Rogers, 2004):

1. Right drug

2. Right dose

3. Right route

4. Right time

5. Right client

6. Right reason

7. Right documentation

Appropriate Documentation

The adage “not documented, not done” holds true

in nursing. According to the law, if something has

not been documented, then the responsible party

box 3-1

Tips for Avoiding Legal Problems • Keep yourself informed regarding new research related

to your area of practice.

• Insist that the health-care institution keep personnel

apprised of all changes in policies and procedures and

in the management of new technological equipment.

• Always follow the standards of care or practice for the


• Delegate tasks and procedures only to appropriate


• Identify clients at risk for problems, such as falls or the

development of decubiti.

• Establish and maintain a safe environment.

• Document precisely and carefully.

• Write detailed incident reports, and file them with the

appropriate personnel or department.

• Recognize certain client behaviors that may indicate the

possibility of a lawsuit.

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chapter 3 | Nursing Practice and the Law 29

did not do whatever needed to be done. If a nurse

did not “do” something, that leaves the nurse open

to negligence or malpractice charges.

Nursing documentation needs to be legally

credible. Legally credible documentation is an

accurate accounting of the care the client received.

It also indicates the competence of the individual

who delivered the care.

Charting by exception creates defense difficul-

ties. When this method of documentation is used,

investigators need to review the entire patient

record in an attempt to reconstruct the care given to

the client. Clear, concise, and accurate documenta-

tion helps nurses when they are named in lawsuits.

Often, this documentation clears the individual of

any negligence or malpractice. Documentation is

credible when it is:

■ Contemporaneous (documenting at the time care was provided)

■ Accurate (documenting exactly what was done) ■ Truthful (documenting only what was done) ■ Appropriate (documenting only what could be

discussed comfortably in a public setting)

Box 3-2 lists some documentation tips.

Marcos, the nursing student earlier in the chapter,

violated the right-dose principle and therefore made

a medication error. By signing off on medications for

all clients for a shift before the medications are

administered, a nurse is leaving himself or herself

open to charges of medication error.

In the case of Mr. Harrison, the institutional

personnel were found negligent because of a direct

violation of the institution’s standards regarding the

application of restraints.

Nursing units are busy and often understaffed.

These realities exist but should not be allowed to

interfere with the safe delivery of health care.

Clients have a right to safe and effective health

care, and nurses have an obligation to deliver

this care.

Common Actions Leading to Malpractice Suits

■ Failure to assess a client appropriately

■ Failure to report changes in client status to the

appropriate personnel

■ Failure to document in the patient record

■ Altering or falsifying a patient record

■ Failure to obtain informed consent

■ Failure to report a coworker’s negligence or poor


■ Failure to provide appropriate education to a

client and/or family members

■ Violation of internal or external standards of


table 3-1

Common Causes of Negligence Problem Prevention

Client falls Identify clients at risk.

Place notices about fall precautions.

Follow institutional policies on the use of restraints.

Always be sure beds are in their lowest positions.

Use side rails appropriately.

Equipment injuries Check thermostats and temperature in equipment used for heat or cold application.

Check wiring on all electrical equipment.

Failure to monitor Observe IV infusion sites as directed by institutional policy.

Obtain and record vital signs, urinary output, cardiac status, etc., as directed by institutional

policy and more often if client condition dictates.

Check pertinent laboratory values.

Failure to communicate Report pertinent changes in client status.

Document changes accurately.

Document communication with appropriate source.

Medication errors Follow the Seven Rights.

Monitor client responses.

Check client medications for multiple drugs for the same actions.

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30 unit 1 | Professional Considerations

In the case Tovar v. Methodist Healthcare (2005), a 75-year-old female client came to the emergency

department complaining of a headache and weakness

in the right arm. Although an order for admission to

the neurological care unit was written, the client was

not transported until 3 hours later. After the client

was in the unit, the nurses called one physician

regarding the client’s status. Another physician

returned the call 90 minutes later. Three hours later,

the nurses called to report a change in neurological

status. A STAT computed tomography scan was

ordered, which revealed a massive brain hemorrhage.

The nurses were cited for the following:

1. Delay in transferring the client to the neurolog-

ical unit

2. Failure to advocate for the client

The client presented with an acute neurological

problem requiring admission to an intensive care

unit where appropriate observation and interven-

tions were available. A delay in transfer may lead to

delay in appropriate treatment. According to the

ANA standards of care for neuroscience nurses

(2002), nurses need to assess the client’s changing

neurological status accurately and advocate for

the client. In this instance, the court stated that the

nurses should have been more assertive in attempt-

ing to reach the physician and request a prompt

medical evaluation. The court sided with the family,

agreeing with the plantiff ’s medical expert’s conclu-

sion that the client’s death was related to improper

management by the nursing staff.

If a Problem Arises

When served with a summons or complaint, peo-

ple often panic, allowing fear to overcome reason.

First, simply answer the complaint. Failure to do

this may result in a default judgment, causing

greater distress and difficulties.

Second, many things can be done to protect

oneself if named in a lawsuit. Legal representation

can be obtained to protect personal property. Never

sign any documents without consulting the mal-

practice insurance carrier or a legal representative.

If you are personally covered by malpractice insur-

ance, notify the company immediately, and follow

their instructions carefully.

Institutions usually have lawyers to defend

themselves and their employees. Whether or not

you are personally insured, contact the legal depart-

ment of the institution where the act took place.

Maintain a file of all papers, proceedings, meetings,

box 3-2

Some Documentation Guidelines Medications:

• Always chart the time, route, dose, and response.

• Always chart PRN medications and the client response.

• Always chart when a medication was not given, the reason (e.g., client in Radiology, Physical Therapy; do not chart that the

medication was not on the floor), and the nursing intervention.

• Chart all medication refusals, and report them.

Physician communication:

• Document each time a call is made to a physician, even if he or she is not reached. Include the exact time of the call. If the

physician is reached, document the details of the message and the physician’s response.

• Read verbal orders back to the physician, and confirm the client’s identity as written on the chart. Chart only verbal orders

that you have heard from the source, not those told to you by another nurse or unit personnel.

Formal issues in charting:

• Before writing on the chart, check to be sure you have the correct patient record.

• Check to make sure each page has the client’s name and the current date stamped in the appropriate area.

• If you forgot to make an entry, chart “late entry,” and place the date and time at the entry.

• Correct all charting mistakes according to the policy and procedures of your institution.

• Chart in an organized fashion, following the nursing process.

• Write legibly and concisely, and avoid subjective statements.

• Write specific and accurate descriptions.

• When charting a symptom or situation, chart the interventions taken and the client response.

• Document your own observations, not those that were told to you by another party.

• Chart frequently to demonstrate ongoing care, and chart routine activities.

• Chart client and family teaching and their response.

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chapter 3 | Nursing Practice and the Law 31

and telephone conversations about the case. Do not

withhold any information from your attorneys,

even if that information can be harmful to you. A

pending or ongoing legal case should not be dis-

cussed with coworkers or friends.

Let the attorneys and the insurance company

help decide how to handle the difficult situation.

They are in charge of damage control. Concealing

information usually causes more damage than dis-

closing it.

Sometimes, nurses believe they are not being

adequately protected or represented by the attor-

neys from their employing institution. If this hap-

pens, consider hiring a personal attorney who is

experienced in malpractice. This information can

be obtained through either the state bar association

or the local trial lawyers association.

Anyone has the right to sue; however, that does

not mean that there is a case. Many negligence and

malpractice courses find in favor of the health-care

providers, not the client or the client’s family. The

following case demonstrates this situation:

The Supreme Court of Arkansas heard a case that originated from the Court of Appeals in Arkansas. A client died in a single car motor vehicle accident shortly after undergoing an outpatient colonoscopy performed under conscious sedation. The family sued the center for performing the procedure and permit- ting the client to drive home. The court agreed that sedation should not be admininstered without the conf irmation of a designated driver for later. It also agreed that an outpatient facility needs to have directives stating that nurses and physicians may not admininster sedation unless transportation is available for later. However, the court ruled physi- cians and nurses may rely on information from the client. If the client states that someone will be avail- able for transportation after the procedure, sedation may be administered. The second aspect of the case revolved around the client’s insistence on leaving the facility and driving himself. When a client leaves against medical advice, the health-care per- sonnel have a legal duty to warn and strongly advise the client against the highly dangerous action. However, nurses and physicians do not have a legal right to restrain the client physically, keep his clothes, or take away car keys. Nurses are not obli- gated to call a taxi, call the police, admit the client to the hospital, or personally escort the client home if the client insists on leaving. Clients have some

responsibility for their own safety ( Young v. GastroIntestinal Center, Inc., 2005). In this case, the nurses acted appropriately. They adhered to the standard of practice, documented that the client stated that someone would be available to transport him home, and f illed the duty to warn.

Professional Liability Insurance

We live in a litigious society. Although there are a

variety of opinions on the issue, in today’s world

nurses need to consider obtaining professional lia-

bility insurance (Aiken, 2004). Various forms of

professional liability insurance are available. These

policies have been developed to protect nurses

against personal financial losses if they are involved

in a medical malpractice suit. If a nurse is charged

with malpractice and found guilty, the employing

institution has the right to sue the nurse to reclaim

damages. Professional malpractice insurance pro-

tects the nurse in these situations.

End-of-Life Decisions and the Law

When a heart ceases to beat, a client is in a state of

cardiac arrest. In health-care institutions and in the

community, it is common to begin cardiopul-

monary resuscitation (CPR) when cardiac arrest

occurs. In health-care institutions, an elaborate

mechanism is put into action when a client “codes.”

Much controversy exists concerning when these

mechanisms should be used and whether individu-

als who have no chance of regaining full viability

should be resuscitated.

Do Not Resuscitate Orders

A do not resuscitate (DNR) order is a specific direc-

tive to health-care personnel not to initiate CPR

measures. Only a physician can write a DNR order,

usually after consulting with the client or family.

Other members of the health-care team are expected

to comply with the order. Clients have the right

to request a DNR order. However, they may make

this request without a full understanding of what it

really means. Consider the following example:

When Mrs. Vincent, 58 years old, was admitted to the hospital for a hysterectomy, she stated, “I want to be made a DNR.” The nurse, concerned by the state- ment, questioned Mrs. Vincent’s understanding of a DNR order. The nurse asked her, “Do you mean that

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32 unit 1 | Professional Considerations

if you are walking down the hall after your surgery and your heart stops beating, you do not want the nurses or physicians to do anything? You want us to just let you die?” Mrs. Vincent responded with a resounding, “No, that is not what I mean. I mean if something happens to me and I won’t be able to be the way I am now, I want to be a DNR!” The nurse then explained the concept of a DNR order.

New York state has one of the most complete laws

regarding DNR orders for acute and long-term

care facilities. The New York law sets up a hierar-

chy of surrogates who may ask for a DNR status for

incompetent clients. The state has also ordered that

all health-care facilities ask clients their wishes

regarding resuscitation (Guido, 2001). The ANA

advocates that every facility have a written policy

regarding the initiation of such orders (ANA,

1992). The client or, if the client is unable to speak

for himself or herself, a family member or guardian

should make clear the client’s preference for either

having as much as possible done or withholding

treatment (see the next section, Advance Directives).

Elements to include in a DNR order are listed

in Box 3-3.

Advance Directives

The legal dilemmas that may arise in relation to

DNR orders often require court decisions. For this

reason, in 1990 Senator John Danforth of Missouri

and Senator Daniel Moynihan of New York intro-

duced the Patient Self-Determination Act to

address questions regarding life-sustaining treat-

ment. The act was created to allow people the

opportunity to make decisions about treatment in

advance of a time when they might become unable

to participate in the decision-making process.

Through this mechanism, families can be spared

the burden of having to decide what the family

member would have wanted.

Federal law requires that health-care institu-

tions that receive federal money (from Medicare,

for example) inform clients of their right to create

advance directives. The Patient Self-Determination

Act (S.R. 13566) provides guidelines for develop-

ing advance directives concerning what will be

done for individuals if they are no longer able to

participate actively in making decisions about care

options. The act states that institutions must:

■ Provide information to every client. On admission, all clients must be informed in

writing of their rights under state law to accept

or refuse medical treatment while they are com-

petent to make decisions about their care. This

includes the right to execute advance directives.

■ Document. All clients must be asked whether they have a living will or have chosen a durable

power of attorney for health care (also known as

a health-care surrogate). The response must be

indicated on the medical record, and a copy of

the documents, if available, should be placed on

the client’s chart.

■ Educate. Nurses, other health-care personnel, and the community need to understand what

the Patient Self-Determination Act and state

laws regarding advance directives require.

■ Be respectful of clients’ rights. All clients are to be treated with respectful care regardless of their

decision regarding life-prolonging treatments.

■ Have cultural humility. Recognize that culture affects clients’ decisions regarding end-of-life

care. Nurses should familiarize themselves with

the cultural and spiritual beliefs of their clients

in order to deliver culturally sensitive care.

Living Will and Durable Power of Attorney for Health Care (Health-Care Surrogate)

The two most common forms of advance directives

are living wills and durable power of attorney for

health care (health-care surrogate).

A living will is a legally executed document that

states an individual’s wishes regarding the use of

life-prolonging medical treatment in the event that

he or she is no longer competent to make informed

treatment decisions on his or her own behalf and is

suffering from a terminal condition (Catalano,

2000; Flarey, 1991).

box 3-3

Elements to Include in a DNR Order • Statement of the institution’s policy that resuscitation

will be initiated unless there is a specific order to

withhold resuscitative measures

• Statement from the client regarding specific desires

• Description of the client’s medical condition to justify a

DNR order

• Statement about the role of family members or significant


• Definition of the scope of the DNR order

• Delineation of the roles of various caregivers

American Nurses Association. (1992). Position statement on nursing care and

do not resuscitate decisions. Washington, DC: ANA.

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chapter 3 | Nursing Practice and the Law 33

A condition is considered terminal when, to a

reasonable degree of medical certainty, there is lit-

tle likelihood of recovery or the condition is

expected to cause death. A terminal condition may

also refer to a persistent vegetative state character-

ized by a permanent and irreversible condition of

unconsciousness in which there is (1) absence of

voluntary action or cognitive behavior of any kind

and (2) an inability to communicate or interact

purposefully with the environment (Hickey, 2002).

Another form of advance directive is the health-

care surrogate. Chosen by the client, the health-care

surrogate is usually a family member or close friend.

The role of the health-care surrogate is to make the

client’s wishes known to medical and nursing per-

sonnel. Imperative in the designation of a health-

care surrogate is a clear understanding of the client’s

wishes should the need arise to know them.

In some situations, clients are unable to express

themselves adequately or competently, although

they are not terminally ill. For example, clients with

advanced Alzheimer’s disease or other forms of

dementia cannot communicate their wishes; clients

under anesthesia are temporarily unable to com-

municate; and the condition of comatose clients

does not allow for expression of health-care wishes.

In these situations, the health-care surrogate can

make treatment decisions on the behalf of the

client. However, when a client regains the ability

to make his or her own decisions and is capable

of expressing them effectively, he or she resumes

control of all decision making pertaining to med-

ical treatment (Reigle, 1992). Nurses and physi-

cians may be held accountable when they go

against a client’s wishes regarding DNR orders and

advance directives.

In the case Wendland v. Sparks (1998), the physi- cian and nurses were sued for “not initiating CPR.”

In this case, the client had been in the hospital for

more than 2 months for lung disease and multiple

myeloma. Although improving at the time, during

the hospitalization she had experienced three car-

diac arrests. Even after this, the client had not

requested a DNR order. Her family had not dis-

cussed this either. After one of the arrests, the

client’s husband had told the physician that he

wanted his wife placed on artificial life support if it

was necessary (Guido, 2001). The client had a

fourth cardiac arrest. One nurse went to obtain the

crash cart, and another went to get the physician

who happened to be in the area. The physician

checked the heart rate, pupils, and respirations and

stated, “I just cannot do it to her.” (Guido, 2001,

p. 158). She ordered the nurses to stop the resusci-

tation, and the physician pronounced the death of

the client. The nurses stated that if they had not

been given a direct order they would have contin-

ued their attempts at resuscitation. “The court

ruled that the physician’s judgment was faulty and

that the family had the right to sue the physician

for wrongful death” (Guido, 2001, p. 158). The

nurses were cleared in this case because they were

following a physician’s order.

Nursing Implications

The Patient Self-Determination Act does not speci-

fy who should discuss treatment decisions or advance

directives with clients. Because directives are often

implemented on nursing units, however, nurses need

to be knowledgeable about living wills and health-

care surrogates and be prepared to answer questions

that clients may have about directives and the forms

used by the health-care institution.

As client advocates, the responsibility for creat-

ing an awareness of individual rights often falls on

nurses. It is the responsibility of the health-care

institution to educate personnel about the policies

of the institution so that nurses and others involved

in client care can inform health-care consumers of

their choices. Nurses who are unsure of the policies

in their health-care institution should contact the

appropriate department.

Legal Implications of Mandatory Overtime

Although mostly a workplace and safety issue,

there are legal implications to mandatory overtime.

Due to nursing shortages, there has been an

increased demand by hospitals forcing nurses to

work overtime (ANA, 2000). Overtime causes

physical and mental fatigue, increased stress, and

decreased concentration. Subsequently, these con-

ditions lead to medical errors such as failure to

assess appropriately, report, document, and admin-

ister medications safely. This practice of overtime

ignores other responsibilities nurses have outside of

their professional lives, which affects their mood,

motivation, and productivity (Vernarec, 2000).

Forced overtime causes already fatigued nurses

to deliver nursing care that may be less than opti-

mum, which in turn may lead to negligence and

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34 unit 1 | Professional Considerations

malpractice. This can result in the nurse losing his

or her license and perhaps even facing a wrongful

death suit due to an error in judgment.

Nurses practice under state or provincial

(Canada) nurse practice acts. These state that nurses

are held accountable for the safety of their clients

Once a nurse accepts an assignment for the client,

that nurse becomes liable under his or her license.

Many states are working to create legislation

restricting mandatory overtime for nurses.


Licensure is defined by the National Council of

State Boards of Nursing as the “process by which an

agency of state government grants permission to an

individual to engage in a given profession upon

finding that the applicant has attained the essential

degree of competency necessary to perform a

unique scope of practice” (NCSBN, 2007). Licenses

are given by a government agency to allow an indi-

vidual to engage in a professional practice and use a

specific title. State boards of nursing issue nursing

licenses, thus limiting practice to a specific jurisdic-

tion (Blais, Hayes, Kozier, & Erb, 2006).

Licensure can be mandatory or permissive.

Permissive licensure is a voluntary arrangement

whereby an individual chooses to become licensed

to demonstrate competence. However, the license is

not required to practice. Mandatory licensure

requires a nurse to be licensed in order to practice.

In the United States and Canada, licensure is


Qualifications for Licensure

The basic qualification for licensure requires grad-

uation from an approved nursing program. In the

United States, states may add additional require-

ments, such as disclosures regarding health or

medications that could affect practice. Most states

require disclosure of criminal conviction.

Licensure by Examination

A major accomplishment in the history of nursing

licensure was the creation of the Bureau of State

Boards of Nurse Examiners. The formation of this

agency led to the development of an identical exam-

ination in all states. The original examination, called

the State Board Test Pool Examination, was created

by the testing department of the National League

for Nursing. This was done through a collaborating

contract with the state boards. Initially, each state

determined its own passing score; however, the

states did adopt a common passing score. The

examination is called the NCLEX-RN and is used

in all states and territories of the United States.

This test is prepared and administered through a

testing company, Pearson Professional Testing of

Minnesota (Ellis & Hartley, 2004).


The NCLEX-RN is administered through com-

puterized adaptive testing (CAT). Candidates must

register to take the examination at an approved

testing center in their area. Because of a large test

bank, CAT permits a variety of questions to be

administered to a group of candidates. Candidates

taking the examination at the same time may not

necessarily receive the same questions. Once a can-

didate answers a question, the computer analyzes

the response and then chooses an appropriate ques-

tion to ask next. If the question was answered cor-

rectly, the following question may be more difficult;

if the question was answered incorrectly, the next

question may be easier.

The minimum number of questions is 75, and

the maximum is 265. Although the maximum

amount of time for taking the examination is

5 hours, candidates who do well or those who are

not performing well may finish as soon as 1 hour.

The test ends once the analysis of the examination

clearly determines that the candidate has success-

fully passed, has undoubtedly failed, has answered

the maximum number of questions, or has reached

the time limit (NCSBN, 2007). The computer

scores the test at the time it is taken; however, can-

didates are not notified of their status at the time of

completion. The information first goes to the test-

ing service, which in turn notifies the appropriate

state board. The state board notifies the candidate

of the examination results.

Nursing practice requires the application of

knowledge, skills, and abilities (NCSBN, 2007).

The items are written to Bloom’s taxonomy and are

organized around client needs to reflect the candi-

dates’ ability to make nursing decisions regarding

client care through application and analysis of

information. The examination is organized into

four major client need categories. Two of these cat-

egories, safe and effective care and physiological

needs, include subdivisions (NCSBN, 2007).

Integrated processes incorporate “nursing process,

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chapter 3 | Nursing Practice and the Law 35

caring, communication and documentation and

teaching/learning” (NCSBN, 2007, p. 3). Table 3-2

summarizes the categories and subcategories.

Previously, all questions were written in a multiple-

choice format. In 2003, alternative formats were

introduced. These alternative-format questions

include fill-in-the-blank; multiple-response answers;

“hot spots” that require the candidate to identify an

area on a picture, graph, or chart; and drag and drop

(NCSBN, 2007, p. 49). More information on alter-

native formats can be found on the NCSBN Web

site: www.ncsbn.org.

Preparing for the NCLEX-RN

There are several ways to prepare for the NCLEX-

RN. Some candidates attend review courses; others

view videos and DVDs, whereas others review

books. These methods assist in reviewing informa-

tion that was learned during education. Everyone

needs to decide what works best for himself or her-

self. It is helpful to take practice tests, because it

familiarizes one with the computer and the exami-

nation format. The NCSBN offers an on-line

NCLEX-RN study program.

To prepare for the NCLEX, take time to look at

the test blueprint provided by the NCSBN.This gives

candidates a comprehensive overview of the types of

questions to expect on the examination. Candidates

can review alternative test formats by accessing

pearsonvue.com/nclex/ Some test taking tips follow:

■ Be positive. Remind yourself that you worked

hard to reach this milestone and how prepared

you are to take the licensure examination.

■ Turn negative thoughts into positive ones.

Rather than saying, “I hope I pass,” tell yourself,

“I know I will do well.”

■ Acknowledge your feelings regarding the NCLEX.

It is fine to admit that you are anxious; however,

use your positive thoughts to control the anxiety.

■ Also use diaphragmatic breathing (deep breath-

ing) to control anxiety. Deep breathing augments

the relaxation response of the body. Use this

method at the beginning of the test or if you

encounter a question that you find confusing.

■ Control the situation by making a list of the

items you may need to take the test. Pack them

in a bag several days before, and keep them in a

place where you will remember to take them.

■ Eat well, and get a good night’s sleep before the

test. Avoid foods high in sugar and caffeine.

Contrary to popular belief, caffeine interferes

with your ability to concentrate. Eat complex

carbohydrates and protein to maintain your

blood glucose level.

■ Several days before you are scheduled to take

the test, travel to the test site along the same

route at the time you plan to go. Have an alter-

nate itinerary just in case there is a disruption in

your route. This will alleviate any unnecessary

stress in arriving at the examination site.

■ Leave early, and give yourself plenty of time to

get to your destination. Arriving early also gives

a sense of control.

■ Finally, remember your own basic needs. Testing

centers tend to be cold. Pack a jacket or sweater.

Check with the testing center to see if you are

allowed water or snacks.

Licensure Through Endorsement

Nurses licensed in one state may obtain a license in

another state through the process of endorsement.

Each application is considered independently and

is granted a license based on the rules and regula-

tions of the state.

States differ in the number of continuing educa-

tion credits required, legal requirements, and other

educational requirements. Some states require that

nurses meet the current criteria for licensure at the

time of application, whereas others may grant the

license based on the criteria in effect at the time of

the original licensure (Ellis & Hartley, 2004). When

applying for a license through endorsement, a nurse

should always contact the board of nursing for

the state and find out the exact requirements for

table 3-2

Major Categories and Subcategories of Client Needs

Category Subcategories

Safe Effective Care Management of Care

Environment Safety and Infection Control

Health Promotion

and Maintenance

Psychosocial Integrity

Physiological Integrity Basic Care and Comfort

Pharmacological and Parenteral


Reduction of Risk Potential

Physiological Adaptation

Adapted from NCSBN NCLEX-RN test plan (NCSBN, 2007, pp. 3–4.)

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36 unit 1 | Professional Considerations

licensure. This information can usually be found on

the board of nursing Web site for that particular state.

Multistate Licensure

The concept of multistate licensure allows a nurse

licensed in one state to practice in additional states

without obtaining additional licenses. NCSBN cre-

ated a Multistate Licensure Compact that permits

this practice. States that belong to the compact

have passed legislation adopting the terms of this

agreement and are known as party states. The

nurse’s home state is the state where he or she lives

and received his or her original license. Renewal of

the license is completed in the home state.

A nurse can hold only one home-state license. If

the nurse moves to another state that belongs to

the compact, the nurse applies for licensure within

that state based on residency. The nurse is expected

to follow the guidelines for nursing practice for

that new state. The multistate licensure applies only

to a basic registered nurse license, not to advanced

practice. More information on multistate licensure

can be found on the NCSBN Web site.

Disciplinary Action

State boards of nursing maintain rules and regula-

tions for the practice of nursing. Violation of these

regulations results in disciplinary actions as delin-

eated by these boards. Issues of primary concern

include but are not limited to the following:

■ Falsifying documents to obtain a license

■ Being convicted of a felony

■ Practicing while under the influence of drugs

or alcohol

■ Functioning outside the scope of practice

■ Engaging in child or elder abuse

Nurses convicted of a felony or found guilty in a

malpractice action may find themselves before their

state board of nursing or, in Canada, the provincial

or territorial regulatory body.

Disciplinary action may include but is not lim-

ited to the suspension or revocation of a nursing

license, mandatory fines, and mandatory continu-

ing education. For more information regarding the

regulations that guide nursing practice, consult the

board of nursing in your state or, in Canada, your

provincial or territorial regulatory body.


Nurses need to understand the legalities involved

in the delivery of safe health care. It is important

to know the standards of care established within

your institution and the rules and regulations in

the nurse practice acts of your state, province, or

territory because these are the standards to which

you will be held accountable. Health-care con-

sumers have a right to quality care and the expec-

tation that all information regarding diagnosis

and treatment will remain confidential. Nurses

have an obligation to deliver quality care and

respect client confidentiality. Caring for clients

safely and avoiding legal difficulties require nurses

to adhere to the expected standards of care and

document changes in client status carefully.

Licensure helps to ensure that health-care con-

sumers are receiving competent and safe care from

their nurses.

Study Questions

1. How do federal laws, court decisions, and state boards of nursing affect nursing practice? Give an

example of each.

2. Obtain a copy of the nurse practice act in your state. What are some of the penalties for violation

of the rules and regulations?

3. The next time you are on your clinical unit, look at the nursing documentation done by several

different staff members. Do you believe it is adequate? Explain your rationale.

4. How does your institution handle medication errors?

5. If a nurse is found to be less than proficient in the delivery of safe care, how should the nurse

manager remedy the situation?

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chapter 3 | Nursing Practice and the Law 37

6. Describe the where appropriate standards of care may be found. Explain whether each is an

example of an internal or external standard of care.

7. Explain the importance of federal agencies in setting standards of care in health-care institutions.

8. What is the difference between consent and informed consent?

9. Look at the forms for advance directives and DNR policies in your institution. Do they follow

the guidelines of the Patient Self-Determination Act?

10. What should a practicing nurse do to stay out of court? What should a nurse not do?

11. What impact would a law that prevents mandatory overtime have on nurses, nursing care, and

the health-care industry?

Case Study to Promote Critical Reasoning

Mr. Evans, 40 years old, was admitted to the medical-surgical unit from the emergency department

with a diagnosis of acute abdomen. He had a 20-year history of Crohn’s disease and had been on

prednisone, 20 mg, every day for the past year. Three months ago he was started on the new biolog-

ical agent, etanercept, 50 mg, subcutaneously every week. His last dose was 4 days ago. Because he

was allowed nothing by mouth (NPO), total parenteral nutrition was started through a triple-

lumen central venous catheter line, and his steroids were changed to Solu-Medrol, 60 mg, by

intravenous (IV ) push every 6 hours. He was also receiving several IV antibiotics and medication

for pain and nausea.

Over the next 3 days, his condition worsened. He was in severe pain and needed more anal-

gesics. One evening at 9 p.m., it was discovered that his central venous catheter line was out. The

registered nurse notified the physician, who stated that a surgeon would come in the morning to

replace it. The nurse failed to ask the physician what to do about the IV steroids, antibiotics, and

fluid replacement; the client was still NPO. She also failed to ask about the etanercept. At 7 a.m.,

the night nurse noticed that the client had had no urinary output since 11 p.m. the night before.

She failed to report this information to the day shift.

The client’s physician made rounds at 9 a.m. The nurse for Mr. Evans did not discuss the fact

that the client had not voided since 11 p.m., did not request orders for alternative delivery of the

steroids and antibiotics, and did not ask about administering the etanercept. At 5 p.m. that evening,

while Mr. Evans was having a computed tomography scan, his blood pressure dropped to 70 mm

Hg, and because no one was in the scan room with him, he coded. He was transported to the ICU

and intubated. He developed severe sepsis and acute respiratory distress syndrome.

1. List all the problems you can find with the nursing care in this case.

2. What were the nursing responsibilities in reporting information?

3. What do you think was the possible cause of the drop in Mr. Evans’ blood pressure and his

subsequent code?

4. If you worked in risk management, how would you discuss this situation with the nurse manager

and the staff?

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38 unit 1 | Professional Considerations

References Aiken, T.D. (2004). Legal, Ethical and Political Issues in Nursing,

2nd ed. Philadelphia: FA Davis. American Nurses Association (ANA) 2000. http://www.

nursingworld.org/MainMenuCategories/ANAMarketplace/ ANAPeriodicals/TAN/2000/JanFebShortStaffing.aspx

American Nurses Association (ANA). (1998). Legal aspects of standards and guidelines for clinical nursing practice. Washington, DC: ANA.

American Nurses Association (ANA). (2004). Nursing: Scope and standards of practice. Pub 03SSNP. Washington, DC: ANA.

American Nurses Association (ANA). (1992). Position statement on nursing care and do not resuscitate decisions. Washington, DC: ANA.

American Nurses Association (ANA). (2002). Scope and standards of neuroscience nursing practice. Pub NNS22. Washington, DC: ANA.

Balas, M., Scott, L., & Rogers, A. (2004). The prevalence and nature of errors and near errors reported by hospital staff nurses. Applied Nursing Research, 17(4), 224–230.

Beckman, J.P. (1995). Nursing Malpractice: Implications for Clinical Practice and Nursing Education. Seattle: Washington University Press.

Bernzweig, E.P. (1996). The Nurse’s Liability for Malpractice: A Programmed Text, 6th ed. St. Louis: C.V. Mosby.

Black, H.C. (2004). In Gardner, B.A. (ed.). Black’s Law Dictionary, 8th ed. St. Paul: West Publishing.

Blais, K.K., Hayes, J.S., Kozier, B., et al. (2006). Professional Nursing Practice: Concepts and Perspectives, 5th ed. Upper Saddle River, N.J.: Prentice-Hall.

Canadian Nurses Association. Canadian registered nurse exami- nation. Retrieved on December 20, 2005, from www. cna-aiic.ca

Catalano, J.T. (2000). Nursing Now! Today’s Issue, Tomorrow’s Trends, 2nd ed. Philadelphia: FA Davis.

Charters, K.G. (2003). HIPAA’s latest privacy rule. Policy, Politics & Nursing Practice, 4(1), 75–78.

Cushing, M. (1999). Nursing Jurisprudence. Upper Saddle River, N.J.: Prentice-Hall.

Ellis, J.R., & Hartley, C.L. (2004). Nursing in Today’s World: Trends, Issues and Management, 8th ed. Philadelphia: Lippincott, Williams & Wilkins.

Flarey, D. (1991). Advanced directives: In search of self- determination. Journal of Nursing Administration, 21(11), 17.

Giese v. Stice. 567 NW 2d 156 (Nebraska, 1997). Guido, G.W. (2001). Legal and Ethical Issues in Nursing, 3rd ed.

Upper Saddle River, N.J.: Prentice-Hall. Hickey, J. (2002). Clinical Practice of Neurological and

Neurosurgical Nursing, 5th ed. Philadelphia: Lippincott, Williams and Wilkins.

Kozier, B., Erb, G., Blais, K., et al. (1995). Fundamentals of Nursing: Concepts, Process and Practice, 15th ed. Menlo Park, Calif.: Addison-Wesley.

National Council of State Boards of Nursing. (2005). Fast facts about alternative item formats and the NCLEX examination. Retrieved on December 27, 2005, from www.ncsbn.org

National Council of State Boards of Nursing. (2004). Nursing regulation. Retrieved on December 16, 2005, from www.ncsbn.org

National Council of State Boards of Nursing. (2007). 2007 NCLEX-RN test plan. Retrieved on October 30, 2008, from www.ncsbn.org

Northrop, C.E., & Kelly, M.E. (1987). State of New Jersey v. Winter. Legal Issues in Nursing. St. Louis: CV Mosby.

Patient Self-Care Determination Act. (1989). S.R. 13566, Congressional Record.

Prosser, W.L., & Keeton, D. (1984). The Law of Torts, 5th ed. St. Paul: West Publishing.

Reigle, J. (1992). Preserving patient self-determination through advance directives. Heart Lung, 21(2), 196–198.

Taylor, C., Lillils, C., & LeMone, P. (2008). Fundamentals of Nursing: The Art and Science of Nursing Care. Philadelphia: Lippincott, Williams & Wilkins.

Tovar v. Methodist Healthcare. (2005). S.W. 3d WL 3079074 (Texas App., 2005).

Vernarec, E. (2000). Just say no to mandatory overtime. RN 63(12), 69–72.

Wendland v. Sparks. (1998). 574 N.W. 2d 327 (Iowa, 1998). Young v. GastroIntestinal Center, Inc. (2005). S.W. 3d WL 675751

(Arkansas, 2005).

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chapter 4 Questions of Values and Ethics

OBJECTIVES After reading this chapter, the student should be able to: ■ Discuss the way values are formed.

■ Differentiate between personal ethics and professional ethics.

■ Compare and contrast various ethical theories.

■ Discuss virtue ethics.

■ Apply the seven basic ethical principles to an ethical issue.

■ Analyze the impact that sociocultural factors have on ethical decision making by nursing personnel.

■ Discuss the influence organizational ethics have on nursing practice.

■ Identify an ethical dilemma in the clinical setting.

■ Discuss current ethical issues in health care and possible solutions.



Values and Moral Reasoning

Value Systems

How Values Are Developed

Values Clarification

Belief Systems

Morals and Ethics



Ethical Theories

Ethical Principles









Ethical Codes

Virtue Ethics

Nursing Ethics

Organizational Ethics

Ethical Issues on the Nursing Unit

Ethical Dilemmas

Resolving Ethical Dilemmas Faced by Nurses





Current Ethical Issues

Practice Issues Related to Technology

Genetics and the Limitations of Technology

Stem Cell Use and Research

Professional Dilemmas



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40 unit 1 | Professional Considerations

It is 1961. In a large metropolitan hospital, ten health-care professionals are meeting to consider the cases of three individuals. Ironically, the cases have something in common. Larry Jones, age 66, Irma Kolnick, age 31, and Nancy Roberts, age 10, are all suffering from chronic renal failure and need hemodialysis. Equipment is scarce, the cost of the treatment is prohibitive, and it is doubtful that treatment will be covered by health insurance. The hospital is able to provide this treatment to only one of these individuals. Who shall live, and who shall die? In a novel of the same name, Noah Gordon called this decision-making group The Death Committee (Gordon, 1963). Today, such groups are referred to as ethics committees.

In previous centuries, health-care practitioners had

neither the knowledge nor the technology to pro-

long life. The main function of nurses and physi-

cians was to support patients through times of

illness, help them toward recovery, or keep them

comfortable until death. There were few “who shall

live, and who shall die?” decisions.

The polio epidemic that raged through Europe

and the United States during 1947–1948 initiated

the development of units for patients on manual

ventilation (the “iron lung”). At this time, Danish

physicians invented a method of manual ventilation

by using a tube placed in the trachea of polio

patients. This was the beginning of mechanical

ventilation as we know it today.

During the 1950s, the development of mechan-

ical ventilation required more intensive nursing

care and patient observation. The care and moni-

toring of patients proved to be more efficient when

they were kept in a single care area; hence the term

intensive care. The late 1960s brought greater tech- nological advances, especially in the care of patients

seriously ill with cardiovascular disease. These new

therapies and monitoring methods made the inten-

sive care unit possible (aacn.org, 2006).

Health care now can keep alive people who

would die without intervention. The development

of new drugs and advances in biomechanical tech-

nology permit physicians and nurses to challenge

nature. This progress also brings new, perplexing

questions. The ability to prolong life has created

some heartbreaking situations for families and ter-

rible ethical dilemmas for health-care profession-

als. How is the decision made when to turn off the

life support machines that are keeping someone’s

son or daughter alive after, for example, a motor

vehicle accident? Families and professionals face

some of the most difficult ethical decisions at times

like this. How is death defined? When does it

occur? Perhaps these questions need to be asked:

“What is life? Is there ever a time when life is no

longer worth living?”

Health-care professionals have looked to philoso-

phy, especially the branch that deals with human

behavior, for resolution of these issues. The field of

biomedical ethics (or, simply, bioethics), a subdisci-

pline of ethics—the philosophical study of

morality—has evolved. In essence, bioethics is the

study of medical morality, which concerns the moral

and social implications of health care and science in

human life (Mappes & DeGrazia, 2005).

To understand biomedical ethics, the basic

concepts of values, belief systems, ethical theo-

ries, and morality are defined, followed by a dis-

cussion of the resolution of ethical dilemmas in

health care.


Webster’s New World Dictionary (2000) defines val- ues as the “estimated or appraised worth of some- thing, or that quality of a thing that makes it more

or less desirable, useful.” Values, then, are judg-

ments about the importance or unimportance of

objects, ideas, attitudes, and attributes. Values

become a part of a person’s conscience and world-

view. They provide a frame of reference and act

as pilots to guide behaviors and assist people in

making choices.

Values and Moral Reasoning

Reasoning entails the use of abstractions to think

creatively for the purpose of answering questions,

solving problems, and formulating a plan that

determine actions (Butts & Rich, 2008). Reasoning

allows individuals to think for themselves and to

not accept the beliefs and judgments of others at

face value. Moral reasoning relates to reasoning

centered around moral and/or ethical issues.

Different values, viewpoints, and methods of moral

reasoning have developed over time. Older world-

views have now emerged in modern history, such

as the emphasis on virtue ethics or a focus on what

type of person one would like to become (Butts

& Rich). Virtue ethics are discussed later in this


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chapter 4 | Questions of Values and Ethics 41

Value Systems

A value system is a set of related values. For exam-

ple, one person may value (believe to be important)

societal aspects of life, such as money, objects, and

status. Another person may value more abstract

concepts, such as kindness, charity, and caring.

Values may vary significantly, based on an individ-

ual’s culture and religious upbringing. An individ-

ual’s system of values frequently affects how he or

she makes decisions. For example, one person may

base a decision on cost, and another person placed

in the same situation may base the decision on a

more abstract quality, such as kindness. There are

different categories of values:

■ Intrinsic values are those related to sustaining life, such as food and water (Steele & Harmon, 1983).

■ Extrinsic values are not essential to life. Things, people, and ideas, such as kindness, understand-

ing, and material items, are extrinsically valuable.

■ Personal values are qualities that people consider valuable in their private lives. Such concepts as

strong family ties and acceptance by others are

personal values.

■ Professional values are qualities considered important by a professional group. Autonomy,

integrity, and commitment are examples of

professional values.

People’s behaviors are motivated by values. Individuals

take risks, relinquish their own comfort and security,

and generate extraordinary efforts because of their

values (Edge & Groves, 2005). Patients with trau-

matic brain injury may overcome tremendous barri-

ers because they value independence. Race-car

drivers may risk death or other serious injury because

they value competition and winning.

Values also generate the standards by which

people judge others. For example, someone who

values work over leisure activities will look unfavor-

ably on the coworker who refuses to work through-

out the weekend. A person who believes that health

is more important than wealth would approve of

spending money on a relaxing vacation or perhaps

joining a health club rather than putting the money

in the bank.

Often people adopt the values of individuals

they admire. For example, a nursing student may

begin to value humor after observing it used effec-

tively with patients. Values provide a guide for

decision making and give additional meaning to

life. Individuals develop a sense of satisfaction

when they work toward achieving values that they

believe are important.

How Values Are Developed

Values are learned (Wright, 1987). Values can be

taught directly, incorporated through societal

norms, and modeled through behavior. Children

learn by watching their parents, friends, teachers,

and religious leaders. Through continuous rein-

forcement, children eventually learn about and then

adopt values as their own. Because of the values they

hold dear, people often make great demands on

themselves, ignoring the personal cost. For example:

David grew up in a family in which educational achievement was highly valued. Not surprisingly, he adopted this as one of his own values. At school, he worked very hard because some of the subjects did not come easily to him. When his grades did not reflect his great effort, he felt as though he had dis- appointed his family as well as himself. By the time David reached the age of 15, he had developed severe migraine headaches.

Values change with experience and maturity. For

example, young children often value objects, such

as a favorite blanket or stuffed animal. Older chil-

dren are more likely to value a particular event, such

as a scouting expedition. As they enter adolescence,

they may value peer opinion over the opinions of

their parents. Young adults often value certain

ideals, such as beauty and heroism. The values of

adults are formed from all of these experiences as

well as from learning and thought.

The number of values that people hold is not as

important as what values they consider important.

Choices are influenced by values. The way people

use their own time and money, choose friends, and

pursue a career are all influenced by values.

Values Clarification

Values clarification is deciding what one believes is

important. It is the process that helps people

become aware of their values. Values play an impor-

tant role in everyday decision making. For this rea-

son, nurses need to be aware of what they do and

do not value. This process helps them to behave in

a manner that is consistent with their values.

Both personal and professional values influence

nurses’ decisions. Understanding one’s own values

simplifies solving problems, making decisions, and

developing better relationships with others when

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42 unit 1 | Professional Considerations

one begins to realize how others develop their

values. Raths, Harmin, and Simon (1979) suggest-

ed using a three-step model of choosing, prizing,

and acting, with seven substeps, to identify one’s

own values (Box 4-1).

You may have used this method when making

the decision to go to nursing school. For some peo-

ple, nursing is a first career; for others, it is a second

career. Using the model in Box 4-1, the valuing

process is analyzed:

1. Choosing. After researching alternative career options, you freely chose nursing school. This

choice was most likely influenced by such fac-

tors as educational achievement and abilities,

finances, support and encouragement from oth-

ers, time, and feelings about people.

2. Prizing. Once the choice was made, you were satisfied with it and told your friends about it.

3. Acting. You have entered school and begun the journey to your new career. Later in your career,

you may decide to return to school for a bache-

lor’s or master’s degree in nursing.

As you progressed through school, you probably

started to develop a new set of values—your profes-

sional values. Professional values are those established

as being important in your practice. These values

include caring, quality of care, and ethical behaviors.

Belief Systems

Belief systems are an organized way of thinking

about why people exist in the universe. The purpose

of belief systems is to explain such issues as life and

death, good and evil, and health and illness. Usually

these systems include an ethical code that specifies

appropriate behavior. People may have a personal

belief system, may participate in a religion that pro-

vides such a system, or both.

Members of primitive societies worshiped

events in nature. Unable to understand the science

of weather, for example, early civilizations believed

these events to be under the control of someone or

something that needed to be appeased, and they

developed rituals and ceremonies to appease these

unknown entities. They called these entities gods

and believed that certain behaviors either pleased

or angered the gods. Because these societies associ-

ated certain behaviors with specific outcomes,

they created a belief system that enabled them to

function as a group.

As higher civilizations evolved, belief systems

became more complex. Archeology has provided

evidence of the religious practices of ancient civi-

lizations (Wack, 1992). The Aztec, Mayan, Incan,

and Polynesian cultures each had a religious belief

system comprised of many gods and goddesses for

the same functions. The Greek, Roman, Egyptian,

and Scandinavian societies believed in a hierarchy

of gods and goddesses. Although given different

names by different cultures, it is very interesting

that most of the deities had similar purposes. For

example, Zeus was the Greek king of the gods, and

Thor was the Norse god of thunder. Both used a

thunderbolt as their symbol. Sociologists believe

that these religions developed to explain what was

then unexplainable. Human beings have a deep

need to create order from chaos and to have logical

explanations for events. Religion explains theolog-

ically what objective science cannot.

Along with the creation of rites and rituals, reli-

gions also developed codes of behaviors, or ethical

codes. These codes contribute to the social order.

There are rules regarding how to treat family mem-

bers, neighbors, the young, and the old. Many

religions also developed rules regarding marriage,

sexual practices, business practices, property owner-

ship, and inheritance.

The advancement of science certainly has not

made belief systems any less important. In fact, the

technology explosion has created an even greater

need for these systems. Technological advances

often place people in situations that justify religious

convictions rather than oppose them. Many reli-

gions, particularly Christianity, focus on the will of

box 4-1

Values Clarification Choosing

1. Choosing freely

2. Choosing from alternatives

3. Deciding after giving consideration to the consequences

of each alternative


4. Being satisfied about the choice

5. Being willing to declare the choice to others


6. Making the choice a part of one’s worldview and

incorporating it into behavior

7. Repeating the choice

Adapted from Raths, L.E., Harmon, M., & Simmons, S.B. (1979). Values and

Teaching. New York: Charles E. Merrill.

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chapter 4 | Questions of Values and Ethics 43

a supreme being, and technology, for example, is con-

sidered a gift that allows health-care personnel to

maintain the life of a loved one. Other religions, such

as certain branches of Judaism, focus on free choice

or free will, leaving such decisions in the hands of

humankind. Many Jewish leaders believe that if

genetic testing indicates, for instance, that an infant

will be born with a disease such as Tay-Sachs, which

causes severe suffering and ultimately death, an abor-

tion may be an acceptable option.

Belief systems often help survivors in making

decisions and living with them afterward. So far,

more questions than answers have emerged from

these technological advances. As science explains

more and more previously unexplainable phenom-

ena, people need beliefs and values to guide their

use of this new knowledge.

Morals and Ethics

Although the terms morals and ethics are often used interchangeably, ethics usually refers to a standard- ized code as a guide to behaviors, whereas morals usually refers to an individual’s own code for

acceptable behavior.


Morals arise from an individual’s conscience. They act as a guide for individual behavior and are learned

through instruction and socialization. You may find,

for example, that you and your patients disagree on

the acceptability of certain behaviors, such as pre-

marital sex, drug use, or gambling. Even in your

nursing class, you will probably encounter some dis-

agreements because each of you has developed a per-

sonal code that defines acceptable behavior.


Ethics is the part of philosophy that deals with the rightness or wrongness of human behavior. It is

also concerned with the motives behind behaviors.

Bioethics, specifically, is the application of ethics to issues that pertain to life and death. The implica-

tion is that judgments can be made about the right-

ness or goodness of health-care practices.

Ethical Theories

Several ethical theories have emerged to justify

moral principles (Guido, 2001). Deontological theo- ries take their norms and rules from the duties that individuals owe each other by the goodness of the

commitments they make and the roles they take

upon themselves. The term deontological comes from the Greek word deon (duty). This theory is attributed to the 18th-century philosopher

Immanuel Kant (Kant, 1949). Deontological ethics

considers the intention of the action, not the con-

sequences of the action. In other words, it is the

individual’s good intentions or goodwill (Kant,

1949) that determines the worthiness or goodness

of the action.

Teleological theories take their norms or rules for behaviors from the consequences of the action.

This theory is also called utilitarianism. According to this concept, what makes an action right or

wrong is its utility, or usefulness. Usefulness is con-

sidered to be the amount of happiness the action

carries. “Right” encompasses actions that have good

outcomes, whereas “wrong” is composed of actions

that result in bad outcomes. This theory had its ori-

gins with David Hume, a Scottish philosopher.

According to Hume, “Reason is and ought to be

the slave of the passions” (Hume, 1978, p. 212).

Based on this idea, ethics depends on what people

want and desire. The passions determine what is

right or wrong. However, individuals who follow

teleological theory disagree on how to decide on

the “rightness” or “wrongness” of an action (Guido,

2001) because individual passions differ.

Principalism is an arising theory receiving a great deal of attention in the biomedical ethics

community. This theory integrates existing ethical

principles and tries to resolve conflicts by relating

one or more of these principles to a given situation.

Ethical principles actually influence professional

decision making more than ethical theories.

Ethical Principles

Ethical codes are based on principles that can be

used to judge behavior. Ethical principles assist

decision making because they are a standard for

measuring actions. They may be the basis for laws,

but they themselves are not laws. Laws are rules

created by a governing body. Laws can operate

because the government has the power to enforce

them. They are usually quite specific, as are the

punishments for disobeying them. Ethical princi-

ples are not confined to specific behaviors. They act

as guides for appropriate behaviors. They also take

into account the situation in which a decision

must be made. Ethical principles speak to the

essence or fundamentals of the law rather than to

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44 unit 1 | Professional Considerations

the exactness of the law (Macklin, 1987). Here is an


Mrs. Van Gruen, 82 years old, was admitted to the hospital in acute respiratory distress. She was diag- nosed with aspiration pneumonia and soon became septic, developing adult respiratory distress syn- drome. She had a living will, and her attorney was her designated health-care surrogate. Her compe- tence to make decisions was uncertain because of her illness. The physician presented the situation to the attorney, indicating that without a feeding tube and tracheostomy Mrs. Van Gruen would die. According to the laws governing living wills and health-care surrogates, the attorney could have made the decision to withhold all treatments. However, he believed he had an ethical obligation to discuss the situation with his client. The client requested that the tracheostomy and the feeding tube be inserted, which was done.

In some situations, two or more principles may

conflict with each other. Making a decision under

these circumstances is very difficult. Following are

several of the ethical principles that are most

important to nursing practice—autonomy, non-

maleficence, beneficence, justice, confidentiality,

veracity, and accountability—and a discussion of

some of the ethical dilemmas that nurses encounter

in clinical practice.


Autonomy is the freedom to make decisions for

oneself. This ethical principle requires that nurses

respect patients’ rights to make their own choices

about treatment. Informed consent before treat-

ment, surgery, or participation in research is an

example. To be able to make an autonomous choice,

individuals need to be informed of the purpose,

benefits, and risks of the procedures to which they

are agreeing. Nurses accomplish this by providing

information and supporting patients’ choices.

Closely linked to the ethical principle of auton-

omy is the legal issue of competence. A patient

needs to be deemed competent in order to make a

decision regarding treatment options. When

patients refuse treatment, health-care personnel

and family members who think differently often

question the patient’s “competence” to make a deci-

sion. Of note is the fact that when patients agree

with health-care treatment decisions, rarely is their

competence questioned (AACN News, 2006).

Nurses are often in a position to protect a

patient’s autonomy. They do this by ensuring that

others do not interfere with the patient’s right to

proceed with a decision. If a nurse observes that a

patient has insufficient information to make an

appropriate choice, is being forced into a decision,

or is unable to understand the consequences of the

choice, then the nurse may act as a patient advocate

to ensure the principle of autonomy.

Sometimes nurses have difficulty with the prin-

ciple of autonomy because it also requires respecting

another’s choice, even if the nurse disagrees with it.

According to the principle of autonomy, a nurse

cannot replace a patient’s decision with his or her

own, even when the nurse honestly believes that the

patient has made the wrong choice. A nurse can,

however, discuss concerns with patients and make

sure patients have thought about the consequences

of the decision they are about to make.

Nonmalef icence

The ethical principle of nonmaleficence requires

that no harm be done, either deliberately or unin-

tentionally. This rather complicated word comes

from Latin roots: non, which means not; male (pronounced mah-leh), which means bad; and

facere, which means to do. The principle of nonmaleficence also requires

that nurses protect from danger individuals who

are unable to protect themselves because of their

physical or mental condition. An infant, a person

under anesthesia, and a person with Alzheimer’s

disease are examples of people with limited ability

to protect themselves. Nurses are ethically obligat-

ed to protect their patients when the patients are

unable to protect themselves.

Often, treatments meant to improve patient

health lead to harm. This is not the intention of the

nurse or of other health-care personnel, but it is a

direct result of treatment. Nosocomial infections as

a result of hospitalization are harmful to patients.

The nurses did not deliberately cause the infection.

The side effects of chemotherapy or radiation ther-

apy may result in harm. Chemotherapeutic agents

cause a decrease in immunity that may result in a

severe infection, whereas radiation may burn or

damage the skin. For this reason, many patients opt

not to pursue treatments.

The obligation to do no harm extends to the

nurse who for some reason is not functioning at an

optimal level. For example, a nurse who is impaired

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chapter 4 | Questions of Values and Ethics 45

by alcohol or drugs is knowingly placing patients at

risk. Other nurses who observe such behavior have

an ethical obligation to protect patients according

to the principle of nonmaleficence.

Benef icence

The word “beneficence” also comes from Latin: bene, which means well, and facere, which means to do.

The principle of beneficence demands that good

be done for the benefit of others. For nurses, this

means more than delivering competent physical or

technical care. It requires helping patients meet all

their needs, whether physical, social, or emotional.

Beneficence is caring in the truest sense, and caring

fuses thought, feeling, and action. It requires know-

ing and being truly understanding of the situation

and the thoughts and ideas of the individual

(Benner & Wrubel, 1989).

Sometimes physicians, nurses, and families

withhold information from patients for the sake of

beneficence. The problem with doing this is that it

does not allow competent individuals to make their

own decisions based on all available information. In

an attempt to be beneficent, the principle of auton-

omy is violated. This is just one of many examples

of the ethical dilemmas encountered in nursing

practice. For instance:

Mrs. Chung has just been admitted to the oncology unit with ovarian cancer. She is scheduled to begin chemotherapy treatment. Her two children and her husband have requested that the physician ensure that Mrs. Chung not be told her diagnosis because they believe she would not be able to cope with it. The information is communicated to the nursing staff. After the f irst treatment, Mrs. Chung becomes very ill. She refuses the next treatment, stating that she did not feel sick until she came to the hospital. She asks the nurse what could possibly be wrong with her that she needs a medicine that makes her sick when she does not feel sick. Only people who get cancer medicine get this sick! Mrs. Chung then asks the nurse, “Do I have cancer?”

As the nurse, you understand the order that the

patient not be told her diagnosis. You also under-

stand your role as a patient advocate.

1. To whom do you owe your duty: the family or

the patient?

2. How do you think you may be able to be a

patient advocate in this situation?

3. What information would you communicate to

the family members, and how can you assist

them in dealing with their mother’s concerns?


The principle of justice obliges nurses and other

health-care professionals to treat every person

equally regardless of gender, sexual orientation,

religion, ethnicity, disease, or social standing (Edge

& Groves, 2005). This principle also applies in the

work and educational setting. Everyone should be

treated and judged by the same criteria according

to this principle. Here is an example:

Mr. Johnson, found on the street by the police, was admitted through the emergency room to a medical unit. He was in deplorable condition: his clothes were dirty and ragged, he was unshaven, and he was covered with blood. His diagnosis was chronic alcoholism, complicated by esophageal varices and end-stage liver disease. Several nursing students overheard the staff discussing Mr. Johnson. The essence of the conversation was that no one wanted to care for him because he was dirty and smelly and brought this condition on himself. The students, upset by what they heard, went to their instructor about the situation. The instructor explained that every individual has a right to good care despite his or her economic or social position. This is the principle of justice.

The concept of distributive justice necessitates the fair allocation of responsibilities and advantages,

especially in a society where resources may be

limited (Davis, Arokar, Liaschenko, & Drought,

1997). Health-care costs have increased tremen-

dously over the years, and access to care has become

a social and political issue. In order to understand

distributive justice, certain concepts need to be

addressed: need, individual effort, ability to pay,

contribution to society, and age (Davis, et al., p. 53).

Age has become an extremely controversial issue

as it leads to quality-of-life questions, particularly

technological care at the end of life. The other issue

regarding age revolves around technology in

neonatal care. How do health-care providers place

value on one person’s quality of life over that of

another? Should millions of dollars be spent pre-

serving the life of an 80-year-old man who volun-

teers in his community, plays golf twice a week, and

teaches reading to underprivileged children, or

should that money be spent on a 26-week-old fetus

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46 unit 1 | Professional Considerations

that will most likely require intensive therapies and

treatments for a lifetime, adding up to more

millions of health-care dollars? In the social and

business world, welfare payments are based on

need, and jobs and promotions are usually distrib-

uted on an individual’s contributions and achieve-

ments. Is it possible to apply these measures to

health-care allocations?

Philosopher John Rawls addressed the issues

of justice as fairness and justice as the foundation of

social structures. According to Rawls, the idea of

the original position should be used to negotiate

the principles of justice. The original position based

on Kant’s social contract theory presents a hypo-

thetical situation in which individuals act as a

trustee for the interests of all individuals. The indi-

viduals, known as negotiators, are knowledgeable

in the areas of sociology, political science, and eco-

nomics. However, they are placed under certain

limitations referred to as the veil of ignorance. These limitations represent the moral essentials of origi-

nal position arguments.

The veil of ignorance eliminates information

about age, gender, socioeconomic status, and reli-

gious convictions from the issues. Once this infor-

mation is unavailable to the negotiators, the vested

interests of involved parties disappear. According

to Rawls, in a just society the rights protected by

justice are not issues for political bargaining or sub-

ject to the calculations of social interests. Simply

put, everyone has the same rights and liberties.


The principle of fidelity requires loyalty. It is a

promise that the individual will fulfill all commit-

ments made to himself or herself and to others. For

nurses, fidelity includes the professional’s loyalty to

fulfill all responsibilities and agreements expected

as part of professional practice. Fidelity is the basis

for the concept of accountability—taking responsi-

bility for one’s own actions (Shirey, 2005).

Conf identiality

The principle of confidentiality states that anything

said to nurses and other health-care providers by

their patients must be held in the strictest confi-

dence. Confidentiality presents both a legal and an

ethical issue. Exceptions exist only when patients

give permission for the release of information or

when the law requires the release of specific infor-

mation. Sometimes, just sharing information

without revealing an individual’s name can be a

breach in confidentiality if the situation and the

individual are identifiable. It is important to realize

that what seems like a harmless statement can

become harmful if other people can piece together

bits of information and identify the patient.

Nurses come into contact with people from

different walks of life. Within communities, people

know other people who know other people, and so

on. Individuals have lost families, jobs, and insur-

ance coverage because nurses shared confidential

information and others acted on that knowledge

(AIDS Update Conference, 1995).

In today’s electronic environment, the principle

of confidentiality has become a major concern.

Many health-care institutions, insurance compa-

nies, and businesses use electronic media to trans-

fer information. These institutions store sensitive

and confidential information in computer databases.

These databases need to have security safeguards to

prevent unauthorized access. Health-care institu-

tions have addressed the situation through the use

of limited access, authorization passwords, and

security tracking systems. However, even the most

secure system is vulnerable and can be accessed by

an individual who understands the complexities of

computer systems.


Veracity requires nurses to be truthful. Truth is fun-

damental to building a trusting relationship.

Intentionally deceiving or misleading a patient is a

violation of this principle. Deliberately omitting a

part of the truth is deception and violates the prin-

ciple of veracity. This principle often creates ethical

dilemmas. When is it permissible to lie? Some

ethicists believe it is never appropriate to deceive

another individual. Others think that if another

ethical principle overrides veracity, then lying is

permissible. Consider this situation:

Ms. Allen has just been told that her father has Alzheimer’s disease. The nurse practitioner wants to come into the home to discuss treatment. Ms. Allen refuses, saying that the nurse practitioner should under no circumstances tell her father the diagnosis. She explains to the practitioner that she is sure he will kill himself if he learns that he has Alzheimer’s disease. She bases this concern on statements he has made regarding this disease. The nurse practitioner replies that medication is available that might help

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chapter 4 | Questions of Values and Ethics 47

her father. However, it is available only through a research study being conducted at a nearby univer- sity. To participate in the research, the patient must be informed of the purpose of the study, the medica- tion to be given and its side effects, and follow-up procedures. Ms. Allen continues to refuse to allow her father to be told his diagnosis because she is certain he will commit suicide.

The nurse practitioner faces a dilemma: does he

abide by Ms. Allen’s wishes based on the principle

of beneficence, or does he abide by the principle of

veracity and inform his patient of the diagnosis.

What would you do?


Accountability is linked to fidelity and means

accepting responsibility for one’s actions. Nurses

are accountable to their patients and to their col-

leagues. When providing care to patients, nurses

are responsible for their actions, good and poor. If

something was not done, do not chart or tell a col-

league that it was. An example of violating

accountability is the story of Anna:

Anna was a registered nurse who worked nights on an acute care unit. She was an excellent nurse, but as the acuity of the patients’ conditions increased, she was unable to keep up with both patients’ needs and the technology, particularly intravenous (IV ) lines. She began to chart that all the IVs were infusing as they should, even when they were not. Each morning, the day shift would f ind that the actual infused amount did not agree with what the paperwork showed. One night, Anna allowed an entire liter to be infused in 2 hours into a patient with congestive heart failure. When the day staff came on duty, they found the patient expired, the bag empty, and the tubing f illed with blood. Anna’s IV sheet showed 800 mL left in the bag. It was not until a lawsuit was f iled that Anna took responsibility for her behavior.

The idea of a standard of care evolves from the

principle of accountability. Standards of care pro-

vide a rule for measuring nursing actions.

Ethical Codes

A code of ethics is a formal statement of the rules

of ethical behavior for a particular group of individ-

uals. A code of ethics is one of the hallmarks of a

profession. This code makes clear the behavior

expected of its members.

The Code of Ethics for Nurses with Interpretive

Statements provides values, standards, and princi-

ples to help nursing function as a profession. The

original code was developed in 1985. In 1995 the

American Nurses Association Board of Directors

and the Congress on Nursing Practice initiated the

Code of Ethics Project (ANA, 2002). The code may

be viewed online at nursingworld.org

Ethical codes are subject to change. They reflect

the values of the profession and the society for which

they were developed. Changes occur as society and

technology evolve. For example, years ago no

thought was given to do not resuscitate (DNR)

orders or withholding food and fluids. Technological

advances have since made it possible to keep people

in a kind of twilight life, comatose and unable to

participate in living in any way, but nevertheless

making DNR and withholding very important

issues in health care. Technology has increased

knowledge and skills, but the ability to make deci-

sions regarding care is still guided by the principles

of autonomy, nonmaleficence, beneficence, justice,

confidentiality, fidelity, veracity, and accountability.

Virtue Ethics

Virtue ethics focuses on virtues, or moral character,

rather than on duties or rules that emphasize the

consequences of actions. Take the following example:

Norman is driving along the road and f inds a cry- ing child sitting by a fallen bicycle. It is obvious that the child needs assistance. From one ethical stand- point (utilitarianism), helping the child will increase Norman’s personal feelings of “doing good.” The deontological stance states that by helping, Norman is behaving in accordance with a moral rule such as “Do unto others....” Virtue ethics looks at the fact that helping the person would be charitable or benevolent.

Plato and Aristotle are considered the founders

of virtue ethics. Its roots can be found in Chinese

philosophy. During the 1800s virtue ethics disap-

peared, but in the late 1950s it reemerged as an

Anglo-American philosophy. Neither deontology

nor utilitarianism considered the virtues of moral

character and education and the question: “What

type of person should I be, and how should I live”

(Hooker, 2000; Driver, 2001). Virtues include such

qualities as honesty, generosity, altruism, and relia-

bility. They are concerned with many other ele-

ments as well, such as emotions and emotional

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48 unit 1 | Professional Considerations

reactions, choices, values, needs, insights, attitudes,

interests, and expectations. To embrace a virtue

means that you are a person with a certain complex

way of thinking. Nursing has practiced virtue ethics

for many years.

Nursing Ethics

Up to this point, the ethical principles discussed

apply to ethics for nurses; however, nurses do not

customarily find themselves enmeshed in the bio-

medical ethical decision-making processes that

gain the attention of the news media. However, the

ethical principles that guide nursing practice are

rooted in the philosophy and science of health care

and are considered a subcategory of bioethics

(Butts & Rich, 2008).

Nursing ethics deals with the experiences and

needs of nurses and nurses’ perceptions of their expe-

riences (Varcoe, et al., 2004). It is viewed from the

perspective of nursing theory and practice ( Johnstone,

1999). Relationships are the center of nursing ethics.

These relationships focus on ethical issues that impact

nurses and their patients.

Organizational Ethics

Organizational ethics focus on the workplace and

are aimed at the organizational level. Every orga-

nization, even one with hundreds of thousands of

employees, consists of individuals. Each individual

makes his and her own decisions about how to

behave in the workplace. Each person has the

opportunity to make the organization a more or

less ethical place. These individual decisions can

have a powerful effect on the lives of many others

in the organization as well as in the surrounding

community. Shirey (2005) explains that employees

need to experience uniformity between what the

organization states and what it practices.

Research conducted by the Ethics Research

Center concluded the following:

■ If positive outcomes are desired, ethical culture

is what makes the difference;

■ Leadership, especially senior leadership, is the

most critical factor in promoting an ethical

culture; and

■ In organizations that are trying to strengthen

their culture, formal program elements can help

to do that (Harned, 2005, p. 1).

When looking for a professional position, it is

important to consider the organizational culture.

What are the values and beliefs of the organization?

Do they blend with yours, or are they in conflict with

your value system? To find out this information, look

at the organization’s mission, vision, and value state-

ments. Speak with other nurses who work in the

organization. Do they see consistency between what

the organization states and what it actually expects

from the employees? For example, if an organization

states that it collaborates with the nurses in decision

making, do nurses sit on committees that have input

into the decision-making process?

Ethical Issues on the Nursing Unit

Organizational ethics refer to the values and

expected behaviors entrenched within the organi-

zational culture. The nursing unit represents a sub-

culture of the organization. Ideally, the nursing unit

should mirror the ethical atmosphere and culture of

the organization. This requires the individuals that

comprise the unit to hold the same values and

model the expected behaviors.

Conflicts of the values and ethics among indi-

viduals who work together on the unit often create

issues that result in moral suffering for some nurses.

Moral suffering occurs when nurses experience a

feeling of uneasiness or concern regarding behav-

iors or circumstances that challenge their own

moral beliefs and values. These situations may be

the result of unit policies, physicians’ orders that

the nurse believes may not be beneficial for the

patient, professional behaviors of colleagues, or

family attitudes about the patient.

Perhaps one of the most disconcerting ethical

issues nurses on the unit face is the one that

challenges their professional values and ethics.

Friendships often emerge from work relationships,

and these friendships may interfere with judg-

ments. Similarly, strong negative feelings may

cloud a nurse’s ability to view a situation fairly and

without prejudice. Take the following example:

Addie and Jamie attended nursing school together and developed a strong friendship. They work together on the pediatric surgical unit of a large teaching hos- pital. Jamie made a medication error that caused a problem, resulting in a child having to be transferred to the intensive care unit. Addie realized what had happened and confronted Jamie. Jamie begged her not to say anything. Addie knew the error should be reported, but how would this affect her long time friendship with Jamie? Taking this situation to the

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chapter 4 | Questions of Values and Ethics 49

other extreme, if a friendship had not been involved, would Addie react the same way?

When working with others, it is important to hold

true to your personal values and morals. Practicing

virtue ethics, i.e., “doing the right thing,” may cause

difficulty due to the possible consequences of the

action. Nurses should support each other but not at

the expense of patients or each other’s professional

duties. There are times when not acting virtuously

may cause a colleague more harm.

Ethical Dilemmas

What is a dilemma? The word dilemma is of Greek derivation. A lemma was an animal resembling a

ram and having two horns. Thus came the saying

“stuck on the horns of a dilemma.” The story of

Hugo illustrates a hypothetical dilemma, with a

touch of humor:

One day, Hugo, dressed in a bright red cape, walked through his village into the countryside. The wind caught the corners of the cape, and it was whipped in all directions. As he walked down the dusty road, Hugo happened to pass by a lemma. Hugo’s bright red cape caught the lemma’s attention. Lowering its head, with its two horns poised in attack position, the ani- mal began to chase Hugo down the road. Panting and exhausted, Hugo reached the end of the road, only to f ind himself blocked by a huge stone wall. He turned to face the lemma, which was ready to charge. A deci- sion needed to be made, and Hugo’s life depended on this decision. If he moved to the left, the lemma would gore his heart. If he moved to the right, the lemma would gore his liver. No matter what his decision, Hugo would be “stuck on the horns of the lemma.”

Like Hugo, nurses are often faced with difficult

dilemmas. Also, as Hugo found, an ethical dilemma

can be a choice between two serious alternatives.

An ethical dilemma occurs when a problem

exists that forces a choice between two or more

ethical principles. Deciding in favor of one princi-

ple will violate the other. Both sides have goodness

and badness to them, but neither decision satisfies

all the criteria that apply. Ethical dilemmas also

have the added burden of emotions. Feelings of

anger, frustration, and fear often override rational-

ity in the decision-making process. Consider the

case of Mr. Sussman:

Mr. Sussman, 80 years old, was admitted to the neuroscience unit after suffering left hemispheric

bleeding. He had a total right hemiplegia and was completely nonresponsive, with a Glasgow Coma Scale score of 8. He had been on IV fluids for 4 days, and the question was raised of placing a percuta- neous endoscopic gastrostomy (PEG) tube for enter- al feedings. The older of the two children asked what the chances of recovery were. The physician explained that Mr. Sussman’s current state was probably the best he could attain but that “miracles happen every day” and stated that tests could help in determining the prognosis. The family asked that these tests be performed. After the results were in, the physician explained that the prognosis was grave and that IV fluids were insuff icient to sustain life. The PEG tube would be a necessity if the fam- ily wished to continue with food and fluids. After the physician left, the family asked the nurse, Gail, who had been with Mr. Sussman during the previ- ous 3 days, “If this was your father, what would you do?” This situation became an ethical dilemma for Gail as well.

If you were Gail, what would you say to the fami-

ly? Depending on your answer, what would be the

possible principles that you might violate?

Resolving Ethical Dilemmas Faced by Nurses

Ethical dilemmas can occur in any aspect of life,

personal or professional. This section focuses on

the resolution of professional dilemmas. The vari-

ous models for resolving ethical dilemmas consist

of 5 to 14 sequential steps. Each step begins with

the complete understanding of the dilemma and

concludes with the evaluation of the implemented


The nursing process provides a helpful mecha-

nism for finding solutions to ethical dilemmas. The

first step is assessment, including identification of

the problem. The simplest way to do this is to cre-

ate a statement that summarizes the issue. The

remainder of the process evolves from this state-

ment (Box 4-2).


Ask yourself, “Am I directly involved in this dilem-

ma?” An issue is not an ethical dilemma for nurses

unless they are directly involved or have been asked

for their opinion about a situation. Some nurses

involve themselves in situations even when their

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50 unit 1 | Professional Considerations

opinion has not been solicited. This is generally

unwarranted, unless the issue involves a violation of

the professional code of ethics.

Nurses are frequently in the position of hearing

both sides of an ethical dilemma. Often, all that is

wanted is an empathetic listener. At other times,

when guidance is requested, nurses can help people

work through the decision-making process (remem-

ber the principle of autonomy).

Collecting data from all the decision makers

helps identify the reasoning process being used by

these individuals as they struggle with the issue.

The following questions assist in the information-

gathering process:

■ What are the medical facts? Find out how the physicians, physical and occupational therapists,

dietitians, and nurses view the patient’s condi-

tion and treatment options. Speak with the

patient, if possible, and determine his or her

understanding of the situation.

■ What are the psychosocial facts? In what emotional state is the patient right now? The

patient’s family? What kind of relationship

exists between the patient and his or her family?

What are the patient’s living conditions? Who

are the individuals who form the patient’s

support system? How are they involved in the

patient’s care? What is the patient’s ability to

make medical decisions about his or her care?

Do financial considerations need to be taken

into account? What does the patient value?

What does the patient’s family value? The

answers to these questions will provide a better

understanding of the situation. Ask more ques-

tions, if necessary, to complete the picture. The

social facts of a situation also include institu-

tional policies, legal aspects, and economic

factors. The personal belief systems of physicians

and other health-care professionals also influ-

ence this aspect.

■ What are the cultural beliefs? Cultural beliefs play a major role in ethical decisions. Some cultures do

not allow surgical interventions as they fear that

the “life force” may escape. Many cultures forbid

organ donation. Other cultures focus on the sanc-

tity of life, thereby requesting all methods for sus-

taining life be used regardless of the futility.

■ What are the patient’s wishes? Remember the ethical principle of autonomy. With very few

exceptions, if the patient is competent, his or her

decisions take precedence. Too often, the fami-

ly’s or physician’s worldview and belief system

overshadow those of the patient. Nurses can

assist by maintaining the focus on the patient.

If the patient is unable to communicate, try to

discover whether the individual has discussed the

issue in the past. If the patient has completed

a living will or designated a health-care

surrogate, this will help determine the patient’s

wishes. By interviewing family members, the

nurse can often learn about conversations in

which the patient has voiced his or her feelings

about treatment decisions. Through guided

interviewing, the nurse can encourage the family

to tell anecdotes that provide relevant insights

into the patient’s values and beliefs.

■ What values are in conflict? To assess values, begin by listing each person involved in the

situation. Then identify the values represented

by each person. Ask such questions as, “What

do you feel is the most pressing issue here?” and

“Tell me more about your feelings regarding this

situation.” In some cases, there may be little

disagreement among the people involved, just a

different way of expressing beliefs. In others,

however, a serious value conflict may exist.


For planning to be successful, everyone involved in

the decision must be included in the process.

Thompson and Thompson (1992) listed three spe-

cific and integrated phases of this planning:

1. Determine the goals of treatment. Is cure a goal, or is the goal to keep the patient comfortable?

Is life at any cost the goal, or is the goal a

peaceful death at home? These goals need to

be patient-focused, reality-centered, and attain-

able. They should be consistent with current

medical treatment and, if possible, be measura-

ble according to an established period.

2. Identify the decision makers. As mentioned earlier, nurses may or may not be decision makers in

box 4-2

Questions to Help Resolve Ethical Dilemmas

• What are the medical facts?

• What are the psychosocial facts?

• What are the patient’s wishes?

• What values are in conflict?

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chapter 4 | Questions of Values and Ethics 51

these health-related ethical dilemmas. It is

important to know who the decision makers are

and what their belief systems are. When the

patient is a capable participant, this task is

much easier. However, people who are ill are

often too exhausted to speak for themselves or

to ensure that their voices are heard. When this

happens, the patient needs an advocate. Family,

friends, spiritual advisers, and nurses often act

as advocates. A family member may need to be

designated as the primary decision maker, a role

often called the health-care surrogate. The creation of living wills, establishment

of advance directives, and appointment of a

health-care surrogate while a person is still

healthy often ease the burden for the decision

makers during a later crisis. Patients can exer-

cise autonomy through these mechanisms, even

though they may no longer be able to commu-

nicate their wishes directly. When these

documents are not available, the information

gathered during the assessment of social factors

helps identify those individuals who may be

able to act in the patient’s best interest.

3. List and rank all the options. Performing this task involves all the decision makers. It is

sometimes helpful to begin with the least

desired choice and methodically work toward

the preferred treatment choice that is most

likely to lead to the desired outcome. Asking

all participating parties to discuss what they

believe are reasonable outcomes to be attained

with the use of available medical treatment

often helps in the decision process. By listening

to others in a controlled situation, family mem-

bers and health-care professionals discover that

they actually want the same result as the patient

but had different ideas about how to achieve

their goal.


During the implementation phase, the patient or

the surrogate (substitute) decision maker(s) and

members of the health-care team reach a mutually

acceptable decision. This occurs through open dis-

cussion and sometimes negotiation. An example of

negotiation follows:

Elena’s mother has metastatic ovarian cancer. She and Elena have discussed treatment options. Her physician suggested the use of a new chemotherapeutic

agent that has demonstrated success in many cases. But Elena’s mother emphatically states that she has “had enough” and prefers to spend her remaining time doing whatever she chooses. Elena wants her mother to try the drug. To resolve the dilemma, the oncology nurse practitioner and the physician talk with Elena and her mother. Everyone reviews the facts and expresses their feel- ings about the situation. Seeing Elena’s distress, Elena’s mother says, “OK, I will try the Taxol for a month. If there is no improvement after this time, I want to stop all treatment and live out the time I have with my daughter and her family.” All agreed that this was a reasonable decision.

The role of the nurse during the implementation

phase is to ensure that communication does not

break down. Ethical dilemmas are often emotional

issues, filled with guilt, sorrow, anger, and other

strong emotions. These strong feelings can cause

communication failures among decision makers.

Remind yourself, “I am here to do what is best for

this patient.”

Keep in mind that an ethical dilemma is not

always a choice between two attractive alternatives.

Many are between two unattractive, even unpleas-

ant, choices. Elena’s mother’s options did not

include the choice she really wanted: good health

and a long life.

Once an agreement is reached, the decision

makers must accept it. Sometimes, an agreement is

not reached because the parties cannot reconcile

their conflicting belief systems or values. At other

times, caregivers are unable to recognize the worth

of the patient’s point of view. Occasionally, the

patient or the surrogate may make a request that is

not institutionally or legally possible. In some

cases, a different institution or physician may be

able to honor the request. In other cases, the

patient or surrogate may request information from

the nurse regarding illegal acts. When this hap-

pens, the nurse should ask the patient and family

to consider the consequences of their proposed

actions. It may be necessary to bring other coun-

selors into the discussion (with the patient’s

permission) to negotiate an agreement.


As in the nursing process, the purpose of evaluation

in resolving ethical dilemmas is to determine

whether the desired outcomes have occurred. In the

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52 unit 1 | Professional Considerations

case of Mr. Sussman, some of the questions that

could be posed by Gail to the family are as follows:

■ “I have noticed the amount of time you have

been spending with your father. Have you

observed any changes in his condition?”

■ “I see Dr. Washburn spoke to you about the test

results and your father’s prognosis. How do you

feel about the situation?”

■ “Now that Dr. Washburn has spoken to you

about your father’s condition, have you consid-

ered future alternatives?”

Changes in patient status, availability of medical

treatment, and social facts may call for reevaluation

of a situation. The course of treatment may need to

be altered. Continued communication and cooper-

ation among the decision makers are essential.

Another model, the MORAL model created by

Thiroux (1977) and refined for nursing by Halloran

(1982), is gaining popularity. The MORAL

acronym reminds nurses of the sequential steps

needed for resolving an ethical dilemma. This ethi-

cal decision-making model is easily implemented in

all patient care settings (Box 4-3).

Current Ethical Issues

During fall 1998, Dr. Jack Kevorkian (sometimes

called Dr. Death in the media) openly admitted that

at the patient’s request, he gave the patient a lethal

dose of medication, causing death. His statement

raised the consciousness of the American people

and the health-care system about the issues of

euthanasia and assisted suicide. Do individuals have

the right to consciously end their own lives when

they are suffering from terminal conditions? If they

are unable to perform the act themselves, should

others assist them in ending their lives? Should

assisted suicide be legal? There are no answers to

these difficult questions, and patients and their fam-

ilies face these same questions every day.

More recently, the Terri Schiavo case gained

tremendous media attention, probably becoming

the most important case of clinical ethics in more

than a decade. Her illness and death created a

major medical, legal, theological, ethical, political,

and social controversy. The case brought to the

forefront the deep divisions and fears that reside in

society regarding life and death, the role of the gov-

ernment and courts in life decisions, and the treat-

ment of disabled persons. Many aspects of this case

will never be clarified; however, many questions

raised by this case need to be addressed for future

ethical decision making. Some of these are:

1. What is the true definition of a persistent

vegetative state?

2. How is cognitive recovery determined?

3. What role do the courts play when there is a

family dispute? Who has the right to make

decisions when an individual is married?

4. What are the duties of surrogate decision

makers? (Hook & Mueller, 2005)

The primary goal of nursing and other health-care

professions is to keep people alive and well or, if

this cannot be done, to help them live with their

problems and die peacefully. To accomplish this,

health-care professionals struggle to improve their

knowledge and skills so they can care for their

patients, provide them with some quality of life,

and help return them to wellness. The costs

involved in achieving this goal can be astronomical.

Questions are being raised more and more often

about who should receive the benefits of this tech-

nology. Managed care and the competition for

resources are also creating ethical dilemmas. Other

difficult questions, such as who should pay for care

when the illness may have been due to poor health-

care practices such as smoking or substance abuse,

are also being debated.

Practice Issues Related to Technology

Genetics and the Limitations of Technology

In issues of technology, the principles of benefi-

cence and nonmaleficence may be in conflict. A

specific technology administered with the inten-

tion of “doing good” may result in enormous suffer-

ing. Causing this type of torment is in direct con-

flict with the idea of “do no harm” (Burkhardt &

Nathaniel, 2007). At times, this is an accepted con-

sequence, such as in the use of chemotherapy.

However, the ultimate outcome in this case is that

box 4-3

The Moral Model M: Massage the dilemma

O: Outline the option

R: Resolve the dilemma

A: Act by applying the chosen option

L: Look back and evaluate the complete process, including

actions taken

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chapter 4 | Questions of Values and Ethics 53

recovery is expected. In situations in which little or

no improvement is expected, the issue of whether

the good outweighs the bad prevails. Suffering

induced by technology may include physical, spiri-

tual, and emotional components for the patient and

the families.

Today, many infants who have low birth weight

or birth defects, who not so long ago would have

been considered unable to live, are maintained on

machines in highly sophisticated neonatal units.

This process may keep babies alive only to die sev-

eral months later or may leave them with severe

chronic disabilities. Children with chronic disabili-

ties require additional medical, educational, and

social services. These services are expensive and

often require families to travel long distances to

obtain them (Urbano, 1992).

Genetic diagnosis and gene therapy present new

ethical issues for nursing. Genetic diagnosis is a process that involves analyzing parents or an

embryo for a genetic disorder. This is usually done

before in vitro fertilization for couples who run a

high risk of conceiving a child with a genetic disor-

der. The embryos are tested, and only those that are

free of genetic flaws are implanted.

Genetic screening is used as a tool to determine whether couples hold the possibility of giving birth

to a genetically impaired infant. Testing for the

most common genetic disorders has become an

expected standard of practice of health-care

providers caring for women who are planning to

become pregnant or who are pregnant. Couples are

encouraged to seek out information regarding their

genetic health history in order to identify the pos-

sibilities of having a child with a genetic disorder.

If a couple has one child with a genetic disorder,

genetic specialists test the parents or the fetus for

the presence of the gene.

Genetic screening leads to issues pertaining to

reproductive rights. It also opens new issues. What is

a disability versus a disorder, and who decides this?

Is a disability a disease, and does it need to be cured

or prevented? The technology is also used to deter-

mine whether individuals are predisposed to certain

diseases, such as breast cancer or Huntington’s

chorea. This has created additional ethical issues

regarding genetic screening. For example:

Bianca, 33 years old, is diagnosed with breast cancer. She has two daughters, ages 6 and 4 years. Bianca’s mother and grandmother had breast cancer. Neither

survived more than 5 years post treatment. Bianca undergoes a lumpectomy followed by radiation and chemotherapy. Her cancer is found to be nonhormon- ally-dependent. Due to her age and family history, Bianca’s oncologist recommends that she see a geneti- cist and have genetic testing for the BRCA-1 and BRCA-2 genes. Bianca makes an appointment to discuss the testing. She meets with the nurse who has additional education in genetics and discusses the following questions: “If I am positive for the genes, what are my options? Should I have a bilat- eral mastectomy with reconstruction?” “Will I be able to get health insurance coverage, or will the companies consider this to be a preexisting condi- tion?” “What are the future implications for my daughters?”

If you were the nurse, how would you address these


Genetic engineering is the ability to change the genetic structure of an organism. Through this

process, researchers have created disease-resistant

fruits and vegetables and certain medications, such

as insulin. This process theoretically allows for the

genetic alteration of embryos, eliminating genetic

flaws and creating healthier babies. This technology

enables researchers to make a brown-haired indi-

vidual blonde, to change brown eyes to blue, and to

make a short person taller. Imagine being able to

“engineer” your child. Imagine, as Aldous Huxley

did in Brave New World (1932), being able to create a society of perfect individuals: “We also predestine

and condition. We decant our babies as socialized

human beings, as Alphas or Epsilons, as future

sewage workers or future . . . he was going to say

future World controllers but correcting himself said

future directors of Hatcheries, instead” (p. 12).

The ethical implications pertaining to genetic

technology are profound. For example, some

questions raised by the Human Genome Project

relate to:

■ Fairness in the use of the genetic information.

■ Privacy and confidentiality of obtained genetic


■ Genetic testing of an individual for a specific

condition due to family history. Should testing

be performed if no treatment is available?

Should parents have the right to have minors

tested for adult-onset diseases? Should parents

have the right to use gene therapy for genetic


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54 unit 1 | Professional Considerations

The Human Genome Project is dedicated to map-

ping and identifying the genetic composition of

humans. Scientists hope to identify and eradicate

many of the genetic disorders affecting individuals.

Initiated in 1990, the Human Genome Project was

projected to be a 13-year effort coordinated by the

U.S. Department of Energy and the National

Institutes of Health. However, because of swift

technological advances, in February 2001 the sci-

entists announced they had cracked the human

genetic code and accomplished the following goals

(Human Genome Project Information, 2002):

■ Identified all of the genes in human DNA.

■ Determined the sequences of the three billion

chemical bases that make up human DNA

■ Stored this information in databases

■ Developed tools for data analysis

■ Addressed the ethical, legal, and social issues

that may arise from the project.

Rapid advances in the science of genetics and its

applications present new and complex ethical and

policy issues for individuals, health-care personnel,

and society. Economics come into play because,

currently, only those who can afford the technology

have access to it. Efforts need to be directed toward

creating standards that identify the uses for genetic

data and the protection of human rights and confi-

dentiality. This is truly the new frontier.

Stem Cell Use and Research

Over the last several years, issues regarding stem

cell research and stem cell transplant technology

have come to the forefront of ethical discussion.

Stem cell research shows promise in possibly curing

neurological disorders such as Parkinson’s disease,

spinal cord injury, and dementia. Questions have

been raised regarding the moral and ethical issues

of using stem cells from fetal tissue for research and

the treatment of disease. Stem cell transplants have

demonstrated success in helping cancer patients

recover and giving them a chance for survival when

traditional treatments have failed.

A new business has emerged from this technol-

ogy as companies now store fetal cord blood for

future use if needed. This blood is collected at the

time of delivery and may be used for the infant and

possibly future siblings if necessary. The cost for

this service is high, which limits its availability to

only those who can afford the process.

When faced with the prospect of a child who is

dying from a terminal illness, some parents have

resorted to conceiving a sibling in order to obtain

the stem cells for the purpose of using them to save

the first child. Nurses who work in pediatrics and

pediatric oncology units may find themselves deal-

ing with this situation. It is important for nurses to

examine their own feelings regarding these issues

and understand that, regardless of their personal

beliefs, the family is in need of sensitivity and the

best nursing care.

A primary responsibility of nursing is to help

patients and families cope with the purposes, ben-

efits, and limitations of the new technologies.

Hospice nurses and critical care nurses help

patients and their families with end-of-life deci-

sions. Nurses will need to have knowledge about

the new genetic technologies because they will fill

the roles of counselors and advisers in these areas.

Many nurses now work in the areas of in vitro fer-

tilization and genetic counseling.

Professional Dilemmas

Most of this chapter has dealt with patient issues,

but ethical problems may involve leadership and

management issues as well. What do you do about

an impaired coworker? Personal loyalties often

cause conflict with professional ethics, creating an

ethical dilemma. For this reason, most nurse prac-

tice acts now address this problem and require the

reporting of impaired professionals and providing

rehabilitation for them.

Other professional dilemmas may involve

working with incompetent personnel. This may be

f rustrating for both staff and management.

Regulations created to protect individuals from

unjustified loss of position and the enormous

amounts of paperwork, remediation, and time that

must be exercised to terminate an incompetent

health-care worker often make management look

the other way.

Employing institutions that provide nursing

services have an obligation to establish a process

for the reporting and handling of practices that

jeopardize patient safety (ANA, 1994). The

behaviors of incompetent staff place patients and

other staff members in jeopardy; eventually, the

incompetency may lead to legal action that may

have been avoidable if a different approach had

been taken.

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chapter 4 | Questions of Values and Ethics 55


Ethical dilemmas are becoming more common in

the changing health-care environment. More ques-

tions are being raised, and fewer answers are avail-

able. New guidelines need to be developed to assist

in finding more answers. Technology has provided

enormous power to alter the human organism and to

keep the human organism alive, but economics may

force answers to the questions of what living is and

when people should be allowed to die. Will society

become the brave new world of Aldous Huxley?

Again and again the question is raised, “Who shall

live, and who shall die?” What is your answer?

Study Questions

1. What is the difference between intrinsic and extrinsic values? Make a list of your intrinsic values.

2. Consider a decision you made recently that was based on your values. How did you make your


3. Describe how you could use the valuing process of choosing, prizing, and acting in making the

decision considered in Question 2.

4. Which of your personal values would be primary if you were assigned to care for a microcephalic

infant whose parents have decided to withhold all food and fluids?

5. The parents of the microcephalic infant in Question 4 confront you and ask, “What would you do

if this were your baby?” What do you think would be most important for you to consider in

responding to them?

6. Your friend is single and feels that her “biological clock is ticking.” She decides to undergo in vitro

fertilization using donor sperm. She tells you that she has researched the donor’s background

extensively and wants to show you the “template” for her child. She asks for your professional

opinion about this situation. How would you respond? Identify the ethical principles involved.

7. Over the past several weeks, you have noticed that your closest friend, Jimmy, has been erratic and

has been making poor patient-care decisions. On two separate occasions, you quietly intervened

and “fixed” his errors. You have also noticed that he volunteers to give pain medications to other

nurses’ patients, and you see him standing very close to other nurses when they remove controlled

substances from the medication distribution center. Today you watched him go to the center

immediately after another colleague and then saw him go into the men’s room. Within about

20 minutes his behavior had changed completely. You suspect that he may be taking controlled

substances. You and Jimmy have been friends for more than 20 years. You grew up together and

went to nursing school together. You realize that if you approach him, you may jeopardize this

close friendship that means a great deal to you. Using the MORAL ethical decision-making

model, devise a plan to resolve this dilemma.

Case Study to Promote Critical Reasoning

Andy is assigned to care for a 14-year-old girl, Amanda, admitted with a large tumor located in the

left groin area. During an assessment, Amanda shares her personal feelings with Andy. She tells

him that she feels “different” from her friends. She is ashamed of her physical development because

all her girlfriends have “breasts” and boyfriends. She is very flat-chested and embarrassed. Andy lis-

tens attentively to Amanda and helps her focus on some of her positive attributes and talents.

A CT scan is ordered and reveals that the tumor extends to what appears to be the ovary. A

gynecological surgeon is called in to evaluate the situation. An ultrasonic-guided biopsy is

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56 unit 1 | Professional Considerations

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heads: Questioning patient autonomy. Retrieved on January 11, 2006, from aacn.org/AACN/aacnnews.nsf/ GetArticle/ArticleThree184?

American Nurses Association (ANA). (2002). Code of Ethics Project. Washington, DC: ANA.

American Nurses Association (ANA). (1994). Guidelines on Reporting Incompetent, Unethical, or Illegal Practices. Washington, DC: ANA.

Benner, P., & Wrubel, J. (1989). The Primacy of Caring: Stress and Coping in Health and Illness. Menlo Park, Calif.: Addison Wesley.

Burkhardt, M.A., & Nathaniel, A.K. (2007). Ethics and Issues in Contemporary Nursing. Albany, N.Y.: Delmar.

Butts, J. B., & Rich, K. L. (2008). Nursing Ethics: Across the Curriculum and Into Practice, 2nd ed. Boston: Jones & Bartlett.

Davis, A.J., Arokar, M.A., Liaschenko, J., & Drought, T.S. (1997). Ethical Dilemmas and Nursing Practice, 4th ed. Stamford, Conn.: Appleton & Lange.

Driver, J. (2001). Uneasy Virtue. New York: Cambridge University Press.

Edge, R.S., & Groves, J.R. (2005). The Ethics of Healthcare: A Guide for Clinical Practice. 3rd ed. Albany, N.Y.: Thomson–Delmar Learning.

Gordon, N. (1963). The Death Committee. New York: Fawcett Crest. Guido, G.W. (2001). Legal and Ethical Issues in Nursing, 3rd ed.

Saddle River, N.J.: Prentice-Hall. Halloran, M.C. (1982). Rational ethical judgments utilizing a

decision-making tool. Heart Lung, 11(6), 566–570. Harned, P. (2005). National business ethics survey, 2005. Ethics

Today Online, 4(2). Retrieved on January 13, 2005, from ethics.org/today/et_current. html pres

Hook, C.C., & Mueller, P.S. (2005). The Terri Schiavo saga: The making of a tragedy and lessons learned. Retrieved on April 20, 2006, from mayoclinicproceedings.com/inside.asp? AID=1054&UID=8934

Hooker, B. (2000). Ideal Code, Real World. Oxford, U.K.: Oxford University Press.

Human Genome Project. Retrieved on July 19, 2002, from ornl.gov/hgmis/about

Hume, D. (1978). A treatise of human nature. In Johnson, O.A. Ethics, 4th ed. New York: Holt, Rinehart, and Winston, p. 212.

Huxley, A. (1932). Brave New World. New York: Harper Row Publishers.

Johnstone, M.J. (1999). Bioethics: A nursing perspective, 3rd ed. Sydney, Australia: Harcourt Saunders.

Kant, I. (1949). Fundamental Principles of the Metaphysics of Morals. New York: Liberal Arts.

Macklin, R. (1987). Mortal Choices: Ethical Dilemmas in Modern Medicine. Boston: Houghton Mifflin.

Mappes, T.A., & DeGrazia, D. (2005). Biomedical Ethics, 6th ed. St. Louis: McGraw-Hill.

Raths, L.E., Harmin, M., & Simon, S.B. (1979). Values and Teaching. New York: Charles E. Merrill.

Shirey, M.R. (2005). Ethical climate in nursing practice: The leader’s role. Journal of Nursing Administration, 7(2), 59–67.

Steele, S.M., & Harmon, V. (1983). Values Clarification in Nursing. New York: Appleton-Century-Crofts.

Thiroux, J. (1977). Ethics: Theory and Practice. Philadelphia: MacMillan.

Thompson, J., & Thompson, H. (1992). Bioethical Decision Making for Nurses. New York: Appleton-Century-Crofts.

Urbano, M.T. (1992). Preschool Children with Special Health-Care Needs. San Diego: Singular Publishing.

Varcoe, C., Doane, G., Pauly, B., Rodney, P., et al. (2007). Journal of Advanced Nursing, 45(3), 316–325.

Wack, J. (1992). Sociology of Religion. Chicago: University of Chicago Press.

Webster’s New World Dictionary. (2000). New York: Simon & Schuster.

Wright, R.A. (1987). Human Values in Health Care. St. Louis: McGraw-Hill.

performed. It is discovered that the tumor is an enlarged lymph node and that the “ovary” is actually

a testis. Amanda has both male and female gonads.

When this information is given to Amanda’s parents, they do not want her to know. They feel that

she was raised as “their daughter.” They ask the surgeon to remove the male gonads and leave only the

female gonads. That way, “Amanda will never need to know.” The surgeon refuses to do this. Andy

believes that the parents should discuss the situation with Amanda as they are denying her choices.

The parents are adamant about Amanda not knowing anything. Andy returns to Amanda’s room, and

Amanda begins asking all types of questions regarding the tests and the treatments. In answering,

Andy hesitates, and Amanda picks up on this, demanding that he tell her the truth.

1. How should Andy respond?

2. What are the ethical principles in conflict?

3. What are the long-term effects of Andy’s decision?

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chapter 5 Organizations, Power,

and Empowerment

OBJECTIVES After reading this chapter, the student should be able to: ■ Recognize the various ways in which health-care

organizations differ.

■ Explain the importance of organizational culture.

■ Define power and empowerment.

■ Identify sources of power in a health-care organization.

■ Describe several ways in which nurses can be empowered.


Understanding Organizations

Types of Health-Care Organizations

Organizational Characteristics

Organizational Culture

Culture of Safety

Care Environments

Identifying an Organization’s Culture

Organizational Goals


The Traditional Approach

More Innovative Structures





Empowering Nurses

Participation in Decision Making

Shared Governance

Professional Organizations

Collective Bargaining

Enhancing Expertise



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58 unit 1 | Professional Considerations

The subjects of this chapter—organizations, power,

and empowerment—are not as remote from a

nurse’s everyday experience as you may first think.

It is difficult to focus on these “big picture” factors

when caught up in the busy day-to-day work of a

staff nurse, but they have an effect on your practice

as you will see in this chapter. Consider two scenar-

ios, which are analyzed later in the chapter.

Were the disappointments experienced by

Hazel Rivera and the critical care department staff

predictable? Could they have been avoided?

Without a basic understanding of organizations

and of the part that power plays in health-care

institutions, people are doomed to be continually

surprised by the responses to their well-intentioned

efforts. As you read this chapter, you will learn why

Hazel Rivera and the critical care department staff

were disappointed.

This chapter begins by looking at some of the

characteristics of the organizations in which nurses

work and how these organizations operate. Then it

focuses on the subject of power within organizations:

what it is, how it is obtained, and how nurses can

become empowered.

Understanding Organizations

One of the attractive features of nursing as a career

is the wide variety of settings in which nurses can

work. From rural migrant health clinics to organ

transplant units, nurses’ skills are needed wherever

there are concerns about people’s health.

Relationships with patients may extend for months

or years, as they do in school health or in nursing

homes, or they may be brief and never repeated, as

often happens in doctors’ offices, operating rooms,

and emergency departments.

Types of Health-Care Organizations

Although some nurses work as independent prac-

titioners, as consultants, or in the corporate

world, most nurses are employed by health-care

In school, Hazel Rivera had always received high praise for the quality

of her nursing care plans. “Thorough, comprehen- sive, systematic, holistic—beautiful!” was the com- ment she received on the last one she wrote before graduation.

Now Hazel is a staff nurse on a busy orthopedic unit. Although her time to write comprehensive care plans during the day is limited, Hazel often

stays after work to complete them. Her friend Carla refuses to stay late with her. “If I can’t com- plete my work during the shift, then they have given me too much to do,” she said.

At the end of their 3-month probationary period, Hazel and Carla received written evaluations of their progress and comments about their value to the organization. To Hazel’s surprise, her friend Carla received a higher rating than she did. Why? ■

Scenario 1

The nursing staff of the critical care department of a large urban hospi-

tal formed an evidence-based practice group about a year ago. They had made many changes in their practice based on reviews of the research on sever- al different procedures, and they were quite pleased with the results.

“Let’s look at the bigger picture next month,” their nurse manager suggested. “We should consider the research on different models of patient care. We might get some good ideas for our unit.” The staff nurses agreed. It would be a nice change to look at the way they organized patient care in their department.

The nurse manager found a wealth of informa- tion on different models for organizing nursing care. One research study about a model for caring

for the chronically critically ill (Rudy, et al., 1995) particularly interested them because they had had many patients in that category.

Several nurses volunteered to form an ad hoc committee to design a similar unit for chronically critically ill patients within their critical care department. When the plan was presented, both the nurse manager and the staff thought it was excellent. The nurse manager offered to present the plan to the vice president for nursing. The staff eagerly awaited the vice president’s response.

The nurse manager returned with discouraging news. The vice president did not support their concept and said that, although they were free to continue developing the idea, they should not assume that it would ever be implemented. What happened? ■

Scenario 2

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chapter 5 | Organizations, Power, and Empowerment 59

organizations. These organizations can be classi-

fied into three types on the basis of their sponsor-

ship and financing:

1. Private not-for-profit. Many health-care organizations were founded by civic, charitable,

or religious groups. Some have been in exis-

tence for generations. Many hospitals, long-

term care facilities, home-care services, and

community agencies began this way. Although

they need money to pay their staff and expenses,

they do not have to generate a profit.

2. Publicly supported. Government-operated service organizations range from county public

health departments to complex medical centers,

such as those operated by the Veterans

Administration, a federal agency.

3. Private for-profit. Increasing numbers of health- care organizations are operated for profit like

any other business. These include large hospital

and nursing home chains, health maintenance

organizations, and many freestanding centers

that provide special services, such as surgical

and diagnostic centers.

The differences between these categories have

become blurred for several reasons:

■ All compete for patients, especially for patients

with health-care insurance or the ability to pay

their own health-care bills.

■ All experience the effects of cost constraints.

■ All may provide services that are eligible for

government reimbursement, particularly

Medicaid and Medicare funding, if they meet

government standards.

Organizational Characteristics

The size and complexity of many health-care organ-

izations make them difficult to understand. One way

to begin is to find a metaphor or image that describes

their characteristics. Morgan (1997) suggested using

animals or other familiar images to describe an organ-

ization. For example, an aggressive organization that

crushes its competitors is like a bull elephant, where-

as a timid organization in danger of being crushed by

that bull elephant is like a mouse. Using images, an

organization adrift without a clear idea of its future in

a time of crisis could be described as a rudderless boat

on a stormy sea, whereas an organization with its

sights set clearly on exterminating its competition

could be described as a guided missile.

Organizational Culture

People seek stability, consistency, and meaning in

their work. To achieve this, some type of culture

will develop within an organization (Schein, 2004).

An organizational culture is an enduring set of

shared values, beliefs, and assumptions (Cameron

& Quinn, 2006). It is taught (often indirectly or

unconsciously) to new employees as the “right way”

or “our way” to assess patient needs, provide care,

and relate to fellow caregivers. As with the cultures

of societies and communities, it is easy to observe

the superficial aspects of an organization’s culture,

but much of it remains hidden from the casual

observer. Edgar Schein, a well-known scholar of

organizational culture, divided the various aspects

of organizational culture into three levels:

1. Artifact level: visible characteristics such as patient room layout, patient record forms, etc.

2. Espoused beliefs: stated, often written, goals; philosophy of the organization

3. Underlying assumptions: unconscious but powerful beliefs and feelings, such as a commit-

ment to cure every patient, no matter the cost

(Schein, 2004)

Organizational cultures differ a great deal. Some are

very traditional, preserving their customary ways of

doing things even when these processes no longer

work well. Others, in an attempt to be progressive,

chase the newest management fad or buy the latest

high-technology equipment. Some are warm, friendly,

and open to new people and new ideas. Others are

cold, defensive, and indifferent or even hostile to the

outside world (Tappen, 2001). These very different

organizational cultures have a powerful effect on the

employees and the people served by the organization.

Organizational culture shapes people’s behavior,

especially their responses to each other, which is a

particularly important factor in health care.

Culture of Safety

The way in which a health-care organization’s oper-

ation affects patient safety has been a subject of much

discussion. The shared values, attitudes, and behav-

iors that are directed to preventing or minimizing

patient harm have been called the culture of safety

(Vogus & Sutcliffe, 2007). The following are impor-

tant aspects of an organization’s culture of safety:

■ Willingness to acknowledge mistakes

■ Vigilance in detecting and eliminating error-

prone situations

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60 unit 1 | Professional Considerations

■ Openness to questioning existing systems and to

changing them to prevent errors (Armstrong &

Laschinger, 2006; Vogus & Sutcliffe, 2007).

It is not easy to change an organization’s culture. In

fact, Hinshaw (2008) points out we are trying to cre-

ate a culture of safety at a particularly difficult time,

given the shortages of nurses and other resources

within the health-care system (Connaughton &

Hassinger, 2007). Nurses who are not well prepared,

not valued by their employer or colleagues, not

involved in decisions about organizing patient care,

and are fatigued due to excessive workloads are cer-

tainly more likely to be error-prone. For example,

increased workload and stress have been found

to increase adverse events by as much as 28%

(Weissman, et al., 2007; Redman, 2008). Clearly,

organizational factors can contribute either to an

increase in errors or to protecting patient safety.

Care Environments

There is also much concern about the environment

in which care is provided, an issue that is closely

related to patient safety. Patients have lower risk of

failure to rescue and death in better care environ-

ments (see Aiken, et al., 2008). What constitutes a

better care environment? Collegial relationships

with physicians, skilled nurse managers with high

levels of leadership ability, emphasis on staff devel-

opment, and quality of care are important factors.

Mackoff and Triolo (2008) offer a similar list of

factors that contribute to excellence and longevity

(low turnover) of nurse managers:

■ Excellence: always striving to be better, refusing to accept mediocrity

■ Meaningfulness: being very clear about the pur- pose of the organization (for example, serving

the poor, healing the environment, protecting

abused women)

■ Regard: understanding the work people do and valuing it

■ Learning and growth: providing mentors, guid- ance, opportunities to grow and develop

Identifying an Organization’s Culture

The culture of an organization is intangible; you

cannot see it or touch it, but you will recognize it

when you bump up against it. To find out what

the culture of an organization is when you are

applying for a new position or trying to familiarize

yourself with your new workplace, you can ask

several people who work there or are familiar with

the organization to describe it in just a few words.

You can also ask about workload and decision mak-

ing, and you can ask for examples of nursing impact

on patient safety.

Does it matter in what type of organization you

work? The answer, emphatically, is yes. For exam-

ple, the extreme value placed on “busyness” in hos-

pitals, i.e., being seen doing something at all times,

leads to manager actions such as floating a staff

member to a “busier” unit if she or he is found read-

ing new research or looking up information on the

Web (Scott-Findley & Golden-Biddle, 2005).

Even more important, a hospital with a positive

work environment is not only a better place for

nurses to work but also safer for patients.

Once you have grasped the totality of an orga-

nization in terms of its overall culture, you are ready

to analyze it in a little more detail, particularly its

goals, structure, and processes.

Organizational Goals

Try answering the following question:

Question: The primary goal of any health-care organization is to keep people healthy, restore them

to health, or assist them in dying as comfortably as

possible. True or false?

Answer: False. The statement is only partially correct. Most health-care organizations have several


What other goals might a health-care organiza-

tion have? Following are some examples:

■ Survival. Organizations have to maintain their own existence. Many health-care organi-

zations are cash-strapped, causing them to

limit hiring, streamline work, and reduce costs,

putting enormous pressure on remaining

staff (Roark, 2005). The survival goal is

threatened when, for example, reimbursements

are reduced, competition increases, the

organization fails to meet standards, or

patients are unable to pay their bills (Trinh

& O’Connor, 2002).

■ Growth. Chief executive officers (CEOs) typically want their organizations to grow by

expanding into new territories, adding new

services, and bringing in new patients.

■ Profit. For-profit organizations are expected to return some profit to their owners. Not-for-profit

organizations have to be able to pay their bills

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chapter 5 | Organizations, Power, and Empowerment 61

and to avoid slipping into too much debt. This

is sometimes difficult to accomplish.

■ Status. The leaders or owners of many health- care organizations also want to be known as the

best in their field; for example, by having the

best open-heart surgeon, providing “the best

nursing care in the world” (Frusti, Niesen, &

Campion, 2003, p. 34), providing gourmet

meals, or having the most attractive birthing

rooms in town.

■ Dominance. Some organizations also want to drive others out of the health-care business or

acquire them, surpassing the goal of survival

and moving toward dominance of a particular

market by driving out the competition.

These additional goals are not discussed in public as often as the f irst, more lofty statement of goals in the true-or-false question. However, they still drive an organization, especially the way an organization handles its f inances and treats its employees.

These goals may have profound effects on every one of the organization’s employees, nurses included. For example, return to the story of Hazel Rivera. Why did she receive a less favorable rating than her friend Carla?

After comparing ratings with those of her friend Carla, Hazel asked for a meeting with her nurse manager to discuss her evaluation. The nurse man- ager explained the rating: Hazel ’s care plans were very well done, and the nurse manager genuinely appreciated Hazel ’s efforts to make them so. The

problem was that Hazel had to be paid overtime for this work according to the union contract, and this reduced the amount of overtime pay the nurse man- ager had available when the patient care load was especially high. “The corporation is very strict about staying within the budget,” she said. “In fact, my rating is higher when I don’t use up all of my budgeted overtime hours.” When Hazel asked what she could do to improve her rating, the nurse man- ager offered to help her streamline the care plans and manage her time better so that the care plans could be done during her shift.


The Traditional Approach

Almost all health-care organizations have a hier-

archical structure of some kind (Box 5-1). In a

traditional hierarchical structure, employees are

ranked from the top to the bottom, as if they were

on the steps of a ladder (Fig. 5.1). The number of

people on the bottom rungs of the ladder is

almost always much greater than the number at

the top. The president or CEO is usually at the

top of this ladder; the housekeeping and mainte-

nance crews are usually at the bottom. Nurses fall

somewhere in the middle of most health-care

organizations, higher than the cleaning people,

aides, and technicians, but lower than physicians

and administrators. The organizational structure

of a small ambulatory care center in a horizontal

form is illustrated in Figure 5.2.

box 5-1

What Is a Bureaucracy? Although it seems as if everyone complains about “the bureaucracy,” not everyone is clear about what a bureaucracy really is.

Max Weber defined a bureaucratic organization as having the following characteristics:

• Division of labor. Specific parts of the job to be done are assigned to different individuals or groups. For example, nurses,

physicians, therapists, dietitians, and social workers all provide portions of the health care needed by an individual.

• Hierarchy. All employees are organized and ranked according to their level of authority within the organization. For

example, administrators and directors are at the top of most hospital hierarchies, whereas aides and maintenance workers

are at the bottom.

• Rules and regulations. Acceptable and unacceptable behavior and the proper way to carry out various tasks are defined,

often in writing. For example, procedure books, policy manuals, bylaws, statements, and memos prescribe many types of

behavior, from acceptable isolation techniques to vacation policies.

• Emphasis on technical competence. People with certain skills and knowledge are hired to carry out specific parts of the

total work of the organization. For example, a community mental health center has psychiatrists, social workers, and nurses

to provide different kinds of therapies and clerical staff to do the typing and filing. Some bureaucracy is characteristic of the

formal operation of every organization, even the most deliberately informal, because it promotes smooth operations within

a large and complex group of people.

Adapted from Weber, M. (1969). Bureaucratic organization. In Etzioni, A. (ed.). Readings on Modern Organizations. Englewood

Cliffs, N.J.: Prentice-Hall.

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62 unit 1 | Professional Considerations

The people at the top of the ladder have authority

to issue orders, spend the organization’s money, and

hire and fire people. Much of this authority is del-

egated to people below them, but they retain the

right to reverse a decision or regain control of these

activities whenever they deem necessary.

The people at the bottom have little authority

but do have other sources of power. They usually

play no part in deciding how money is spent or

who will be hired or fired but are responsible for

carrying out the directions from people above them

on the ladder. If there was no one at the bottom, the

work would not get done.

Some amount of bureaucracy is characteristic of

the formal operation of every organization, even

the most deliberately informal, because it promotes

smooth operations within a large and complex

group of people.

More Innovative Structures

There is much interest in restructuring organiza-

tions, not only to save money but also to make the

best use of a health-care organization’s most valu-

able resource: its people. This begins with hiring

the right people. It also involves providing them

with the resources they need to function and the

kind of leadership that can inspire the staff and

unleash their creativity (Rosen, 1996).

Increasingly, people recognize that organizations

need to be both efficient and adaptable. Orga-

nizations need to be prepared for uncertainty, for rapid

changes in their environment, and for quick, creative

responses to these challenges. In addition, they need

to provide an internal climate that not only allows but

also motivates employees to work to the best of their

ability. They need to stop thinking of the managers

as the brains of the organization and employees as the

muscle (Parker & Gadbois, 2000, p. 428).

Innovative organizations have adapted an increasingly organic structure that is more dynamic, more flexible, and less centralized than the static

traditional hierarchical structure (Yourstone &

Smith, 2002). In these organically structured

organizations, decisions are made by the people

who will implement them, not by their bosses.

The organic network emphasizes increased flex-

ibility of the organizational structure, decentralized

decision making, and autonomy for working groups

or teams. Rigid unit structures are reorganized into

autonomous teams that consist of professionals

from different departments and disciplines. Each

team is given a specific task or function (e.g., intra-

venous team, a hospital infection control team, a

child protection team in a community agency). The

teams are responsible for their own self-correction

and self-control, although they may also have a

designated leader. Together, team members make

decisions about work assignments and how to deal

with problems that arise. In other words, the teams

supervise and manage themselves.

Supervisors, administrators, and support staff

have different functions in an organic network.

Instead of spending their time observing and con-

trolling other people’s work, they become planners

and resource people. They are responsible for pro-

viding the conditions required for the optimal

functioning of the teams, and they are expected to

ensure that the support, information, materials, and

funds needed to do the job well are available to the

teams. They also act as coordinators between the

teams so that the teams are cooperating rather than

blocking each other, working toward the same

goals, and not duplicating effort.

Organic networks have been compared with

spider plants, with a central cluster and offshoots of

smaller clusters (Morgan, 1997). Each cluster rep-

resents a discipline (e.g., nursing, social work, occu-

pational therapy) or a service (e.g., psychiatry,

orthopedics). For example, Figure 5.3 shows an

organic network for a wellness center. Each cluster

represents a separate set of services. A patient

might use just one or all of them to develop a per-

sonal plan for wellness. Staff members may move

from one cluster to another, or the entire configu-

ration of interconnected clusters may be reorga-

nized as the organization shapes and is shaped by

the environment.



Managers (also medical staff)

Staff nurses

Technicians (including LPNs)

Aides; housekeeping; maintenance

Figure 5.1 The organizational ladder.

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chapter 5 | Organizations, Power, and Empowerment 63

Figure 5.2 Table of organization of an ambulatory care center. (Adapted from DelBueno, D.J. [1987]. An organizational checklist. Journal of Nursing Administration, 17[5], 30–33.)

Assistant Administrator for Clinical Services

Director, Environmental Services

Maintenance Supervisor

Maintenance Technician

Payroll Clerk

Payroll Clerk


Maintenance Technician

Maintenance Technician

Maintenance Technician

Director, Personnel

Records Supervisor

Training Supervisor


Payroll Supervisor

Accounting Supervisor

Social Work Supervisor

Social Work Supervisor

Social Worker Community Worker Community Worker



Consultant Dietitian

Nursing Supervisor

Nursing Supervisor

Social Work Supervisor

Nurse Practitioner

Nurse Practitioner

Nurse Practitioner

Medical Director

Director, Accounting and Payroll

Director, Outreach Program

Director, Satellite Clinic

Director, Main Clinic


Physician LPN






Social Worker

Social Worker

Assistant Administrator for Managerial Services

Social Worker Community Worker Community Worker

Social Worker

Social Worker



Records Clerk

Records Clerk






Administrator/ Executive Director

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64 unit 1 | Professional Considerations


Organizations have formal processes for getting

things done and informal ways to get around the

formal processes (Perrow, 1969). The formal processes are the written policies and procedures

that all health-care organizations have. The infor- mal processes are neither written nor discussed most of the time. They exist in organizations as a

kind of “shadow” organization that is harder to see

but equally important to recognize and understand

(Purser & Cabana, 1999).

The informal process is often much simpler and

faster than the formal one. Because the informal

ways of getting things done are seldom discussed

(and certainly not a part of a new employee’s orien-

tation), it may take some time for you to figure out

what they are and how to use them. Once you

know they exist, they may be easier for you to iden-

tify. The following is an example:

Jocylene noticed that Harold seemed to get STAT laboratory results on his patients faster than she did. At lunch one day, Jocylene asked Harold why that happened. “That’s easy,” he said. “The people in our lab feel unappreciated. I always tell them how help- ful they are. Also, if you call and let them know that the specimens are coming, they will get to them faster. They can’t monitor their e-mail constantly.” Harold has just explained an informal process to Jocylene.

Sometimes, people are unwilling to discuss the

informal processes. However, careful observation

of the most experienced “system-wise” individuals

in an organization will eventually reveal these

processes. This will help you do things as efficient-

ly as they do.


There are times when one’s attempts to influence

others are overwhelmed by other forces or individ-

uals. Where does this power come from? Who has

it? Who does not?

In the earlier section on hierarchy, it was noted

that, although people at the top of the hierarchy

have most of the authority in the organization, they do not have all of the power. In fact, the people at the bottom of the hierarchy also have some sources

of power. This section explains how this can be

true. First, power is defined, and then the sources of

power available to people on the lower rungs of the

ladder are considered.


Power is the ability to influence other people despite their resistance. Using power, one person or

group can impose its will on another person or

group (Haslam, 2001). The use of power can be

positive, as when the nurse manager gives a staff

member an extra day off in exchange for working

during the weekend, or negative, as when a nurse

administrator transfers a “bothersome” staff nurse

to another unit after the staff nurse pointed out a

physician error (Talarico, 2004).


There are numerous sources of power. Many of

them are readily available to nurses, but some of

them are not. The following is a list derived primar-

ily from the work of French, Raven, and Etzioni

(Barraclough & Stewart, 1992):

■ Authority. The power granted to an individual or a group by virtue of position (within the

organizational hierarchy, for example)

■ Reward. The promise of money, goods, services, recognition, or other benefits

■ Expertise. The special knowledge an individual is believed to possess; as Sir Francis Bacon said,

“Knowledge is power” (Bacon, 1597, quoted in

Fitton, 1997, p. 150)

Health and Wellness


Exercise and Massage


Relaxation and

Meditation Group

Nutrition Group

Aromatherapy and Imagery


Figure 5.3 An organic organizational structure for a non- traditional wellness center. (Based on Morgan, A. [1993]. Imaginization: The Art of Creative Management. Newbury Park, Calif.: Sage.)

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chapter 5 | Organizations, Power, and Empowerment 65

■ Coercion. The threat of pain or of harm, which may be physical, economic, or psychological

There is power at the bottom of the organizational

ladder as well as at the top. Patients also have

sources of power (Bradbury-Jones, Sambrook, &

Irvine, 2007). Various groups of people in a health-

care organization have different types of power

available to them:

■ Managers are able to reward people with salary increases, promotions, and recognition. They can

also cause economic or psychological pain for the

people who work for them, particularly through

their authority to evaluate and fire people but

also through their responsibility for making

assignments, allowing days off, and so on.

■ Patients at first appear to be relatively powerless within the health-care organization. However, if

patients refused to use the services of a particular

organization, that organization would eventually

cease to exist. Patients can reward health-care

workers by praising them to their supervisors.

They can also cause problems by complaining

about them.

■ Assistants and technicians may also appear to be relatively powerless because of their

low positions in the hierarchy. Imagine, how-

ever, how the work of the organization (e.g.,

hospital, nursing home) would be impeded

if all the nursing aides failed to appear one


■ Nurses have expert power and authority over licensed practical nurses, aides, and other per-

sonnel by virtue of their position in the hierar-

chy. They are critical to the operation of most

health-care organizations and could cause

considerable trouble if they refused to work,

another source of nurse power.

Fralic (2000) offered a good example of the power of

information that nurses have always had: Florence

Nightingale showed very graphically in the 1800s

that wherever her nurses were, far fewer died, and

wherever they were not, many more died. Think

of the power of that information. Immediately,

people were saying, “What would you like, Miss

Nightingale? Would you like more money? Would

you like a school of nursing? What else can we do for

you?” She had solid data, she knew how to collect it,

and she knew how to interpret and distribute it in

terms of things that people valued (p. 340).

Empowering Nurses

This final section looks at several ways in which

nurses, either individually or collectively, can maxi-

mize their power and increase their feelings of


Power is the actual or potential actual ability to “recognize one’s will even against the resistance of

others,” according to Max Weber (quoted in

Mondros & Wilson, 1994, p. 5). Empowerment is a psychological state, a feeling of competence, con-

trol, and entitlement. Given these definitions, it is

possible to be powerful and yet not feel empow-

ered. Power refers to ability, and empowerment refers to feelings. Both are of importance to nurs-

ing leaders and managers.

Feeling empowered includes the following:

■ Self-determination. Feeling free to decide how to do your work

■ Meaning. Caring about your work, enjoying it, and taking it seriously

■ Competence. Confidence in your ability to do your work well

■ Impact. Feeling that people listen to your ideas, that you can make a difference (Spreitzer &

Quinn, 2001)

The following contribute to nurse empowerment:

■ Decision-making. Control of nursing practice within an organization

■ Autonomy. Ability to act on the basis of one’s knowledge and experience (Manojlovich, 2007)

■ Manageable workload. Reasonable work assign- ments

■ Reward and recognition. Appreciation received for a job well done

■ Fairness. Consistent, equitable treatment of all staff (Spence, Laschinger, & Finegan, 2005)

The opposite of empowerment is disempower- ment. Inability to control one’s own practice leads to frustration and sometimes failure. Work over-

load and lack of meaning, recognition, or reward

produce emotional exhaustion and burnout

(Spence, Laschinger, & Finegan, 2005). Nurses,

like most people, want to have some power and to

feel empowered. They want to be heard, to be

recognized, to be valued, and to be respected.

They do not want to feel unimportant or

insignificant to society or to the organization in

which they work.

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66 unit 1 | Professional Considerations

Participation in Decision Making

Actions can be taken by managers and higher-level

administrators to empower nursing staff. The

amount of power available to or exercised by a

given group (e.g., nurses) within an organization can vary considerably from one organization to the

next. Three sources of power are particularly

important in health-care organizations:

■ Resources. The money, materials, and human help needed to accomplish the work

■ Support. Authority to take action without having to obtain permission

■ Information. Patient care expertise and knowl- edge about the organization’s goals and activities

of other departments

In addition, nurses also need access to opportunities: opportunities to be involved in decision making, to

be involved in vital functions of the organization, to

grow professionally, and to move up the organiza-

tional ladder (Sabiston & Laschinger, 1995).

Without these, employees cannot be empowered

(Bradford & Cohen, 1998). Nurses who are part-

time, temporary, or contract employees are less

likely to feel empowered than full-time permanent

employees, who generally feel more secure in their

positions and connected to the organization

(Kuokkanen & Katajisto, 2003).

Shared Governance

In shared governance, staff nurses are included in the

highest levels of decision making within the nursing

department through representation on various coun-

cils that govern practice and management issues.

These councils set the standard for staffing, promo-

tion, and so forth. In many cases, a change in the

organizational culture is necessary before shared

governance can work (Currie & Loftus-Hills, 2002).

Genuine sharing of decision making is difficult

to accomplish, partly because managers are reluc-

tant to relinquish control or to trust their staff

members to make wise decisions. Yet genuine

empowerment of the nursing staff cannot occur

without this sharing. Having some control over

one’s work and the ability to influence decisions are

essential to empowerment (Manojlovich &

Laschinger, 2002). For example, if staff members

do not control the budget for their unit, they can-

not implement a decision to replace aides with reg-

istered nurses without approval from higher-level

management. If they want increased autonomy in

decision making about the care of individual

patients, they cannot do so if opposition by another

group, such as the physicians, is given greater cre-

dence by the organization’s administration.

Return to the example of the staff of the critical

care department (Scenario 2). Why did the vice

president for nursing tell the nurse manager that

the plan would not be implemented?

Actually, the vice president for nursing thought

the plan had some merit. He believed that the pro-

posal to implement a nurse-managed model of

care for the chronically critically ill could save

money, provide a higher quality of patient care, and

result in increased nursing staff satisfaction.

However, the critical care department was the cen-

terpiece of the hospital’s agreement with a nearby

medical school. In this agreement, the medical

school provided the services of highly skilled

intensivists in return for the learning opportunities

afforded their students. In its present form, the

nurses’ plan would not allow sufficient autonomy

for the medical students, a situation that would not

be acceptable to the medical school. The vice pres-

ident knew that the board of trustees of the hospi-

tal believed their affiliation with the medical

school brought a great deal of prestige to the

organization and that they would not allow any-

thing to interfere with this relationship.

“If shared governance were in place here, I think

we could implement this or a similar model of

care,” he told the nurse manager.

“How would that work?” she asked.

“If we had shared governance, the nursing

practice council would review the plan and, if

they approved it, forward it to a similar medical

practice council. Then committees from both

councils would work together to figure out a way

for this to benefit everyone. It wouldn’t necessar-

ily be easy to do, but it could be done if we had

real collegiality between the professions. I have

been working toward this model but haven’t con-

vinced the rest of the administration to put it into

practice yet. Perhaps we could bring this up at the

next nursing executive meeting. I think it is time

I shared my ideas on this subject with the rest of

the nursing staff.”

In this case, the organizational goals and

processes existing at the time the nurses developed

their proposal did not support their idea. However,

the vice president could see a way for it to be

accomplished in the future. Implementation of real

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chapter 5 | Organizations, Power, and Empowerment 67

shared governance would make it possible for the

critical care nurses to accomplish their goal.

Professional Organizations

Although the purposes of the American Nurses

Association and that of other professional organi-

zations are discussed in Chapter 15, these organi-

zations are considered here specifically in terms of

how they can empower nurses.

A collective voice, expressed through these

organizations, can be stronger and more easily

heard than one individual voice. By joining togeth-

er in professional organizations, nurses make their

viewpoint known and their value recognized. The

power base of nursing professional organizations is

derived from the number of members and their

expertise in health matters.

Why there is power in numbers may need some

explanation. Large numbers of active, informed

members of an organization represent large num-

bers of potential voters to state and national legis-

lators, most of whom wish to be remembered

favorably in forthcoming elections. Large groups of

people also have a “louder” voice: they can write

more letters, speak to more friends and family

members, make more telephone calls, and generally

attract more attention than small groups can.

Professional organizations can empower nurses

in a number of ways:

■ Collegiality, the opportunity to work with peers

on issues of importance to the profession

■ Commitment to improving the health and well-

being of the people served by the profession

■ Representation at the state or province and

national level when issues of importance to

nursing arise

■ Enhancement of nurses’ competence through

publications and continuing education

■ Recognition of achievement through certifica-

tion programs, awards, and the media

Collective Bargaining

Like professional organizations, collective bargain-

ing uses the power of numbers, in this case for the

purpose of equalizing the power of employees and

employer to improve working conditions, gain

respect, increase job security, and have greater input

into collective decisions (empowerment) and pay

increases (Tappen, 2001). When people join for a

common cause, they can often exert more power

than when they attempt to bring about change

individually. Large numbers of people have the

potential to cause more psychological or economic

pain than an individual can. For example, the resig-

nation of one nursing assistant or one nurse may

cause a temporary problem, but it is usually resolved

rather quickly by hiring another individual. If 50 or

100 aides or nurses resign, however, the organization

can be paralyzed and will have much more difficulty

replacing these essential workers. Collective bargain-

ing takes advantage of this power in numbers.

An effective collective bargaining contract can

provide considerable protection to employees.

However, the downside of collective bargaining

(as with most uses of coercive power) is that it may

encourage conflict rather than cooperation between

employees and managers, an “us” against “them”

environment (Haslam, 2001). Many nurses are also

concerned about the effect that going out on strike

might have on their patients’ welfare and on their

own economic security. Most administrators and

managers prefer to operate within a union-free

environment (Hannigan, 1998).

Research Example

Can nurse managers empower their staff? The

answer is yes, according to nurse researchers who

surveyed 537 staff nurses in two large hospitals.

Fostering autonomy and showing confidence in the

staff were especially empowering. Empowered staff

worked more effectively and had lower levels of

job-related tension. (Laschinger, H.K.S., Wong, C.,

McMahon, L., & Kaufman, C. (1999). Leader

behavior impact on staff nurse empowerment, job

tension, and work effectiveness. Journal of Nursing Administration, 29[5], 28–39.)

Enhancing Expertise

Most health-care professionals, including nurses, are

empowered to some extent by their own profession-

al knowledge and competence. You can take steps to

enhance your own competence, thereby increasing

your own sense of empowerment (Fig. 5.4)

■ Participate in interdisciplinary team confer-

ences and patient-centered conferences on

your unit.

■ Attend continuing education offerings to

enhance your expertise.

■ Attend local, regional, and national conferences

sponsored by relevant nursing and specialty


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68 unit 1 | Professional Considerations

■ Read journals and books in your specialty area.

■ Participate in nursing research projects related to

your clinical specialty area.

■ Discuss with colleagues in nursing and other dis-

ciplines how to handle a difficult clinical situation.

■ Observe the practice of experienced nurses.

■ Return to school to earn a bachelor’s degree and

higher degrees in nursing.

You can probably think of more, but this list at least

gives you some ideas. You can also share the knowl-

edge and experience you have gained with other

people. This means not only using your knowledge

to improve your own practice but also communi-

cating what you have learned to your colleagues in

nursing and in other health-care professions. It also

means letting your supervisors know that you have

enhanced your professional competence. You can

share your knowledge with your patients, empow-

ering them as well. You may even reach the point at

which you have learned more about a particular

subject than most nurses have and want to write

about it for publication.


Although most nurses are employed by health-care

organizations, too few nurses have taken the time

to analyze the operation of their employing health-

care organizations and the effect it has on their

practice. Understanding organizations and the

power relationships within them will increase the

effectiveness of your leadership.

Study Questions

1. Describe the organizational characteristics of a facility in which you currently have a clinical

assignment. Include the following: the type of organization, the organizational culture, how the

organization is structured, and the formal and informal goals and processes of the organization.

2. Define power, and describe how power affects the relationships between people of different

disciplines (e.g., nursing, medicine, physical therapy, housekeeping, administration, finance, social

work) in a health-care organization.

3. Discuss ways in which nurses can become more empowered. How can you use your leadership

skills to do this?

Case Study to Promote Critical Reasoning

Tanya Washington will finish her associate’s degree nursing program in 6 weeks. Her preferred

clinical area is pediatric oncology, and she hopes to become a pediatric nurse practitioner one day.

Tanya has received two job offers, both from urban hospitals with large pediatric populations.

Because several of her friends are already employed by these facilities, she asked them for their


“Central Hospital is a good place to work,” said one friend. “It is a dynamic, growing institution,

always on the cutting edge of change. Any new idea that seems promising, Central is the first to try

it. It’s an exciting place to work.”

“City Hospital is also a good place to work,” said her other friend. “It is a strong, stable institution

where traditions are valued. Any new idea must be carefully evaluated before it is adapted. It’s been a

pleasure to work there.”

Participate in interdisciplinary conferences

Attend continuing education offerings

Attend professional organization meetings

Read books and journals related to your nursing practice

Problem-solve and brainstorm with colleagues

Return to school to earn a higher degree

Figure 5.4 How to increase your expert power.

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chapter 5 | Organizations, Power, and Empowerment 69

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Hannigan, T.A. (1998). Managing tomorrow’s high-performance unions. Westport, Conn.: Greenwood Publishing.

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Kuokkanen, L., & Katajisto, J. (2003). Promoting or impeding empowerment? Journal of Nursing Administration, 33(4), 209–215.

Laschinger, H.K., & Finegan, J. (2005). Empowering nurses for work engagement and health in hospital settings. Journal of Nursing Administration, 35(10), 439–441.

Laschinger, H.K.S., Wong, C., McMahon, L., & Kaufman, C. (1999). Leader behavior impact on staff nurse empowerment, job tension, and work effectiveness. Journal of Nursing Administration, 29(5), 28–39.

Mackoff, B.L., & Triolo, P.K. (2008). Why do nurses, managers stay? Building a model of engagement: Part 2: Cultures of

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Manojlovich, M., & Laschinger, H.K. (2002). The relationship of empowerment and selected personality characteristics to nursing job satisfaction. Journal of Nursing Administration, 32(11), 586–595.

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1. How would the organizational culture of each hospital affect a new graduate?

2. Which organizational culture do you think would be best for a new graduate, Central’s or City’s?

3. Would your answer differ if Tanya were an experienced nurse?

4. What do you need to know about Tanya before deciding which hospital would be best for her?

5. What else would you like to know about the two hospitals?

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2 unit

Working Within the Organization

chapter 6 Getting People to Work Together

chapter 7 Dealing With Problems and Conflicts

chapter 8 People and the Process of Change

chapter 9 Delegation of Client Care

chapter 10 Quality and Safety

chapter 11 Time Management

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chapter 6 Getting People

to Work Together

OBJECTIVES After reading this chapter, the student should be able to: ■ Describe the basic listening sequence and principles for

effective communication.

■ Identify barriers to effective communication.

■ Discuss strategies for communication with colleagues and patients in health-care settings.

■ Provide positive and negative feedback in a constructive manner.

■ Respond to feedback in a constructive manner.

■ Evaluate the conduct of performance appraisals.

■ Participate in formal peer review.



The Basic Listening Sequence

Principles for Effective Communication

Assertiveness in Communication

Barriers to Effective Communication in the Workplace

Physical Barriers

Psychological Barriers

Semantic Barriers

Gender Barriers

Communication With Colleagues

Information Systems and E-Mail

Computerized Systems


Reporting Patient Information

Change-of-Shift Report

Team Conferences

Communicating With Other Disciplines

Communicating with the Health-Care Provider


Health-Care Provider Orders

Communicating With Patients and Their Families


Why Do People Need Feedback?

Guidelines for Providing Feedback

Provide Both Positive and Negative Feedback

Give Immediate Feedback

Provide Frequent Feedback

Give Negative Feedback Privately

Be Objective

Base Feedback on Observable Behavior

Include Suggestions for Change

Accept Feedback in Return

Seeking Evaluative Feedback

When Is Evaluative Feedback Needed?

Responding to Evaluative Feedback

Performance Appraisal


Standards for Evaluation

Peer Review

Fundamentals of Peer Review

A Comprehensive Peer Review System



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74 unit 2 | Working Within the Organization

Claude has been working on a busy oncology floor for several years. He usually has a caseload of six to eight patients on his shift, and he believes that he provides safe, competent care. While Claude was on his way to medicate a patient suffering from osteosarcoma, a colleague called to him, “Claude, come with me, please.” Claude responded, “I need to medicate Mr. J. in Room 203. I will come right after that. Where will you be?” “Never mind!” his colleague answered. “I’ll f ind someone who’s more helpful. Don’t ask me for help in the future.” This was not the response Claude had expected. He thought he had expressed both an interest in his patient and a willingness to help his colleague. What was the problem?

After Claude gave Mr. Juniper his pain medica- tion, he went back to his colleague. “Sonja, what’s the matter?” he asked. Sonja replied, “Mrs. Vero fell in the bathroom. I needed someone to stay with her while I got her walker.” “Why didn’t you tell me it was urgent?” asked Claude. “I was so upset that I wasn’t thinking about what else you were doing,” answered Sonja. Claude added, “And I didn’t ask you why you needed me. I guess we need to work on our communication, don’t we?”

In the busy and sometimes chaotic world of nursing

practice, nurses work continuously with all sorts of

people. This variety makes the job dynamic and

challenging. Just when things appear to have settled

down, something happens that requires immediate

attention. Busy people need to communicate effec-

tively with each other. This chapter helps new nurses

communicate effectively with their colleagues and

work with people in all kinds of activities, even

those that are filled with multiple demands and

constant change.


People often assume that communication is

simply giving information to another person.

Communication involves the spoken word as well

as the nonverbal message, the emotional state of

people involved, and the cultural background that

affects their interpretation of the message

(Fontaine & Fletcher, 2002). Superficial listening

often results in misinterpretation of the message.

An individual’s attitude also influences what is

heard and how the message is interpreted. Active

listening is necessary to pick up all these levels of

meaning in a communication.

It is important for nurses to observe nonverbal

behavior when communicating with colleagues and

patients and to try to make their own nonverbal

behavior congruent with their verbal communica-

tions. Telling people you understand their problem

when you appear thoroughly confused or inatten-

tive is an example of incongruence between verbal

and nonverbal communication.

The Basic Listening Sequence

Listening is the most critical of all communication skills. To be a good listener, one needs to listen

for both the information (content) and emotion

(feelings) conveyed. A good listener also shows

attentiveness through eye contact and body language

and gives the speaker some feedback to indicate that

what is being said is understood (Rees, 2005)

(Box 6-1). Contrast this to the poor listener who

interrupts, misinterprets what is said, or misses it

entirely due to inattention (Rees, 2005).

Principles for Effective Communication

To communicate effectively with others, consider

the following principles (Table 6-1).

1. Be sure that the message is understood. Ask for

feedback from the receiver to clarify any confu-

sion. Bring focus to the interaction. Repeating key

words or phrases as questions or using open-ended

questions can accomplish this. For example: “You

have been telling me that Susan is not providing

safe care to her patients. Can you tell me specifi-

cally what you have identified as unsafe care?”

box 6-1

Basic Listening Sequence Listen to the:

• Information

• Emotion

Demonstrate attentiveness through:

• Eye contact

• Body language

Verify understanding by:

• Asking occasional questions

• Repeating important points

• Summarizing

Adapted from Rees, F. (2005). 25 Activities for Developing Team Leaders.

San Francisco: Pfeiffer.

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chapter 6 | Getting People to Work Together 75

2. Use direct and exact language. In both written

and spoken messages, use language that is easily

understood by all involved.

3. Encourage feedback. This is the best way to

help people understand each other and work

together better. Remember, though, that feed-

back may not be complimentary. This is dis-

cussed later in the chapter.

4. Acknowledge the contributions of others.

Everyone wants to feel that he or she has worth.

5. Use the most direct channel of communica-

tion available. The greater the number of indi-

viduals involved in filtering a message, the less

likely the message will be received correctly.

Just as in an old children’s game, messages

sent through a number of senders become

more and more distorted. Information that is

controversial or distressing should definitely

be delivered in person so that the receiver can

ask questions or receive further clarification. A

memo delivered “To all nursing staff ” in

which cutbacks in staffing are announced

would deliver a message very different from

that in a meeting in which staff are allowed to

talk and ask questions.

Assertiveness in Communication

Assertive behaviors allow people to stand up for

themselves and their rights without violating the

rights of others. Several authors have stated that

nurses lack assertiveness, claiming that nurses would

rather be silent than voice opinions that may result

in confrontation (Tappen, 2001). Assertiveness is

different from aggressiveness. People use aggressive

behaviors to force their wishes or ideas on others. In

assertive communication, an individual’s position

is stated clearly and firmly, using “I” statements.

For example:

The nurse manager noticed that Steve’s charting has been of lower quality than expected during the past few weeks. She approached Steve and said, “JCAHO surveyors are coming in several months. I have been reviewing records and noticed that on several of your charts some pertinent information is missing. I have scheduled time today and tomorrow from 1:00 to 2:00 in the afternoon for us to review the charts. This allows you time to make the neces- sary corrections and return the charts to me.”

By using “I” statements, the nurse manager is con-

fronting the issue without being accusatory. Assertive

communication always requires congruence between

verbal and nonverbal messages. Had she shaken her

finger close to Steve’s face or used a loud voice, the

nurse manager might think she was being assertive

when in fact her manner would have been aggressive.

There is a misconception that people who com-

municate assertively always get what they want.

Being assertive involves both rights and responsi-

bilities. Assertive communicators have the right to

speak up, but they must also be prepared to listen to

the response.

Barriers to Effective Communication in the Workplace

People are often unwilling or unable to accept

responsibility or to perform a specific task because

they do not fully understand what is expected of

them. Professional nurses are required to commu-

nicate patient information to other members of the

nursing team. Although this may sound easy, there

are many potential barriers to communication.

These barriers may be physical, psychological,

semantic, or even gender-related.

Physical Barriers

Physical barriers to communication include extra-

neous noise, too much activity in the area where the

communication is taking place, and physical sepa-

ration of the people trying to engage in verbal


Psychological Barriers

Psychological “noise,” such as increased anxiety, may

interfere with the ability to pay attention to the

other speaker. Social values, emotions, judgments,

table 6-1

Principles for Effective Communication Principle One Aim for clarity and focus.

Principle Two Use direct and exact language.

Principle Three Encourage feedback.

Principle Four Acknowledge the contributions of


Principle Five Use the most direct channels of

communication available.

Tappen, R.M. (2001). Nursing Leadership and Management: Concepts

and Practice (4th ed.). Philadelphia: FA Davis, with permission.

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76 unit 2 | Working Within the Organization

and cultural influences also impede communication.

Previous life experiences and preconceived ideas

about other cultures also influence how people


Semantic Barriers

Semantic refers to the meaning of words. Sometimes, no matter how great the effort, the

message just does not get across. For example, words

such as neat, cool, and bad, may convey meanings other than those intended. Many individuals have

learned English as a second language and therefore

understand only the literal meaning of certain

words. For example, to many people, cool means interesting, unique, or clever (e.g., “This is a cool

way to find the vein.”). To someone for whom the

word cool refers only to temperature (e.g., “It is cool outside.”), the preceding statement would make

very little sense.

Gender Barriers

Men and women develop dissimilar communication

skills and are inclined to communicate differently.

Often, they give different meanings to conveyed

information or feelings. This may be related to

psychosocial development. Boys learn to use commu-

nication as a way to negotiate and to develop inde-

pendence, whereas girls use communication to con-

firm, minimize disparities, and create or strengthen

closeness (Blais, Hayes, Kozier, & Erb, 2002).

Communication With Colleagues

Information Systems and E-Mail

Computerized Systems

Communication through the use of computer tech-

nology is rapidly growing in nursing practice. A

study conducted by KPMG–Peat Marwick of

health-care systems that used bedside terminals

found that medication errors and use of patient call

bells decreased and nurse productivity increased.

The use of electronic patient records allows health-

care providers to retrieve and distribute patient

information precisely and quickly. Decisions regard-

ing patient care can be made more efficiently with

less waiting time. Information systems in many

organizations also provide opportunities to access

current, high-quality clinical and research data to

support evidence-based practice. Unfortunately,

these rich resources are still underutilized by

most nurses (Dee, 2005). Additional benefits of

computerized systems for health-care applications

are listed in Box 6-2 (Arnold & Pearson, 1992;

Hebda, Czar, & Mascara, 1998).


Today, most institutions use e-mail. Using e-mail

competently and effectively requires writing skills;

the same communication principles apply to both

e-mail and letter writing. Remember, when com-

municating by e-mail, you are not only making an

impression but also leaving a written record

(Shea, 2000).

The rules for using e-mail in the workplace are

somewhat different than for using e-mail among

friends. Much of the humor and wit found in per-

sonal e-mail is not appropriate for the work setting.

Professional e-mail may remain informal.

However, the message must be clear, concise, and

courteous. Think about what you need to say before

you write it. Then write it, read it, and reread it.

Once you are satisfied that the message is clear and

concise, send it.

Many executives read personal e-mail sent to

them, which means that it is often possible to

contact them directly. Many systems make it easy

to send e-mail to everyone at the health-care

institution. For this reason, it is important to

keep e-mail professional. Remember the “chain

of command”: always go through the proper


The fact that you have the capability to send

e-mail instantly to large groups of people does not

necessarily make sending it a good idea. Be careful

if you have access to an all-company mailing list. It

is easy to send an e-mail throughout the system

box 6-2

Potential Benefits of Computer-Based Patient Information Systems

• Increased hours for direct patient care

• Patient data accessible at bedside

• Improved accuracy and legibility of data

• Immediate availability of all data to all members of the


• Increased safety related to positive patient identification,

improved standardization, and improved quality

• Decreased medication errors

• Increased staff satisfaction

Adapted from Arnold, J., & Pearson, G. (eds.). (1992). Computer Applications

in Nursing Education and Practice. N.Y.: National League for Nursing.

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chapter 6 | Getting People to Work Together 77

without intending this to happen. Consider the fol-

lowing example:

A respiratory therapist and a department adminis- trator at a large health-care institution were engaged in a relationship. They started sending each other personal notes over the company e-mail sys- tem. One day, one of them accidentally sent one of these notes to all the employees at the health-care institution. Both were f ired. The moral of this story is simple: Do not send anything by e-mail that you would not want published on the front page of a national newspaper or hear on your favorite radio station tomorrow morning.

Although voice tone cannot be “heard” in e-mail,

the use of certain words and writing styles indicates

emotion. A rude tone in an e-mail message may

provoke extreme reactions. Follow the “rules of neti-

quette” (Shea, 2000) when communicating through

e-mail. Some of these rules are listed in Box 6-3.

Reporting Patient Information

Change-of-Shift Report

It is important to understand exactly how your day

at work will begin. Regardless of which shift an indi-

vidual works, some things never change. Nurses

traditionally give one another a “report.” The

change-of-shift report has become the accepted

method of communicating patient care needs from

one nurse to another. In the report, pertinent infor-

mation related to events that occurred is given to the

individuals responsible for providing continuity of

care (Box 6-4). Although historically the report has

been given face to face, there are newer ways to share

information. Many health-care institutions use

audiotape and computer printouts as mechanisms

for sharing information. These mechanisms allow

the nurses from the previous shift to complete their

tasks and those coming on duty to make inquiries

for clarification as necessary.

The report should be organized, concise, and

complete, with relevant details. Not every unit uses

the same system for giving a change-of-shift

report. The system is easily modified according to

the pattern of nursing care delivery and the types of

patients serviced. For example, many intensive care

units, because of their small size and the more acute

needs of their patients, use walking rounds as a

means for giving the report. This system allows

nurses to discuss the current patient status and to

set goals for care for the next several hours.

Together, the nurses gather objective data as one

nurse ends a shift and another begins. This way,

there is no confusion as to the patient’s status at

shift change. This same system is often used in

emergency departments and labor and delivery

units. Larger patient care units may find the “walk-

ing report” time-consuming and an inefficient use

of resources.

It is helpful to take notes or create a worksheet

while listening to the report. A worksheet helps

box 6-3

Rules of Netiquette 1. If you were face-to-face, would you say this?

2. Follow the same rules of behavior online that you follow

when dealing with individuals personally.

3. Send information only to those individuals who need it.

4. Avoid flaming; that is, sending remarks intended to

cause a negative reaction.

5. Do not write in all capital letters; this suggests anger.

6. Respect other people’s privacy.

7. Do not abuse the power of your position.

8. Proofread your e-mail before sending it.

Adapted from Shea, V. (2000). Netiquette. San Rafael, Calif.: Albion.

box 6-4

Information for Change-of-Shift Report • Identify the patient, including the room and bed numbers.

• Include the patient diagnosis.

• Account for the presence of the patient on the unit. If the

patient has left the unit for a diagnostic test, surgery, or

just to wander, it is important for the oncoming staff

members to know the patient is off the unit.

• Provide the treatment plan that specifies the goals of

treatment. Note the goals and the critical pathway steps

either achieved or in progress. Personalized approaches

can be developed during this time and patient readiness

for those approaches evaluated. It is helpful to mention

the patient’s primary care physician. Include new orders

and medications and treatments currently prescribed.

• Document patient responses to current treatments. Is the

treatment plan working? Present evidence for or against

this. Include pertinent laboratory values as well as any

negative reactions to medications or treatments. Note

any comments the patient has made regarding the

hospitalization or treatment plan that the oncoming staff

members need to address.

• Omit personal opinions and value judgments about

patients as well as personal/confidential information not

pertinent to providing patient care. If you are using

computerized information systems, make sure you know

how to present the material accurately and concisely.

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78 unit 2 | Working Within the Organization

organize the work for the day (Fig. 6.1). As specific

tasks are mentioned, the nurse coming on duty

makes a note of the activity in the appropriate time

slot. Medications and treatments can also be added.

Any changes from the previous day are noted,

particularly when the nurse is familiar with the

patient. Recording changes counteracts the tendency

to remember what was done the day before and

Name_________________________ Room # __________ Allergies ________________________

0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800

Name_________________________ Room # __________ Allergies ________________________

0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800

Name_________________________ Room # __________ Allergies ________________________

0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800

Figure 6.1 Organization and time management schedule for patient care.

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chapter 6 | Getting People to Work Together 79

repeat it, often without checking for new orders.

During the day, the worksheet acts as a reminder of

the tasks that have been completed and of those

that still need to be done.

Reporting skills improve with practice. When

presenting information in a report, certain details

must be included. Begin the report by identifying

the patient and the admitting as well as current

diagnoses. Include the expected treatment plan and

the patient’s responses to the treatment. For exam-

ple, if the patient has had multiple antibiotics and a

reaction occurred, this information is important to

relay to the next nurse. Value judgments and per-

sonal opinions about the patient are inappropriate

(Fig. 6.2).

Team Conferences

Members of a team share information through

verbal and written communication in an interdisci-

plinary team conference. The team conference

begins by stating the patient’s name, age, and diag-

noses. Each member of an interdisciplinary team

Figure 6.2 Patient information report.

Room # __________ Patient Name __________________ Diagnoses ______________________

Diet _____________ Activity_______________________________________________________

1900 0100

2000 0200

2100 0300

2200 0400

2300 0500

2400 0600

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80 unit 2 | Working Within the Organization

then explains the goal of his or her discipline, the

interventions, and the outcome. Effectiveness of

treatment, development of new interventions, and

setting new goals are discussed. The key to a suc-

cessful interdisciplinary conference is presenting

information in a clear, concise manner and ensur-

ing input from all disciplines and levels of care

providers, from unlicensed assistive personnel to


Communicating With Other Disciplines

Breakdowns in verbal and written communication

among health-care providers present a major concern

in the health-care delivery system. The Joint

Commission (www.jcaho.org) attributes a high per-

centage of sentinel events to be related to poor com-

munication among health-care providers. In many

settings, nurses act as patient care managers.

Integration, coordination, and communication

among all disciplines that are delivering care to a spe-

cific patient ultimately are the responsibility of the

nurse care manager. Nurses often find themselves in

the particularly advantageous position to observe the

patient’s responses to treatments. For example:

Mr. Richards is a 75-year-old man who was in a motor vehicle accident with closed head trauma. He had right-sided weakness and dysphagia. The speech therapy, physical therapy, and social services departments were called in to see Mr. Richards. A speech therapist was working with Mr. Richards to assist him with swallowing. He was to receive pureed foods for the second day. The RN assigned an LPN to feed Mr. Richards. The LPN reported that although Mr. Richards had done well the previous day, he had diff iculty swallowing today. The RN immediately notif ied the speech therapist, and a new treatment plan was developed.

Communicating With the Health-Care Provider

The function of professional nurses in relation to

their patients’ health-care providers is to communi-

cate changes in the patient’s condition, share other

pertinent information, discuss modifications of the

treatment plan, and clarify orders. This can be

stressful for a new graduate who still has some role

insecurity. Using good communication skills and

having the necessary information at hand are help-

ful when discussing patient needs.

Before calling a health-care provider, make sure

that all the information you need is available. The

provider may want more clarification. If you are

calling to report a drop in a patient’s blood pres-

sure, be sure to have the list of the patient’s medica-

tions, laboratory results, vital signs, and blood pres-

sure trends, together with a general assessment of

the patient’s present status.

Sometimes when a nurse calls a physician or

health-care provider, the physician does not return

the call. It is important to document all health-care

provider contacts in the patient’s record. Many

units keep calling logs. In the log, enter the health-

care provider’s name, the date, the time, the reason

for the call, and the time the health-care provider

returns the call.


In response to the number of patients who die from

or confront a preventable adverse event during

hospitalization, health-care institutions have been

challenged to improve patient safety standards. This

challenge forced health-care institutions to look at

the causes of most sentinel events within their envi-

ronments. SBAR, developed by experts at Kaiser

Permanente, one of the largest health-care systems,

is an abbreviation for Situation, Background, Assessment, and Recommendation (Haig, Sutton, & Whittingdon, 2006). It provides a framework for

communicating critical patient information in a

systemized and organized fashion. The SBAR

method focuses on the immediate situation so that

decisions regarding patient care may be made

quickly and safely.

Although originally established to be used as an

“escalation tool,” to be implemented when a rapid

change in patient status occurs or is imminent, many

institutions have decided to implement the method

as a standard for shift report and other coordinating

communications (Haig, Sutton, & Whittingdon;

www.rwjf.org, 2008). The use of the SBAR format

helps to standardize a communication system to

effectively transmit needed information to provide

safe and effective patient care. Table 6-2 defines the

steps of the SBAR communication model.

The implementation of SBAR as a communica-

tion technique has demonstrated such success that

the Institute for Healthcare Improvement recom-

mends its use as a standard for communicating

between and among health-care providers. The Joint

Commission is now requiring it as a standard for

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chapter 6 | Getting People to Work Together 81

communicating patient information for hand-off

reporting (Haig, Sutton & Whittingdon, 2006;

IHI, 2006).

Health-Care Provider Orders

Professional nurses are responsible for accepting,

transcribing, and implementing health-care

provider orders. The two main types of orders are

written and telephone. Written orders are dated and placed on the appropriate institutional form.

Telephone orders are given from the health-care provider directly to the nurse by telephone. Many

health-care institutions are moving to maintaining

the electronic medical record (EMR) and away

from verbal orders as the health-care provider is

present and can enter the order on the appropriate

form in the patient’s record. A telephone order

needs to be written on the appropriate institution-

al form, the time and date noted, and the form

signed as a telephone order by the nurse.

Most institutions require the physician to cosign

the order within 24 hours. When receiving a tele-

phone order, repeat it back to the physician for con-

firmation. If the health-care provider is speaking

too rapidly, ask him or her to speak more slowly.

Then repeat the information for confirmation.

Professionalism and a courteous attitude by all par-

ties are necessary to maintain collegial relationships

with physicians and other health-care professionals.

One nurse explained their importance as follows:

RN satisfaction simply is not about money. A major factor is how well nurses feel supported in their

work. Do people listen to us—our managers, upper management, human resources? Being able to com- municate with each other—to be able to speak directly with your peers, physicians, or managers in a way that is nonconfrontational—is really impor- tant to having good working relationships and to providing good care. You need to have mutual respect. (Quoted by Trossman, 2005, p. 1.)

Communicating With Patients and Their Families

Communicating with patients and their families

occupies a major portion of the nurse’s day. Nurses

teach patients and their families about medications

and the patient’s condition, clarify the treatment

plan, and explain procedures. To do this effectively,

nurses need to use communication skills and recog-

nize the barriers to communication.

The health-care consumer may enter the setting

in a highly emotional state. Nurses need to recog-

nize the signs of an anxious or angry patient and

promptly intervene to defuse the situation before it

escalates. Practicing good listening skills and show-

ing interest in the patient often helps.

Short-term stays and early-morning admissions

on the day of surgery make patient teaching a chal-

lenge. The nurse must complete the admission

requirements, surgical checklists, and preoperative

teaching within a short time. Time for postopera-

tive teaching is also shortened. It is important for

the nurse to communicate clearly and concisely

what will be done and what is expected of the

patient. Allow time for questions and clarifications.

table 6-2

SBAR (Situation, Background, Assessment, Recommendation) Elements Description Example

Situation Brief description of the existing situation Critical laboratory value that needs to be

addressed (critical blood gas value, International

Normalized ratio [INR], etc.)

Background Medical, nursing, or family information Patient admitted with a pulmonary embolus and on

that is significant to the care and/or heparin therapy, receiving oxygen at 4 L via nasal

patient condition cannula; what steps have been taken

Assessment Recent assessment data that indicate Vital signs, results of laboratory values, lung sounds,

the most current clinical state of mental status, pulse oximetry results,

the patient electrocardiogram results

Recommendation Information for future interventions Monitor patient

and/or activities Change heparin dose

Repeat INR

Repeat computed tomography or ventilation-

perfusion scan

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82 unit 2 | Working Within the Organization

For many patients, a written preoperative and/or

postoperative teaching guide helps to clarify the



Why Do People Need Feedback?

In good weather, Herbert usually played basketball with his kids after dinner. Yesterday, however, he told them he was too tired. This evening, he said the same thing. When they urged him to play anyway, he snapped at them and told them to leave him alone.

“Herbert!” his wife exclaimed, “Why did you do that?”

“I don’t know,” he responded. “I’m just so tense these days. My annual review was supposed to be today, but my nurse manager was out sick. I have no idea what she is going to say. I can’t think about anything else.”

Had Herbert’s nurse manager been providing infor-

mal feedback to staff on a regular basis, Herbert

would have known his rating. He would have had a

good idea about what his strengths and weaknesses

were and would not be afraid of an unpleasant sur-

prise during the review. He would also be looking

forward to the opportunity to review his accom-

plishments and make plans with his manager for

further developing his skills. He still would have

been disappointed that she was unavailable, but he

would not have been as distressed by it.

The process of giving and receiving evaluative

feedback is an essential leadership responsibility.

Done well, it is very helpful, promoting growth and

increasing employee satisfaction. Done poorly, as in

Herbert’s case, it can be stressful, even injurious.

This section considers the do’s and don’t’s of giving

and receiving feedback, how to share positive and

negative evaluative comments with coworkers, and

how people can respond constructively when they

receive negative comments.

We all need feedback because it is difficult for us

to see ourselves as others see us. Curiously, compe-

tent people generally underestimate their ability

and focus on their shortcomings, and incompetent

people generally fail to recognize their incompe-

tence (Channer & Hope, 2001). The following are

just a few of the reasons that evaluative feedback is

so important:

■ Reinforces constructive behavior. Positive feedback lets people know which behaviors are

the most productive and encourages continua-

tion of those behaviors.

■ Discourages unproductive behavior. Correction of inappropriate behavior begins

with provision of negative feedback.

■ Provides recognition. The power of praise (positive feedback) to motivate people is under-


■ Develops employee skills. Feedback helps peo- ple identify their strengths and weaknesses and

guides them in seeking opportunities to further

develop their strengths and manage their weak-

nesses (Rosen, 1996).

Guidelines for Providing Feedback

Done well, evaluative feedback can reinforce moti-

vation, strengthen teamwork, and improve the

quality of care given. When done poorly, evaluation

can reinforce poor work habits, increase insecurity,

and destroy motivation and morale (Table 6-3).

Evaluation involves making judgments and

communicating these judgments to others. People

make judgments all the time about all types of

things. Unfortunately, these judgments are often

based on opinions, preferences, and inaccurate or

partial information.

Subjective, biased judgment offered as objective

feedback has given evaluation a bad name. Poorly

communicated feedback has an equally negative

effect. Many people who are uncomfortable with

evaluation have been recipients of subjective,

biased, or poorly communicated evaluations.

Evaluative feedback is most effective when

given immediately, frequently, and privately. To be

constructive, it must be objective, based on

observed behavior, and skillfully communicated.

The feedback message should include the reasons

table 6-3

Do’s and Don’t’s of Providing Feedback Do Don’t

Include positive comments Focus only on the negative

Be objective Let personalities intrude

Be specific when correcting Be vague


Treat everyone the same Play favorites

Correct people in private Correct people in front of


Adapted from Gabor, D. (1994). Speaking Your Mind in 101 Difficult

Situations. N.Y.: Stonesong Press (Simon & Schuster).

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chapter 6 | Getting People to Work Together 83

that a behavior has been judged satisfactory or

unsatisfactory. If the message is negative, it should

include both suggestions and support for change

and improvement (Box 6-5).

Provide Both Positive and Negative Feedback

Leaders and managers often neglect to provide

positive feedback. If questioned about this, they

often say, “If I don’t say anything, that means every-

thing is okay.” They do not realize that some peo-

ple assume that everything is not okay when they

receive no feedback. Others assume that no one is

aware of how much effort they have made unless it

is acknowledged with positive feedback.

Most people want to do their work well. They

also want to know that their efforts are recognized

and appreciated. Kron (1981) called positive feed-

back a “psychological paycheck.” She pointed out that

it is almost as important to people as their actual

paychecks. It is a real pleasure, not only for staff

members but also for their leaders and managers, to

be able to share the satisfaction of a job well done

with someone else. Leaders and managers should do

everything they can to reward and retain their best

staff members (Bowers & Lapziger, 2001). In fact,

some claim that the very best managers focus on

people’s strengths and work around their weaknesses

(DiMichele & Gaffney, 2005).

Providing negative feedback is just as necessary

but probably more difficult to do well. Too often,

negative feedback is critical rather than helpful.

Simply telling someone that something has gone

wrong or could have been done better is inade-

quate. Instead, make feedback a learning experience

by suggesting ways to make changes or by working

together to develop a strategy for improvement. It

is easier to make broad, critical comments (e.g.,

“You’re too slow.”) than to describe the specific

behavior that needs improvement (e.g., “Waiting in

Mr. D.’s room while he cleans his dentures takes up

too much of your time.”) and to add a suggestion

for change (e.g., “You could get your bath supplies

together while he finishes.”).

Unsatisfactory work must be acknowledged and

discussed with the people involved. Too many

managers avoid it, not wanting to hurt people’s

feelings (Watson & Harris, 1999). Tolerating poor

work encourages its continuation.

Give Immediate Feedback

The most helpful feedback is given as soon as pos-

sible after the behavior has occurred. There are sev-

eral reasons for this. Immediate feedback is more

meaningful to the person receiving it. Address

inappropriate behavior when it occurs, whether it is

low productivity, tardiness, or other problems.

Problems that are ignored often get worse.

Ignoring them puts stress on others and reduces

morale. Resolving them boosts productivity, lowers

stress, increases retention of good staff, and ulti-

mately results in higher-quality care (Briles, 2005).

Provide Frequent Feedback

Frequent feedback keeps motivation high. It also

becomes easier with practice. If giving and receiv-

ing feedback are frequent, integral parts of team

functioning, such communication will be easier

to accomplish and will be less threatening. It

becomes an ordinary, everyday occurrence, one that

happens spontaneously and is familiar to everyone

on the team.

Give Negative Feedback Privately

Giving negative feedback privately prevents unnec-

essary embarrassment. It avoids the possibility that

those who overhear the discussion misunderstand

it and draw erroneous conclusions. A good manag-

er praises staffers in public but corrects them in pri-

vate (Matejka, Ashworth, & Dodd-McCue, 1986).

Be Objective

Being objective can be very difficult. Evaluate peo-

ple on the basis of job expectations and the results

of their efforts (Fonville, Killian, & Tranberger,

1998). Do not compare them, favorably or unfavor-

ably, with other staff members (Gellerman &

Hodgson, 1988).

Another way to increase objectivity is to always

give a reason why a behavior has been judged as

good or poor. Consider the effect or outcome of the

behavior in forming your conclusion. Give reasons

box 6-5

Tips for Providing Helpful Feedback • Provide both positive and negative feedback.

• Give feedback immediately.

• Provide feedback frequently.

• Give negative feedback privately.

• Base feedback on observable behavior.

• Communicate effectively.

• Include suggestions for change.

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84 unit 2 | Working Within the Organization

for both positive and negative messages. For exam-

ple, if you tell a coworker, “That was a good patient

interview,” you have told that person only that the

interview pleased you. However, when you add,

“because you asked open-ended questions that

encouraged the patient to explore personal feel-

ings,” you have identified and reinforced this spe-

cific behavior that made your evaluation positive.

Finally, use broad and generally accepted stan-

dards for making judgments as much as possible

rather than basing evaluation on your personal

likes and dislikes. Objectivity can be increased by

using standards that reflect the consensus of the

team, the organization, the community, or the

nursing profession. Formal evaluation is based

on commonly accepted, written standards of

behavior. Informal evaluation, however, is based

on unwritten standards. If these unwritten stan-

dards are based on personal preferences, the eval-

uation will be highly subjective. The following

are examples:

■ A team leader who describes a female social

worker as having a professional appearance

because she wears muted suits instead of bright

dresses to work is using a personal standard to

evaluate that social worker.

■ A supervisor who asks an employee to stop

wearing jewelry that could get caught in the

equipment used at work is applying a standard

for safety in making the evaluative statement.

Base Feedback on Observable Behavior

An evaluative statement should describe observed

performance, not your interpretation of another’s

behavior. For example, saying, “You were impatient

with Mrs. G. today” is an interpretive comment.

Saying, “You interrupted Mrs. G. before she finished

explaining her problem” is based on observable

behavior. The second statement is more specific and

may be more accurate because the caregiver may

have been trying to redirect the conversation to more

immediate concerns rather than being impatient.

The latter statement is also more likely to evoke an

explanation than a defensive response.

Include Suggestions for Change

When you give feedback that indicates that some

kind of change in behavior is needed, it is helpful to

suggest some alternative behaviors. This is easier to

do when the change is a simple one.

When complex change is needed (as with

Mr. S. below), you may find that the person is aware

of the problem but does not know how to solve it.

In such a case, offering to engage in searching for

the solution is appropriate. A willingness to listen

to the other person’s side of the story and assist in

finding a solution indicates that your purpose is to

help rather than to criticize.

Accept Feedback in Return

An evaluative statement is a form of confrontation.

Any message that contains a statement about the

behavior of a staff member confronts that staff

member with his or her behavior. The leader who

gives evaluative feedback needs to be prepared to

receive feedback in return and to engage in active

listening. Active listening is especially important

because the person receiving the evaluation may

respond with intense emotion. The following is an

example of what may happen:

You point out to Mr. S. that his clients need to be mon- itored more frequently. Mr. S. responds, with some agitation, that he is doing everything possible for the patients and does not have a free moment all day for one extra thing. In fact, Mr. S. tells you, he never even takes a lunch break and goes home exhausted. Active listening and problem solving aimed at relieving his overloaded time schedule are a must in this situation.

When you give negative feedback, allow time for the

receiver to express his or her opinions and for problem

solving. This is particularly important if the problem

has been ignored or has become serious (Box 6-6).

Seeking Evaluative Feedback

It is equally important to be able to accept con-

structive The reasons for seeking feedback are the

same as those for giving it to others. The criteria

box 6-6

TACTFUL Guidelines for Providing Negative Feedback

T: Think before you speak.

A: Apologize quickly if you make a mistake.

C: Converse; do not be patronizing or sarcastic.

T: Time your comments carefully.

F: Focus on behavior, not on personality.

U: Uncover hidden feelings.

L: Listen for feedback.

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chapter 6 | Getting People to Work Together 85

for evaluating the feedback you receive are also

the same.

When Is Evaluative Feedback Needed?

You may find yourself in a work situation in which

you receive very little feedback, or you may be get-

ting only positive and no negative comments (or

vice versa) (Box 6-7).

You also need to look for feedback when you

feel uncertain about how well you are doing or

whether you have interpreted the expectations of

the job correctly. The following are examples of

these situations:

■ You have been told that good patient care is the

highest priority, but you feel frustrated by never

having enough staff members to give good care.

■ You thought you were expected to do case find-

ing and health teaching in your community, but

you receive the most recognition for the number

of home visits made and the completeness of

your records.

Another instance in which you should request

feedback is when you believe that your needs for

recognition and job satisfaction have not been met


Request feedback in the form of “I” messages. If

you have received only negative comments, ask, “In

what ways have I done well?” If you receive only

positive comments, you can ask, “In what areas do

I need to improve?” If you are seeking feedback

from a patient, you could ask, “How can I be of

more help to you?”

Responding to Evaluative Feedback

Sometimes, it is appropriate to critically analyze the

feedback you are getting. If the feedback seems

totally negative or you feel threatened by receiving

it, ask for further explanation. You may have misun-

derstood what your nurse manager intended to say.

It is hard to avoid responding defensively to

negative feedback that is subjective or laced with

threats and blame. If you are the recipient of such a

poorly done evaluation, however, it may help both

you and your supervisor to try to guide the discus-

sion into more constructive areas. You can ask for

reasons why the evaluation was negative, on what

standard it was based, what the person’s expecta-

tions were, and what the person suggests as alterna-

tive behavior.

When the feedback is positive but nonspecific,

you may also want to ask for some clarification so

that you can learn what that person’s expectations

really are. Do not hesitate to seek that psychologi-

cal paycheck. Tell other people about your successes;

most are happy to share the satisfaction of a suc-

cessful outcome or positive development in a

patient’s care.

Performance Appraisal

Performance appraisal is the formal evaluation of an

employee by a superior, usually a manager or super-

visor. To prepare an appraisal, the employee’s behav-

ior is compared with his or her job description and

the standard describing how the employee is

expected to perform (Hayes, 2002). Employees

need to know what has to be done, how much has

to be done, and when it has to be done. Evaluate

actual performance, not good intentions.


In the ideal situation, the performance appraisal

begins when the employee is hired. Based on the

written job description, the employee and manager

discuss performance expectations and then write a

set of objectives they think the employee can rea-

sonably accomplish within a given time. The objec-

tives should be written at a level of performance

that demonstrates that some learning, refinement

of skill, or advancement toward some long-range

objective will have occurred. The following are

examples of objectives a new staff nurse could

accomplish in the first 6 months of employment:

■ Complete the staff nurse orientation program


■ Master the basic skills necessary to function as a

staff nurse on the assigned unit.

■ Supervise the unlicensed assistive personnel

assigned to his or her patients.

Monthly reviews of progress toward these goals help

keep the new staff member on track and provide

box 6-7

Situations in Which to Ask for Feedback • When you do not know how well you are doing

• When you receive only positive comments

• When you receive only negative comments

• When you believe that your accomplishments have not

been recognized

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86 unit 2 | Working Within the Organization

opportunities to identify needs for further orientation

or extended training (Hayes, 2002; Lombardi, 2001).

Six months later, the staff nurse and nurse manager

sit down again and evaluate the staff nurse’s perfor-

mance in terms of the previously set goals. The evalu-

ation is based on the staff nurse’s self-evaluation and

the nurse manager’s observation of specific behaviors.

New objectives for the next 6 months and plans for

achieving them may be agreed on at the time of the

appraisal or at a separate meeting (Beer, 1981). A

copy of the performance appraisal and the new goals

must be available to employees so that they can refer

to them and check on their progress.

It is important to set aside adequate time for

feedback and goal-setting processes. Both the staff

nurse and the nurse manager bring data for use at

this session. These data include a self-evaluation by

the staff nurse and observations by the evaluator of

the employee’s activities and their outcomes. Data

may also be obtained from peers and patients.

Some organizations use surveys for getting this

information from patients.

Most of the guidelines for providing evaluative

feedback discussed earlier apply to the conduct of

performance appraisals. Although not as frequent

or immediate as informal feedback, formal evalua-

tion should be just as objective, private, skillfully

communicated, and growth-promoting.

Standards for Evaluation

Unfortunately, many organizations’ employee eval-

uation procedures are far from ideal. Such proce-

dures may be inconsistent, subjective, and even

unknown to the employee in some cases. The fol-

lowing is a list of standards for a fair and objective

employee evaluation procedure that you can use to

judge your employer’s procedures:

■ Standards are clear, objective, and known in


■ Criteria for pay raises and promotions are clearly

spelled out and uniformly applied.

■ Conditions under which employment may be

terminated are known.

■ Appraisals are part of the employee’s perma-

nent record and have space for employee


■ Employees may inspect their own personnel file.

■ Employees may request and be given a reason-

able explanation of any rating and may appeal

the rating if they do not agree with it.

■ Employees are given a reasonable amount of

time to correct any serious deficiencies before

other action is taken, unless the safety of self or

others is immediately threatened.

In some organizations, collective bargaining agree-

ments are used to enforce adherence to fair and

objective performance appraisals. However, collec-

tive bargaining agreements may emphasize senior-

ity (length of service) over merit, a situation that

does not promote growth or change.

Peer Review

Peer review is the evaluation of an individual’s prac- tice by his or her colleagues (peers) who have similar

education, experience, and occupational status. Its

purpose is to provide the individual with feedback

from those who are best acquainted with the

requirements and demands of that individual’s posi-

tion: colleagues. Peer review is directed to both

actions (process) and the outcomes of actions. It also encompasses decision making (critical thinking) and

technical and interpersonal skills (Mustard, 2002).

Professionals frequently observe and judge their

colleagues’ performance. However, many feel

uncomfortable telling colleagues directly what they

think of their performance, so they do not indicate

their thoughts unless informal feedback is shared

regularly or a formal system of peer review is estab-

lished (Katzenbach & Smith, 2003). Whenever

staff members meet to audit records or otherwise

evaluate the quality of care they have given, they are

engaging in a kind of peer review.

Formal peer review programs are often one of

the last formal evaluation procedures to be imple-

mented in a health-care organization. They

increase the number of sources of feedback and

contribute to a rich, comprehensive evaluation

process (Guthrie & King, 2004).

Fundamentals of Peer Review

There are many possible variations of the peer

review process. The observations may be shared

only with the person being reviewed, with the per-

son’s supervisor, or with a review committee. The

evaluation report may be written by the reviewer, or

it may come from the review committee. The use of

a committee defeats the purpose of peer review if

the committee members are not truly peers of the

individual being reviewed.

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chapter 6 | Getting People to Work Together 87

A Comprehensive Peer Review System

Peer review systems can simply be informal feed-

back regularly shared among colleagues, or they

may be comprehensive systems that are fully inte-

grated into the formal evaluation structure of a

health-care organization. When a peer review sys-

tem is fully integrated, the evaluative feedback from

peers is joined with the performance appraisals by

the nurse manager, and both are used to determine

pay raises and promotions for individual staff nurs-

es. This is a far more collegial approach than the

hierarchical one typically used, in which employees

are evaluated only by their manager.

A comprehensive peer review system begins

with the development of job descriptions and

performance standards for each level within the

nursing staff. The job description is a very general

statement, whereas the standards are specific

behaviors that can be observed and recorded.

In a participative environment, the standards are

developed by committees having representatives

from different units and from each staff level, from

the new staff nurse to top-level management. In

some instances, they are very specific, quantifiable

criteria, but others are likely to require professional

judgment as to the quality of the care provided

(Chang et al., 2002).

In some organizations, the standards may be

considered the minimal qualifications for each

level. In this case, additional activities and profes-

sional development are expected before promotion

to the next level. The candidate for promotion to

an advanced-level position prepares a promotion

portfolio for review (Schultz, 1993). The promo-

tion portfolio may include a self-assessment, peer

reviews, patient surveys, a management perform-

ance appraisal, and evidence of professional

growth. Such evidence can derive from participat-

ing in the quality improvement program, evaluating

a new product or procedure, serving as a translator

or disaster volunteer, making post-discharge visits

to patients from the unit, or taking courses related

to nursing.

Writing useful job descriptions and measurable

standards of performance is an arduous but reward-

ing task. It requires clarification and explication of

the work nurses actually do and goes beyond the

usual generalizations. Under effective group leader-

ship and with strong administrative support for this

process, it can be a challenging and stimulating

experience. Without administrative support and

guidance, however, the committee work can be

frustrating when the group gets bogged down in

details and disagreements.

When the job descriptions and performance

standards for each level have been developed and

agreed on, a procedure for their use must also be

worked out. This can be done in several ways. In

some organizations, an evaluation form that lists

the performance standards can be completed by

one or two colleagues selected by the individual

staff member. In some organizations, the informa-

tion from these forms is used along with the nurse

manager’s evaluation to determine pay raises and

promotions. In others, the evaluation from one’s

peers is used for counseling purposes only and is

not taken into consideration in determining pay

raises or promotions. This second approach pro-

vides useful feedback but weakens the impact of

peer review.

A different approach is the use of a professional

practice committee. The committee, consisting of

colleagues selected by the nursing staff, reviews the

peer evaluation forms and makes its recommenda-

tions to the director of nursing or vice president

for patient care services, who then makes the final

decision regarding the appropriate rewards (raises,

promotions, commendations) or penalties (demo-

tion, transfer, termination of employment).


The responsibility for delivering and coordinat-

ing patient care is an important part of the role

of the professional nurse. To accomplish this,

nurses need good communication skills. Being

assertive without being aggressive and conduct-

ing interactions in a professional manner

enhance the relationships that nurses develop

with colleagues, physicians, and other members

of the interdisciplinary team.

A major focus of the national safety goals is

improved communication among health-care pro-

fessionals. In an effort to improve patient safety,

health-care institutions have moved toward imple-

menting a communication protocol referred to as

the SBAR method. SBAR sets a specific procedure

that reminds nurses how to relay information

quickly and effectively to the patient’s health-care

provider, which ultimately leads to improved

patient outcomes.

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88 unit 2 | Working Within the Organization

Communication skills are also part of evalua-

tion. A comprehensive evaluation system can be an

effective mechanism for improving staff skills and

morale and for reducing costs by increasing staff

productivity. Constructive feedback demands

objectivity and fairness in dealing with each other

and leadership of both staff members and manage-

ment. Done well, feedback can provide many

opportunities for increased professionalism and

learning as well as ensure appropriate rewards for

high performance levels and professionalism on

the job.

Study Questions

1. This is your first position as an RN, and you are working with an LPN who has been on the unit

for 20 years. On your first day she says to you, “The only difference between you and me is the

size of the paycheck.” Demonstrate how you would respond to this statement, using assertive

communication techniques.

2. A physician orders “Vit K 10 mg IV.” You realize that this is a dangerous order. How would you

approach the physician?

3. A patient is admitted to the same-day surgical center for a breast biopsy. She is accompanied by

her significant other, who has just had an altercation with an admissions secretary about their

insurance. The patient then has to wait 30 minutes after her designated arrival time. When the

nurse comes to call the patient, her significant other turns and says loudly, “What is wrong with

you people? Can’t you ever get anything straight? If you can’t get the insurance right, and you can’t

get the time right, how can we expect you to get the surgery right?” How would you defuse the


4. Why is feedback important? Who needs to receive feedback? Who should give feedback to

health-care providers?

5. Describe the difference between constructive (helpful) and destructive (unhelpful) feedback.

6. Describe an ideal version of a 3-month performance appraisal of a new staff nurse. Why do nurse

managers sometimes fail to meet this ideal when providing formal evaluative feedback? Can new

staff nurses do anything to improve these procedures in their place of employment?

7. What is peer review? How is it different from other types of evaluation? Why is it important?

Case Study to Promote Critical Reasoning

Tyrell Jones is a new unlicensed assistant who has been assigned to your acute rehabilitation unit.

Tyrell is a hard worker; he comes in early and often stays late to finish his work. But Tyrell is gruff

with the patients, especially with the male patients. If a patient is reluctant to get out of bed, Tyrell

often challenges him, saying, “C’mon, man. Don’t be such a wimp. Move your big butt.” Today, you

overheard Tyrell telling a female patient who said she did not feel well, “You’re just a phony. You

like being waited on, but that’s not why you’re here.” The woman started to cry.

1. You are the newest staff nurse on this unit. How would you handle this situation? What would

happen if you ignored it?

2. If you decided that you should not ignore it, with whom should you speak? Why? What would you


3. Why do you think Tyrell speaks to patients this way?

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chapter 6 | Getting People to Work Together 89

References Arnold, J., & Pearson, G. (eds.). (1992). Computer Applications in

Nursing Education and Practice. N.Y.: National League for Nursing.

Beer, M. (1981, Winter). Performance appraisal: Dilemmas and possibilities. Organizational Dynamics, 24.

Blais, K.B., Hayes, J.S., Kozier, B., & Erb, G. (2002). Professional Nursing Practice: Concepts and Perspectives, 4th ed. Upper Saddle River, N.J.: Prentice-Hall.

Bowers, B., & Lapziger, D. (2001). The New York Times Management Reader. N.Y.: Times Books.

Briles, J. (2005). Steer your solution in the right direction. Nursing Management, 36:5, 68.

Chang, B.L., Lee, J.L., Pearson, M.L., Kahn, K.L., et al. (July/ August 2002). Evaluating quality of nursing care. Journal of Nursing Administration, 32(7/8), 405–415.

Channer, P., & Hope, T. (2001). Emotional Impact: Passionate Leaders and Corporate Transformation. Hampshire, U.K.: Palgrave.

Dee, C. (2005). Making the most of nursing’s electronic resources. American Journal of Nursing, 105:9, 79–85.

DiMichele, C., & Gaffney, L. (2005). Proactive teams yield exceptional care. Nursing Management, 36:5, 61.

Fontaine, K.L., & Fletcher, J.S. (2002). Mental Health Nursing, 5th ed. Redwood City, Calif.: Prentice-Hall.

Fonville, A.M., Killian, E.R., & Tranberger, R.E. (1998). Developing new nurse leaders. Nurse Economics, 16, 83–87.

Gabor, D. (1994). Speaking Your Mind in 101 Difficult Situations. N.Y.: Stonesong Press (Simon & Schuster).

Gellerman, S.W., & Hodgson, W.G. (1988). Cyanamid’s new take on performance appraisal. Harvard Business Review, 88(3), 36–41.

Guthrie, V.A., & King, S.N. (2004). Feedback-Intensive Program. In McCauly, C.D., & Van Velsor, E. (eds.). The Center for Creative Leadership Handbook of Leadership Development. San Francisco: Jossey-Bass.

Haig, K.M., Sutton, S., & Whittingdon, J. (2006). SBAR: A shared mental model for improving communication between clini- cans. Journal on Quality and Patient Safety, 32(3), 167-175.

Hayes, H. (Winter 2002). Employee training and job descriptions. Maryland Medicine, 3(1), 39–41.

Hebda, T., Czar, P., & Mascara, C. (1998). Handbook of Informatics for Nurses and Health Care Professionals. Menlo Park, Calif.: Addison-Wesley.

Institute for Healthcare Improvement. (2006). Using SBAR to improve communication between caregivers. Retrieved November 30, 2008, from http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/ WebACTIONUsingSBARtoImproveCommunication.htm? TabId=7

Katzenbach, J.R., & Smith, D.K. (2003). The Wisdom of Teams. N.Y.: Harper Collins.

Kron, T. (1981). The Management of Patient Care: Putting Leadership Skills to Work. Philadelphia: WB Saunders.

Lombardi, D.N. (2001). Handbook for the New Health Care Manager. San Francisco: Jossey-Bass.

Matejka, J.K., Ashworth, D.N., & Dodd-McCue, D. (1986). Discipline without guilt. Supervisory Management, 31(5), 34–36.

Mustard, L.W. (2002). Caring and competency. JONA’s Healthcare Law, Ethics and Regulation, 4(2), 36–43.

Rees, F. (2005). 25 Activities for Developing Team Leaders. San Francisco: Pfeiffer.

Robert Wood Johnson Foundation. (2008). Improving nurse-physician communication. Retrieved November 30, 2008, from http://www.rwjf.org

Rosen, R.H. (1996). Leading People: Transforming Business From the Inside Out. N.Y.: Viking Penguin.

Schultz, A.W. (1993). Evaluation for clinical advancement systems. Journal of Nursing Administration, 23(2), 13–19.

Shea, V. (2000). Netiquette. San Rafael, Calif.: Albion. Tappen, R.M. (2001). Nursing Leadership and Management:

Concepts and Practice, 4th ed. Philadelphia: FA Davis. Trossman, S. (2005). Who you work with matters. American

Nurse, 37:4, 1, 8. American Nurses Association. Watson, T., & Harris, P. (1999). The Emergent Manager. London:

Sage Publications.

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chapter 7 Dealing With Problems

and Conflicts

OBJECTIVES After reading this chapter, the student should be able to: ■ Identify common sources of conflict in the workplace.

■ Guide an individual or small group through the process of problem resolution.

■ Participate in informal negotiations.

■ Discuss the purposes of collective bargaining.



Many Sources of Conflict

Power Plays and Competition Between Groups

Increased Workload

Multiple Role Demands

Threats to Safety and Security

Scarce Resources

Cultural Differences

Invasion of Personal Space

When Conflict Occurs

Resolving Problems and Conflicts

Win, Lose, or Draw?

Other Conflict Resolution Myths

Problem Resolution

Identify the Problem or Issue

Generate Possible Solutions

Evaluate Suggested Solutions

Choose the Best Solution

Implement the Solution Chosen

Is the Problem Resolved?

Negotiating an Agreement Informally

Scope the Situation

Set the Stage

Conduct the Negotiation

Agree on a Resolution of the Conflict

Formal Negotiation: Collective Bargaining

The Pros and Cons of Collective Bargaining



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92 unit 2 | Working Within the Organization

Various pressures and demands in the workplace

generate problems and conflicts among people.

These conflicts can interfere with the ability to

work together. If the various polls and surveys

of nurses are correct, there seems to be an

increasing amount of hostility and unresolved

conflict experienced by nurses at work (Lazoritz

& Carlson, 2008; Siu, Laschinger, & Finegan,

2008;). Harassment from doctors, supervisors,

managers, and colleagues can be very stressful

(McVicar, 2003; Vivar, 2006). Consider Case 1,

which is the first of three in this chapter that will

be used to illustrate how to deal with problems

and conflicts.


There are no conflict-free work groups (Van de

Vliert & Janssen, 2001). Small or large, conflicts are

a daily occurrence in the life of nurses (McElhaney,

1996), and they can interfere with getting work

done, as shown in Case 1.

Serious conflicts can be very stressful for the

people involved. Stress symptoms—such as diffi-

culty concentrating, anxiety, sleep disorders, and

withdrawal—or other interpersonal relationship

problems can occur. Bitterness, anger, and even vio-

lence can erupt in the workplace if conflicts are not


Conflict also has a positive side, however. For

example, in the process of learning how to manage

conflict, people can develop more open, cooperative

ways of working together (Tjosvold & Tjosvold,

1995). They can begin to see each other as people

with similar needs, concerns, and dreams instead of

as competitors or blocks in the way of progress.

Being involved in successful conflict resolution can

be an empowering experience (Horton-Deutsch &

Wellman, 2002).

The goal in dealing with conflict is to create an

environment in which conflicts are dealt with in as

cooperative and constructive a manner as possible,

rather than in a competitive and destructive manner.

Many Sources of Conflict

Why do conflicts occur? Health care brings people of

different ages, gender, income levels, ethnic groups,

educational levels, lifestyles, and professions together

for the purpose of restoring or maintaining people’s

Case 1

Team A and Team B

Team A has stopped talking to Team B. If several members of Team A are out sick, no one on Team B will help Team A with their work. Likewise, Team A members will not take telephone messages for anyone on Team B. Instead, they ask the person to call back later. When members of the two teams pass each other in the hall, they either glare at each other or turn away to avoid eye contact. Arguments erupt when members of the two teams need the same computer terminal or another piece of equipment at the same time.

When a Team A nurse reached for a pulse oximeter at the same moment as a Team B nurse did, the second nurse said, “You’ve been using that all morning.”

“I’ve got a lot of patients to monitor,” was the response.

“Oh, you think you’re the only one with work to do?”

“We take good care of our patients.”

“Are you saying we don’t?”

The nurses fell silent when the nurse manager entered the room.

“Is something the matter?” she asked. Both nurses shook their heads and left quickly.

“I’m not sure what’s going on here,” the nurse manager thought to herself, “but something’s wrong, and I need to find out what it is right away.”

We will return to this case later as we discuss workplace problems and conflicts, their sources, and how to resolve them.

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chapter 7 | Dealing With Problems and Conflicts 93

health. Some conflicts are focused on issues related to

the work being done; these are task-related conflicts.

Others are primarily related to personal and social

issues; these are relationship conflicts ( Jordan &

Troth, 2004). Differences of opinion over how to best

accomplish this goal are a normal part of working

with people of various skill levels and backgrounds

(Wenckus, 1995). In addition, the workplace itself

can be a generator of conflict. Following are some

of the most common reasons why conflict occurs in

the workplace.

Power Plays and Competition Between Groups

Nurse-physician relationships are frequent sources

of conflicts (Vivar, 2006). The most common prob-

lem is disrespect, but sarcasm, finger pointing,

throwing things, inappropriate language, and

demeaning remarks also occur (Lazoritz &

Carlson, 2008). Disagreements over professional

“territory” can occur in any setting. Nurse practi-

tioners and physicians may disagree over limita-

tions on nurse practitioner independence. Bullying

involves behavior intended to exert power over

another person. Physician dominance and authori-

tarian management may create an environment in

which bullying occurs.

In some settings nurses feel powerless, trapped by

the demands of the tasks they must complete and

frustrated that they cannot provide quality care

(Ramos, 2006). Union-management conflicts occur

regularly in some workplaces. Gender-based conflicts,

including equal pay for women and sexual harassment

issues, are other examples (Ehrlich, 1995).

Increased Workload

Emphasis on cost reductions has resulted in work intensif ication, a situation in which employees are required to do more in less time (Willis,

Taffoli, Henderson, & Walter, 2008). Common

examples are skipping lunch and unpaid over-

time. This leaves many health-care workers

believing that their employers are taking advan-

tage of them (Ketter, 1994) and causes conflict if

they believe others are not working as hard as

they are.

Multiple Role Demands

Inappropriate task assignments (e.g., asking nurses

to clean the floors as well as nurse their patients)

are often the result of cost-control efforts, which

can lead to disagreements about who does what

task and who is responsible for the outcome.

Threats to Safety and Security

When cost saving is emphasized and staff mem-

bers face layoffs, people’s economic security is

threatened. This can be a source of considerable

stress and tension (Qureshi, 1996; Rondeau &

Wagar, 2002).

Scarce Resources

Inadequate money for pay raises, equipment, sup-

plies, or additional help can increase competition

between or among departments and individuals as

they scramble to grab their share of what little

there is available.

Cultural Differences

Different beliefs about how hard a person should

work, what constitutes productivity, and even what

it means to arrive at work “on time” can lead to

problems if they are not reconciled.

Invasion of Personal Space

Crowded conditions and the constant interactions

that occur at a busy nurses’ station can increase

interpersonal tension and lead to battles over scarce

work space (McElhaney, 1996).

When Conflict Occurs

Conflicts can occur at any level and involve any

number of people, including supervisors, subordi-

nates, peers, or patients (Sanon-Rollins, 2000). On

the individual level, they can occur between two

people on a team, between two people in different

departments, or between a staff member and a

patient or family member (Box 7-1). On the

group level, conflict can occur between two teams

box 7-1

Signs That Conflict Resolution Is Needed • You feel very uncomfortable in a situation.

• Members of your team are having trouble working


• Team members stop talking with each other.

• Team members begin “losing their cool,” attacking each

other verbally.

Adapted from Patterson, K., Grenny, J., McMillan, R., & Surtzler, A. (18 March

2003). Crucial conversations: Making a difference between being healed

and being seriously hurt. Vital Signs, 13(5), 14–15.

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94 unit 2 | Working Within the Organization

(as in Case 1), two departments, or two different

professional groups (e.g., nurses and social workers,

over who is responsible for discharge planning). On

the organizational level, conflicts can occur

between two organizations (e.g., when two home

health agencies compete for a contract with a large

hospital). The focus in this chapter is primarily on

the first two levels: among individuals and groups

of people within a health-care organization.

Resolving Problems and Conflicts

Win, Lose, or Draw?

Some people think about problems and conflicts

that occur at work in the same way they think about

a football game or tennis match: unless the score is

tied at the end of the game, someone has won, and

someone has lost. There are some problems in this

comparison with sports competition. First, the aim

of conflict resolution is to work together more effec-

tively, not to defeat the other party. Second, the peo-

ple who lose are likely to feel bad about losing. As a

result, they may spend their time and energy prepar-

ing to win the next round rather than on their work.

A win-win result in which both sides gain some

benefit is the best resolution (Haslan, 2001).

However, sometimes the people involved cannot

reach agreement (consensus) but can recognize and

accept their differences and get on with their work

(McDonald, 2008).

Other Conflict Resolution Myths

Many people think of what can be “won” as a fixed

amount: “I get half, and you get half.” This is the

f ixed pie myth of conflict resolution (Thompson & Fox, 2001). The problem is that if one side gets

everything, then the other side gets nothing.

Another erroneous assumption is called the deval- uation reaction: “If the other side is getting what they want, then it has to be bad for us.” These erro-

neous beliefs can be serious barriers to achievement

of a mutually beneficial resolution of a conflict.

When disagreements first arise, problem solving may be sufficient. If the situation has already devel-

oped into a full conflict, however, negotiation, either informal or formal, of a settlement may be necessary.

Problem Resolution

The use of the problem-solving process in patient

care should be familiar. The same approach can be

used when staff problems occur. The goal is to find

a solution to a given problem that satisfies every-

one involved. The process itself, illustrated in

Figure 7.1, includes identifying the issue, generat-

ing solutions, evaluating the suggested solutions,

choosing what appears to be the best solution,

implementing that solution, evaluating the extent

to which the problem has been resolved and, finally,

concluding either that the problem has been

resolved or that it will be necessary to repeat the

process to find a better solution.

Identify the Problem or Issue

Ask participants in the conflict what they want

(Sportsman, 2005). If the issue is not highly charged

or highly political, they may be able to give a direct

answer. At other times, however, some discussion

and exploration of the issues are necessary before

the real problem emerges. “It would be nice,” wrote

Browne and Kelley, “if what other people were really

saying was always obvious, if all their essential

thoughts were clearly labeled for us . . . and if all

knowledgeable people agreed about answers to

important questions” (1994, p. 5). Of course, this is

not what usually happens. People are often vague

about what their real concern is; sometimes they are

genuinely uncertain about what the real problem is.

High emotion may further cloud the issue. All this

needs to be sorted out so that the problem is iden-

tified clearly and a solution can be sought.

Problem resolved

If yes, end

Begin hereIf not,

repeat process

Implement solution chosen

Generate possible solutions

Choose best


Evaluate suggested solutions

Identify the


Figure 7.1 The process of resolving a problem.

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chapter 7 | Dealing With Problems and Conflicts 95

Generate Possible Solutions

Here, creativity is especially important. Try to dis-

courage people from using old solutions for new

problems. It is natural for people to try to repeat

something that has already worked well, but previ-

ously successful solutions may not work in the

future (Walsh, 1996). Instead, encourage searching

for innovative solutions (Smialek, 2001).

When an innovative solution is needed, sug-

gest that the group take some time to brainstorm. Ask everyone to write down (or call out as you

write on a flip chart) as many solutions as he or

she can come up with (Rees, 2005). Then give

everyone a chance to consider each suggestion on

its own merits.

Evaluate Suggested Solutions

An open-minded evaluation of each suggestion is

needed, but accomplishing this is not always easy.

Some groups are “stuck in a rut,” unable to “think

outside the box.” Other times, groups find it diffi-

cult to separate the suggestion from its source.

On an interdisciplinary team, for example, the sta-

tus of the person who made the suggestion may

influence whether the suggestion is judged to be

useful. Whose solution is most likely to be the best

one: the physician’s or the unlicensed assistant’s?

That depends. Judge the suggestion on its merits,

not its source.

Choose the Best Solution

Which of the suggested solutions is most likely to

work? A combination of suggestions is often the

best solution.

Implement the Solution Chosen

The true test of any suggested solution is how well

it actually works. Once a solution has been imple-

mented, it is important to give it time to work.

Impatience sometimes leads to premature aban-

donment of a good solution.

Is the Problem Resolved?

Not every problem is resolved successfully on the

first attempt. If the problem has not been resolved,

then the process needs to be resumed with even

greater attention to what the real problem is and

how it can be resolved successfully.

Consider the following situation in which prob-

lem solving was helpful (Case 2)

The nurse manager asked Ms. Deloitte to meet

with her to discuss the problem. The following is a

summary of their problem solving:

■ The Issue. Ms. Deloitte wanted to take her vacation from the end of December through

early January. Making the assumption that she

was going to be permitted to go, she had pur-

chased nonrefundable tickets. The policy forbids

vacations from December 20 to January 5. The

Case 2

The Vacation

Francine Deloitte has been a unit secretary for 10 years. She is prompt, efficient, accurate, courteous, flexible, and productive—everything a nurse manager could ask for in a unit secretary. When nursing staff members are very busy, she distributes afternoon snacks or sits with a family for a few minutes until a nurse is available. There is only one issue on which Ms. Deloitte is insistent and stubborn: taking her 2-week vacation over the Christmas and New Year holidays. This is forbidden by hospital policy, but every nurse manager has allowed her to do this because it is the only special request she ever makes and because it is the only time she visits her family during the year.

A recent reorganization of the administrative structure had eliminated several layers of nursing manag- ers and supervisors. Each remaining nurse manager was given responsibility for two or three units. The new nurse manager for Ms. Deloitte’s unit refused to grant her request for vacation time at the end of December. “I can’t show favoritism,” she explained. “No one else is allowed to take vacation time at the end of December.” Assuming that she could have the time off as usual, Francine had already purchased a nonrefundable ticket for her visit home. When her request was denied, she threatened to quit. On hearing this, one of the nurses on Francine’s unit confronted the new nurse manager saying, “You can’t do this. We are going to lose the best unit secretary we’ve ever had if you do.”

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96 unit 2 | Working Within the Organization

former nurse manager had not enforced this

policy with Ms. Deloitte, but the new nurse

manager thought it fair to enforce the policy

with everyone, including Ms. Deloitte.

■ Possible Solutions

1. Ms. Deloitte resigns.

2. Ms. Deloitte is fired.

3. Allow Ms. Deloitte to take her vacation as


4. Allow everyone to take vacations between

December 20 and January 5 as requested.

5. Allow no one to take a vacation between

December 20 and January 5.

■ Evaluate Suggested Solutions. Ms. Deloitte preferred solutions 3 and 4. The new nurse man-

ager preferred 5. Neither wanted 1 or 2. They

could agree only that none of the solutions satis-

fied both of them, so they decided to try again.

■ Second List of Possible Solutions

1. Reimburse Ms. Deloitte for the cost of the


2. Allow Ms. Deloitte to take one last vacation

between December 20 and January 5.

3. Allow Ms. Deloitte to take her vacation during

Thanksgiving instead.

4. Allow Ms. Deloitte to begin her vacation on

December 26 so that she would work on

Christmas Day but not on New Year’s Day.

5. Allow Ms. Deloitte to begin her vacation earlier

in December so that she could return in time

to work on New Year’s Day.

■ Choose the Best Solution. As they discussed the alternatives, Ms. Deloitte said she could

change the day of her flight without a penalty.

The nurse manager said she would allow solu-

tion 5 on the second list if Ms. Deloitte under-

stood that she could not take vacation time

between December 20 and January 5 in the

future. Ms. Deloitte agreed to this.

■ Implement the Solution. Ms. Deloitte returned on December 30 and worked both New Year’s

Eve and New Year’s Day.

■ Evaluate the Solution. The rest of the staff members had been watching the situation very

closely. Most believed that the solution had been

fair to them as well as to Ms. Deloitte. Ms.

Deloitte thought she had been treated fairly.

The nurse manager believed both parties had

found a solution that was fair to Ms. Deloitte

but still reinforced the manager’s determination

to enforce the vacation policy.

■ Resolved, or Resume Problem Solving? Ms. Deloitte, staff members, and the nurse man-

ager all thought the problem had been solved


Negotiating an Agreement Informally

When disagreement has become too big, too com-

plex, or too heated, a more elaborate process may be

required to resolve it. On evaluating Case 1, the

nurse manager decided that the tensions between

Team A and Team B had become so great that

negotiation would be necessary.

The process of negotiation is a complex one that

requires much careful thought beforehand and

considerable skill in its implementation. Box 7-2 is

an outline of the most essential aspects of negotia-

tion. Case 1 is used to illustrate how it can be done.

Scope the Situation

For a strategy to be successful, it is important that the

entire situation be understood thoroughly. Walker

and Harris (1995) suggested asking three questions:

1. What am I trying to achieve? The nurse manager in Case 1 is concerned about the tensions

between Team A and Team B. She wants the

members of these two teams to be able to work

together in a cooperative manner, which they

are not doing at the present time.

2. What is the environment in which I am operating? The members of Teams A and B were openly

hostile to each other. The overall climate of the

organization, however, was benign. The nurse

manager knew that teamwork was encouraged

box 7-2

The Informal Negotiation Process • Scope the situation. Ask yourself:

What am I trying to achieve?

What is the environment in which I am operating?

What problems am I likely to encounter?

What does the other side want?

• Set the stage.

• Conduct the negotiation.

• Set the ground rules.

• Clarify the problem.

• Make your opening move.

• Continue with offers and counteroffers.

• Agree on the resolution of the conflict.

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chapter 7 | Dealing With Problems and Conflicts 97

and that her actions to resolve the conflict

would be supported by administration.

3. What problems am I likely to encounter? The nurse manager knew that she had allowed the problem

to go on too long. Even physicians, social work-

ers, and visitors to the unit were getting caught

up in the conflict. Team members were actively

encouraging other staff to take sides, making clear

they thought that “if you’re not with us, you’re

against us.” This made people from other depart-

ments very uncomfortable because they had to

work with both teams. The nurse manager knew

that resolution of the conflict would be a relief to

many people. It is important to ask one additional

question in preparation for negotiations:

4. What does the other side want? In this situation, the nurse manager was not certain what either

team really wanted. She realized that she

needed this information before she could begin

to negotiate.

Set the Stage

When a conflict such as the one between Teams A

and B has gone on for some time, the opposing

sides are often unwilling to meet to discuss the

problem. If this occurs, it may be necessary to con-

front them with direct statements designed to open

communications between the two sides to chal-

lenge them to seek resolution of the situation.

At the same time, it is important to avoid any

implication of blame because this provokes defen-

siveness rather than willingness to change.

To confront Teams A and B with their behavior

toward one another, the nurse manager called them

together at the end of the day shift. “I am very con-

cerned about what I have been observing lately,”

she told them. “It appears to me that instead of

working together, our two teams are working

against each other.” She continued with some

examples of what she had observed, taking care not

to mention names or blame anyone for the prob-

lem. She was also prepared to take responsibility for

having allowed the situation to deteriorate before

taking this much-needed action.

Conduct the Negotiation

As indicated earlier, conducting a negotiation

requires a great deal of skill.

1. Manage the emotions. When staff members are very emotional, they have trouble thinking

clearly. Acknowledging these emotions is

essential to negotiating effectively (Fiumano,

2005). When faced with a highly charged

situation, do not respond with added emotion.

Take time out if you need to get your own

feelings under control. Then find out why

emotions are high (watch both verbal and

nonverbal cues carefully) (Hart & Waisman,

2005), and refocus the discussion on the issues

(Shapiro & Jankowski, 1998). Without effective

leadership to prevent emotional outbursts and

personal attacks, a mishandled negotiation can

worsen a situation. With effective leadership,

the conflict may be resolved (Box 7-3).

2. Set ground rules. Members of Teams A and B began flinging accusations at each other as soon

as the nurse manager made her statement. The

nurse manager stopped this quickly and said,

“First, we need to set some ground rules for this

discussion. Everyone will get a chance to speak

but not all at once. Please speak for yourself, not

for others. And please do not make personal

remarks or criticize your coworkers. We are here

to resolve this problem, not to make it worse.”

She had to remind the group of these ground

rules several times during the meeting. Teaching

others how to negotiate can create a more col-

laborative environment in which the negotiation

will take place (Schwartz & Pogge, 2000).

3. Clarification of the problem. The nurse man- ager wrote a list of problems raised by team

members on a chalkboard. As the list grew

longer, she asked the group, “What do you

box 7-3

Tips for Leading the Discussion • Create a climate of comfort.

• Let others know the purpose is to resolve a problem or


• Freely admit your own contribution to the problem.

• Begin with the presentation of facts.

• Recognize your own emotional response to the situation.

• Set ground rules.

• Do not make personal remarks.

• Avoid placing blame.

• Allow each person an opportunity to speak.

• Do speak for yourself but not for others.

• Focus on solutions.

• Keep an open mind.

Adapted from Patterson, K., Grenny, J., McMillan, R., & Surtzler, A. (18 March

2003). Crucial conversations: Making a difference between being healed

and being seriously hurt. Vital Signs, 13(5), 14–15.

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98 unit 2 | Working Within the Organization

see here? What is the real problem?” The group

remained silent. Finally, someone said, “We

don’t have enough people, equipment, or

supplies to get the work done.” The rest of the

group nodded in agreement.

4. Opening move. Once the problem is clarified, it is time to obtain everyone’s agreement to seek

a way to resolve the conflict. In more formal

negotiation, you may make a statement about

what you wish to achieve. For example,

if you are negotiating a salary increase, you

might begin by saying, “I am requesting a

10% increase for the following reasons: . . .” Of

course, your employer will probably make a

counteroffer, such as, “The best I can do is 3%.”

These are the opening moves of a negotiation.

5. Continue the negotiations. The discussion should continue in an open, nonhostile manner.

Each side’s concerns may be further explained

and elaborated. Additional offers and

counteroffers are common. As the discussion

continues, it is usually helpful to emphasize

areas of agreement as well as disagreement so

that both parties are encouraged to continue

the negotiations (Tappen, 2001).

Agree on a Resolution of the Conflict

After much testing for agreement, elaborating each

side’s positions and concerns, and making offers

and counteroffers, the people involved should

finally reach an agreement.

The nurse manager of Teams A and B led them

through a discussion of their concerns related to

working with severely limited resources. The teams

soon realized that they had a common concern and

that they might be able to help each other rather than

compete with each other. The nurse manager agreed

to become more proactive in seeking resources for the

unit. “We can simultaneously seek new resources and

develop creative ways to use the resources we already

have,” she told the teams. Relationships between

members of Team A and Team B improved remark-

ably after this meeting. They learned that they could

accomplish more by working together than they had

ever achieved separately.

Formal Negotiation: Collective Bargaining

There are many varieties of formal negotiations, from

real estate transactions to international peace treaty

negotiations. A formal negotiation process of special

interest to nurses is collective bargaining, which is

highly formalized because it is governed by laws and

contracts called collective bargaining agreements. Collective bargaining involves a formal proce-

dure governed by labor laws, such as the National

Labor Relations Act in the United States.

Nonprofit health-care organizations were added to

the organizations covered by these laws in 1974.

Once a union or professional organization has

been designated as the official bargaining agent for

a group of nurses, a contract defining such impor-

tant matters as salary increases, benefits, time off,

unfair treatment, safety issues, and promotion of

professional practice is drawn up. This contract

governs employee-management relations within

the organization.

Case 3 is an example of how collective bargain-

ing agreements can influence the outcome of a

conflict between management and staff in a health-

care organization.

A collective bargaining contract is a legal docu-

ment that governs the relationship between man-

agement and staff, which is represented by the

union (for nurses, it may be the nurses’ association

or another health-care workers’ union). The con-

tract may cover some or all of the following:

■ Economic issues: Salaries, shift differentials, length of the workday, overtime, holidays, sick

leave, breaks, health insurance, pensions,

severance pay

■ Management issues: Promotions, layoffs, trans- fers, reprimands, grievance procedures, hiring

and firing procedures

■ Practice issues: Adequate staffing, standards of care, code of ethics, safe working environment,

other quality-of-care issues, staff development


Better patient-nurse staffing ratios, more reason-

able workloads, opportunities for professional

development, and better relationships with manage-

ment are among the most important issues (Budd,

Warino, & Patton, 2004).

The Pros and Cons of Collective Bargaining

Some nurses believe it is unprofessional to belong

to a union. Others point out that physicians and

teachers are union members and that the protec-

tions offered by a union outweigh the downside.

There is no easy answer to this question.

Probably the greatest advantages of collective bar-

gaining are protection of the right to fair treatment

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chapter 7 | Dealing With Problems and Conflicts 99

and the availability of a written grievance procedure

that specifies both the employee’s and the employer’s

rights and responsibilities if an issue arises that can-

not be settled informally (Forman & Merrick, 2003).

Having a say in practice and work-related issues

empowers nurses (Budd, Warino, & Patton, 2004;

Crochette, 2008). Another advantage is salary: nurs-

es working under a collective bargaining agreement

can earn as much as 28% more than those who do

not (Pittman, 2007).

The greatest disadvantage of using collective

bargaining as a way to deal with conflict is that it

clearly separates management-level people from

staff-level people, often creating an adversarial rela-

tionship. Any nurses who make staffing decisions

may be classified as supervisors and, therefore, may

be ineligible to join the union, separating them

from the rest of their colleagues (Martin, 2001).

The result is that management and staff are treated

as opposing parties rather than as people who are

trying to work together to provide essential services

to their clients. The collective bargaining contract

also adds another layer of rules and regulations

between staff members and their supervisors.

Because management of such employee-related

rules and regulations can take almost a quarter of a

manager’s time (Drucker, 2002), this can become a

drain on a nurse manager’s time and energy.


Conflict is inevitable within any large, diverse

group of people who are trying to work together

over an extended period. However, conflict does

not have to be destructive, nor does it have to be a

negative experience. If it is handled skillfully by

everyone involved, conflict can stimulate people

to learn more about each other and how to work

together in more effective ways. Resolving a

conflict, when done well, can lead to improved

working relationships, more creative methods of

operation, and higher productivity.

Case 3

Collective Bargaining

The chief executive officer (CEO) of a large home health agency in a southwestern resort area called a general staff meeting. She reported that the agency had grown rapidly and was now the largest in the area.

“Much of our success is due to the professionalism and commitment of our staff members,” she said. “With growth come some problems, however. The most serious problem is the fluctuation in patient census. Our census peaks in the winter months when seasonal residents are here and troughs in the summer. In the past, when we were a small agency, we all took our vacations during the slow season. This made it possible to continue to pay everyone his or her full salary all year. However, given pressures to reduce costs and the large number of staff members we now have, we cannot continue to do this. We are very concerned about maintaining the high quality of patient care currently provided, but we have calculated that we need to reduce staff by 30 percent over the summer in order to survive financially.”

The CEO then invited comments from the staff members. The majority of the nurses said they wanted and needed to work full-time all year. Most supported families and had to have a steady income all year. “My rent does not go down in the summer,” said one. “Neither does my mortgage payment or the grocery bill,” said another. A small number said that they would be happy to work part-time in the summer if they could be guaranteed full-time employment from October through May. “We have friends who would love this work schedule,” they added.

“That’s not fair,” protested the nurses who needed to work full-time all year. “You can’t replace us with part-time staff.” The discussion grew louder and the participants more agitated. The meeting ended without a solution to the problem. Although the CEO promised to consider all points of view before making a decision, the nurses left the meeting feeling very confused and concerned about the security of their future income. Some grumbled that they probably should begin looking for new positions “before the ax falls.”

The next day the CEO received a telephone call from the nurses’ union representative. “If what I heard about the meeting yesterday is correct,” said the representative, “ your plan is in violation of our collective bargaining contract.” The CEO reviewed the contract and found that the representative was correct. A new solution to the financial problems caused by the seasonal fluctuations in patient census would have to be found.

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100 unit 2 | Working Within the Organization

Study Questions

1. Debate the question of whether conflict is constructive or destructive. How can good leadership

affect the outcome of a conflict?

2. Give an example of how each of the seven sources of conflict listed in this chapter can lead to a

serious problem. Then discuss ways to prevent the occurrence of conflict from each of the eight


3. What is the difference between problem resolution and negotiation? Under what circumstances

would you use one or the other?

4. Identify a conflict (actual or potential) in your clinical area, and explain how either problem

resolution or negotiation could be used to resolve it.

Case Study to Promote Critical Reasoning

A not-for-profit hospice center in a small community received a generous gift from the grateful

family of a patient who had died recently. The family asked only that the money be “put to the best

use possible.”

Everyone in this small facility had an opinion about the “best” use for the money. The

administrator wanted to renovate the old, run-down headquarters. The financial officer wanted to

put the money in the bank “for a rainy day.” The chaplain wanted to add a small chapel to the

building. The nurses wanted to create a food bank to help the poorest of their clients. The social

workers wanted to buy a van to transport clients to health-care providers. The staff agreed that all

the ideas had merit, that all of the needs identified were important ones. Unfortunately, there was

enough money to meet only one of them.

The more the staff members discussed how to use this gift, the more insistent each group

became that their idea was best. At their last meeting, it was evident that some were becoming

frustrated and that others were becoming angry. It was rumored that a shouting match between the

administrator and the financial officer had occurred.

1. In your analysis of this situation, identify the sources of the conflict that are developing in this


2. What kind of leadership actions are needed to prevent the escalation of this conflict?

3. If the conflict does escalate, how could it be resolved?

4. Which idea do you think has the most merit? Why did you select the one you did?

5. Try role-playing a negotiation among the administrator, the financial officer, the chaplain, a

representative of the nursing staff, and a representative of the social work staff. Can you suggest

a creative solution?

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Drucker, P.F. (2002). They’re not employees, they’re people. Harvard Business Review, 80(2), 70–77, 128.

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Ehrlich, H.J. (1995). Prejudice and ethnoviolence on campus. Higher Education Extension Service Review, 6(2), 1–3.

Fiumano, J. (2005). Navigate through conflict, not around it. Nursing Management, 36(8), 14, 18.

Forman, H., & Merrick, F. (2003). Grievances and complaints: Valuable tools for management and for staff. Journal of Nursing Administration, 33(3), 136–138.

Hart, L.B., & Waisman, C.S. (2005). The Leadership Training Activity Book. N.Y.: AMACOM.

Haslan, S.A. (2001). Psychology in Organizations. Thousand Oaks, Calif.: Sage.

Horton-Deutsch, S.L., & Wellman, D.S. (2002). Christman’s principles for effective management. Journal of Nursing Administration, 32, 596–601.

Jordan, P., & Troth, A.C. (2004). Managing emotions during team problem solving: Emotional intelligence and conflict resolution. Human Performance, 17(2), 195–218.

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Lazoritz, S., & Carlson, P.J. (2008). Descriptive physician behavior. American Nurse Today, 3(3), 20–22.

Martin, R.H. (June 2001). Ruling may limit ability to unionize. Advance for Nurses, 9.

McDonald, D. (2008). Revisiting a theory of negotiation: The utility of Markiewicz (2005) proposed six principles. Evaluation and Program Planning, 31(3), 259–265.

McElhaney, R. (1996). Conflict management in nursing administration. Nursing Management, 27(3), 49–50.

McVicar, A. (2003). Workplace stress in nursing: A literature review. Journal of Advanced Nursing, 44(6), 633–642.

Patterson, K., Grenny, J., McMillan, R., & Surtzler, A. (18 March 2003). Crucial conversations: Making a difference between being healed and being seriously hurt. Vital Signs, 13(5), 14–15.

Pittman, J. (2007). Registered nurse job satisfaction and collective bargaining unit membership status. Journal of Nursing Administration, 37(10), 471–476.

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Sanon-Rollins, G. (2000). Surviving conflict on the job. Nursing Spectrum Career Fitness Guide, 6767–6868. Barrington, Ill.: Gannett.

Schwartz, R.W., & Pogge, C. (2000). Physician leadership: Essential skills in a changing environment. American Journal of Surgery, 180(3), 187–192.

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chapter 8 People and the Process

of Change

OBJECTIVES After reading this chapter, the student should be able to: ■ Describe the process of change.

■ Recognize resistance to change and identify its sources.

■ Suggest strategies to reduce resistance to change.

■ Assume a leadership role in implementing change.



A Natural Phenomenon

Macro and Micro Change

Change and the Comfort Zone

Resistance to Change

Receptivity to Change

Recognizing Different Information Processing Styles

Speaking to People’s Feelings

Sources of Resistance

Technical Concerns

Psychosocial Needs

Position and Power

Recognizing Resistance

Lowering Resistance

Sharing Information

Disconfirming Currently Held Beliefs

Providing Psychological Safety

Dictating Change

Leading the Implementation of Change

Designing the Change


Implementing the Change

Integrating the Change

Personal Change



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104 unit 2 | Working Within the Organization

When asked the theme of a nursing management

conference, a top nursing executive replied,

“Change, change, and more change.” Whether it is

called innovation, turbulence, or change, this theme

seems to be a constant in the workplace today.

Mismanaging change is common. In fact, as many

as three out of four major change efforts fail

(Cameron & Quinn, 2006; Hempel, 2005). This

chapter discusses how people respond to change,

how you can influence change, and how you can

help people cope with it when it becomes difficult.


A Natural Phenomenon

Change is a part of everyone’s lives. Every day, peo-

ple have new experiences, meet new people, and

learn something new. People grow up, leave home,

graduate from college, begin a career, and perhaps

start a family. Some of these changes are mile-

stones, ones for which people have prepared and

have anticipated for some time. Many are exciting,

leading to new opportunities and challenges. Some

are entirely unexpected, sometimes welcome and

sometimes not. When change occurs too rapidly or

demands too much, it can make people uncomfort-

able (Bilchik, 2002), even anxious or stressed.

Macro and Micro Change

The “ever-whirling wheel of change” (Dent, 1995,

p. 287) in health care seems to spin faster every

year. By itself, managed care profoundly changed

the way health care is provided in the United States

(Trinh & O’Connor, 2002). Medicare and

Medicaid cuts, increasing numbers of people who

are uninsured or underinsured, restructuring,

downsizing, and staff shortages are major concerns.

Such changes sweep through the health-care sys-

tem, affecting patients and caregivers alike. They

are the macro-level (large-scale) changes that affect virtually every health-care facility.

Change anywhere in a system creates “ripples

throughout the system” (Parker & Gadbois, 2000,

p. 472). Every change that occurs at this macro

level filters down to the micro level (small-scale change), to teams and to individuals. Nurses, col-

leagues in other disciplines, and patients are parti-

cipants in these changes. This micro level of change

is the primary focus of this chapter.

Change and the Comfort Zone

The basic stages of the change process described by

Kurt Lewin in 1951 are unfreezing, change, and refreezing (Lewin, 1951; Schein, 2004). Imagine a work situation that is basically stable. People are

generally accustomed to each other, have a routine

for doing their work, and believe they know what

to expect and how to deal with whatever problems

come up. They are operating within their “comfort

zone” (Farrell & Broude, 1987; Lapp, 2002).

A change of any magnitude is likely to move peo-

ple out of this comfort zone into discomfort. This

move out of the comfort zone is called unfreezing (Fig. 8.1). For example:

Many health-care institutions offer nurses the choice of weekday or weekend work. Given these choices, nurses with school-age children are likely to f ind their comfort zone on weekday shifts. Imagine the discomfort they would experience if they were transferred to weekends. Such a change would rap- idly unfreeze their usual routine and move them into the discomfort zone. They might have to f ind a new babysitter or begin a search for a new child- care center that is open on weekends. Another alter- native would be to establish a child-care center where they work. Yet another alternative would be to f ind a position that offers better working hours.

Unfreezing Change Refreezing

Comfort Zone

New Comfort Zone

Discomfort Zone

Figure 8.1 The change process. (Based on Farrell, K., & Broude, C. [1987]. Winning the Change Game: How to Implement Information Systems With Fewer Headaches and Bigger Paybacks. Los Angeles: Breakthrough Enterprises; and Lewin, K. [1951]. Field Theory in Social Science: Selected Theoretical Papers. N.Y.: Harper & Row.)

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chapter 8 | People and the Process of Change 105

Whatever alternative they chose, the nurses were being challenged to f ind a solution that enabled them to move into a new comfort zone. To accomplish this, they would have to f ind a consistent, dependable source of child care suited to their new schedule and to the needs of their children and then refreeze their situation. If they did not f ind a satisfactory alterna- tive, they could remain in an unsettled state, in a discomfort zone, caught in a conflict between their personal and professional responsibilities.

As this example illustrates, even what seems to be a

small change can greatly disturb the people

involved in it. The next section considers the many

reasons why change provokes resistance and how

change can be unsettling.

Resistance to Change

People resist change for a variety of reasons that

vary from person to person and situation to situa-

tion. You might find that one patient-care techni-

cian is delighted with an increase in responsibility,

whereas another is upset about it. Some people are

eager to risk change; others prefer the status quo

(Hansten & Washburn, 1999). Managers may find

that one change in routine provokes a storm of

protest and that another is hardly noticed Why

does this happen?

Receptivity to Change

Recognizing Different Information Processing Styles

An interesting research study suggests that nurse

managers are more receptive to change than their

staff members (Kalisch, 2007). Nurse managers

were found to be more innovative and decisive,

whereas staff nurses preferred proven approaches,

thus being resistant to change. Nursing assistants,

unit secretaries, and licensed practical nurses were

also unreceptive to change, adding layers of people

who formed a “solid wall of resistance” to change.

Kalisch suggests that helping teams recognize their

preference for certainty (as opposed to change) will

increase their receptivity to necessary changes in

the workplace.

Speaking to People’s Feelings

Although both thinking and feeling responses to

change are important, Kotter (1999) says that the

heart of change lies in the emotions surrounding it.

He suggests that a compelling story will increase receptivity to a change more than a carefully

crafted analysis of the need for change. How is this

done? The following are some examples of appeals

to feelings.

■ Instead of presenting statistics about the number

of people who are re-admitted due to poor dis-

charge preparation, providing a story is more per-

suasive: an older man collapsed at home the

evening after discharge because he had not been

able to control his diabetes post surgery. Trying to

break his fall, he fractured both wrists and is now

unable to return home or take care of himself.

■ Even better, videotape an interview with this

man, letting him tell his story and describe

the repercussions of poor preparation for


■ Drama may also be achieved through visual

display. A culture plate of pathogens grown

from swabs of ventilator equipment and patient

room furniture is more attention-getting than an

infection control report. A display of disposables

with price tags attached used for just one surgi-

cal patient is more memorable than an account-

ing sheet listing the costs.

The purpose of these activities is to present a

compelling image that will affect people emotion-

ally, increasing their receptivity to change and

moving them into a state of readiness to change

(Kotter, 1999).

Sources of Resistance

Resistance to change comes from three major

sources: technical concerns, psychosocial needs,

and threats to a person’s position and power

(Araujo Group).

Technical Concerns

Some resistance to change is based on concerns

about whether the proposed change is a good idea.

The change itself may have design flaws.

The Professional Practice Committee of a small hos- pital, in order to save money, suggested replacing a commercial mouthwash with a mixture of hydrogen peroxide and water. A staff nurse objected to this proposed change, saying that she had read a research study several years ago that found peroxide solutions to be an irritant to the oral mucosa (Tombes & Gallucci, 1993). Fortunately, the chairperson of the

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106 unit 2 | Working Within the Organization

committee recognized that this objection was based on technical concerns and requested a study of the evidence before instituting the change. “It’s important to investigate the evidence supporting a proposed change thoroughly before recommending it,” she said.

A change may provide resistance for practical rea- sons. For example, if the bar codes on patients’ arm-

bands are difficult to scan, nurses may develop a

way to work around this safety feature by taping a

duplicate armband to the bed or to a clipboard

(Englebright & Franklin, 2005), defeating the

purpose of instituting electronically monitored

medication administration.

Psychosocial Needs

Change often creates anxiety, much of it related to

what people fear they might lose (Berman-Rubera,

2008; Johnston, 2008). According to Maslow

(1970), human beings have a hierarchy of needs,

from the basic physiological needs for oxygen, flu-

ids, and nutrients to the higher-order needs

for belonging, self-esteem, and self-actualization

(Fig. 8.2). Maslow observed that the more basic

needs (those lower on the hierarchy) must be at

least partially met before a person is motivated to

seek fulfillment of the higher-order needs.

Change may make it more difficult for a person

to meet any or all of his or her needs. It may

threaten the powerful safety and security needs that

Maslow discussed (Hunter, 2004). For example, if a

massive downsizing occurs and a person’s job is

eliminated, fulfillment of all of these levels of needs

may be threatened, from having enough money to

pay for food and shelter to opportunities to fulfill

one’s career potential.

In other cases, the threat is subtler and may be

harder to anticipate. For example, an institution-wide

reevaluation of the effectiveness of the advanced

practice role would be a great concern to a staff nurse

who is working toward accomplishing a lifelong

dream of becoming an advanced practice nurse in

oncology. In contrast, it would have little effect on

unlicensed assistive personnel (UAPs), but a staff

reorganization that moves UAP to different units

could threaten the belonging needs of those who

have close friends on the unit but few friends outside.

Position and Power

Once gained within an organization, status, power,

and influence are hard to give up. This applies to

people anywhere in the organization, not just those

at the top. For example:

A clerk in the surgical suite had been preparing the operating room schedule for many years. Although his supervisor was expected to review the schedule before it was posted, she rarely did so because the clerk was skillful in balancing the needs of various parties, including some very demanding surgeons. When the supervisor was transferred to another facility, her replacement decided that she had to review the schedules before they were posted because they were ultimately her responsibility. The clerk became defensive. He tried to avoid the new supervisor and posted the schedules without her approval. This sur- prised her. She knew the clerk was skilled and did not think that her review of them would be threatening.

Why did this happen? The supervisor had not real-

ized the importance of this task to the clerk. The

opportunity to tell others when and where they

could perform surgery gave the clerk a feeling of

power and importance. The supervisor’s insistence

on reviewing his work reduced the importance of

his position. What seemed to the new supervisor to

Highest Level

Lowest Level

Self-actualization Growth, development,

fulfill potential

Esteem Self-esteem, respect,


Love and belonging Acceptance, approval, inclusion, friendship

Safety and security Physical safety, trust, stability, assistance

Physiological needs Air, water, food, sleep,

shelter, sex, stimulation

Figure 8.2 Maslow’s hierarchy of needs. (Based on Maslow, A.H. [1970]. Motivation and Personality. N.Y.: Harper & Row.)

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chapter 8 | People and the Process of Change 107

be a very small change in routine had provoked sur-

prisingly strong resistance because it threatened the

clerk’s sense of importance and power.

Recognizing Resistance

Resistance may be active or passive (Heller, 1998). It is easy to recognize resistance to a change when

it is expressed directly. When a person says to you,

“That’s not a very good idea,” “I’ll quit if you

schedule me for the night shift,” or “There’s no way

I’m going to do that,” there is no doubt you are

encountering resistance. Active resistance can take

the form of outright refusal to comply, such as these

statements, writing memos that destroy the idea,

quoting existing rules that make the change diffi-

cult to implement, or encouraging others to resist.

When resistance is less direct, however, it can be

difficult to recognize unless you know what to look

for. Passive approaches usually involve avoidance:

canceling appointments to discuss implementation

of the change, being too busy to make the change,

refusing to commit to changing, agreeing to it but

doing nothing to change, and simply ignoring the

entire process as much as possible (Table 8-1).

Once resistance has been recognized, action can be

taken to lower or even eliminate it.

Lowering Resistance

A great deal can be done to lower people’s resis-

tance to change. Strategies fall into four categories:

sharing information, disconfirming currently held

beliefs, providing psychological safety, and dictat-

ing (forcing) change (Tappen, 2001).

Sharing Information

Much resistance is simply the result of misunder-

standing a proposed change. Sharing information

about the proposed change can be done on a

one-to-one basis, in group meetings, or through

written materials distributed to everyone involved

via print or electronic means.

Disconf irming Currently Held Beliefs

Disconfirming current beliefs is a primary force for

change (Schein, 2004). Providing evidence that

what people are currently doing is inadequate,

incorrect, or inefficient can increase people’s will-

ingness to change. The dramatic presentations

described in the section on receptivity disconfirm

current beliefs and practices. The following is a less

dramatic example but still persuasive:

Jolene was a little nervous when her turn came to present information to the Safe Clinical Practice Committee on a new enteral feeding procedure. Committee members were very demanding: they wanted clear, research-based information presented in a concise manner. Opinions and generalities were not acceptable. Jolene had prepared thoroughly and had practiced her presentation at home until she could speak without referring to her notes. The pre- sentation went well. Committee members commented on how thorough she was and on the quality of the information presented. To her disappointment, however, no action was taken on her proposal.

Returning to her unit, she shared her disap- pointment with the nurse manager. Together, they used the unfreezing-change-refreezing process as a guide to review the presentation. The nurse manager agreed that Jolene had thoroughly reviewed the information on enteral feeding. The problem, she explained, was that Jolene had not attended to the need to unfreeze the situation. Jolene realized that she had not put any emphasis on the high risk of contamination and resulting gastrointestinal dis- turbances of the procedure currently in use. She had left members of the committee feeling comfortable with current practice because she had not empha- sized the risk involved in failing to change it.

At the next meeting, Jolene presented additional information on the risks associated with the current enteral feeding procedures. This disconf irming evidence was persuasive. The committee accepted her proposal to adopt the new, lower-risk procedure.

Without the addition of the disconfirming evidence,

it is likely that Jolene’s proposed change would never

have been implemented. The inertia (tendency to remain in the same state rather than to move toward

change) exhibited by the Safe Clinical Practice

Committee is not unusual (Pearcey & Draper, 1996).

table 8-1

Resistance to Change Active Passive

Attacking the idea Avoiding discussion

Refusing to change Ignoring the change

Arguing against the change Refusing to commit to the


Organizing resistance Agreeing but not acting

of other people

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108 unit 2 | Working Within the Organization

Providing Psychological Safety

As indicated earlier, a proposed change can threaten

people’s basic needs. Resistance can be lowered by

reducing that threat, leaving people feeling more

comfortable with the change. Each situation poses

different kinds of threats and, therefore, requires

different actions to reduce the levels of threat; the

following is a list of useful strategies to increase

psychological safety:

■ Express approval of people’s interest in

providing the best care possible.

■ Recognize the competence and skill of the

people involved.

■ Provide assurance (if possible) that no one will

lose his or her position because of the change.

■ Suggest ways in which the change can provide

new opportunities and challenges (new ways to

increase self-esteem and self-actualization).

■ Involve as many people as possible in the design

or plan to implement change.

■ Provide opportunities for people to express their

feelings and ask questions about the proposed


■ Allow time for practice and learning of any new

procedures before a change is implemented.

Dictating Change

This is an entirely different approach to change.

People in authority in an organization can simply

require people to make a change in what they are

doing or can reassign people to new positions

(Porter-O’Grady, 1996). This may not work well if

there are ways for people to resist; for example:

■ When passive resistance can undermine the change

■ When high motivational levels are necessary to

make the change successful

■ When people can refuse to obey the order with-

out negative consequences

The following is an example of an unsuccessful

attempt to dictate change:

A new and insecure nurse manager believed that her staff members were taking advantage of her inexperi- ence by taking more than the two 15-minute coffee breaks allowed during an 8-hour shift. She decided that staff members would have to sign in and out for their coffee breaks and their 30-minute meal break. Staff members were outraged. Most had been taking fewer than 15 minutes for coffee breaks or 30 minutes for lunch because of the heavy care demands of the

unit. They refused to sign the coffee break sheet. When asked why they had not signed it, they replied “I for- got,” “I couldn’t f ind it,” or “I was called away before I had a chance.” This organized passive resistance was suff icient to overcome the nurse manager’s authority. The nurse manager decided that the coffee break sheet had been a mistake, removed it from the bulletin board, and never mentioned it again.

For people in authority, dictating a change often

seems to be the easiest way to institute change: just

tell people what to do, and do not listen to any

arguments. There is risk in this approach, however.

Even when staff members do not resist authority-

based change, overuse of dictates can lead to a pas-

sive, dependent, unmotivated, and unempowered

staff. Providing high-quality patient care requires

staff members who are active, motivated, and highly

committed to their work.

Leading the Implementation of Change

New graduates may find themselves given respon-

sibility for bringing about change. Following are

examples of the kinds of changes they might be

asked to help implement:

■ Introduce a new technical procedure

■ Implement evidence-based practice guidelines

■ Develop new policies for staff evaluation and


■ Participate in quality-improvement and patient-

safety projects

■ Prepare for accreditation reviews and safety


Now that you understand how change can affect

people and have learned some ways to lower their

resistance to change, taking a leadership role in suc-

cessful implementation of change is presented.

The entire process of bringing about change can

be divided into four phases: designing the change,

deciding how to implement the change, carrying

out the actual implementation, and following

through to ensure the change has been integrated

into the regular operation of the facility (Fig. 8.3).

Designing the Change

This is the starting point. The first step in bringing

about change is to craft the change carefully. Not

every change is for the better: some changes fail

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chapter 8 | People and the Process of Change 109

because they are poorly conceived in the first place.

Ask yourself:

■ What are we trying to accomplish?

■ Is the change necessary?

■ Is the change technically correct?

■ Will it work?

■ Is this change a better way to do things?

This is a good time to use creativity and innovation

(Handy, 2002). Encourage people to talk about the

changes planned, to express their doubts, and to

provide their input (Fullan, 2001). Those who do

are usually enthusiastic supporters later in the



Now is the time to build a “road map” to guide you

on the journey from status quo to completed

change (McCarthy, 2005). All the information pre-

sented previously about sources of resistance and

ways to overcome that resistance should be taken

into consideration when deciding how to imple-

ment a change.

Remember that some research has found nurs-

ing staff to be resistant to change. You are likely to

find supporters, “fence-sitters,” and resisters within

your group (McCarthy, 2005). The supporters will

help you lead people on the path to change, but be

sure to include those who are neutral (the fence-

sitters) and opposed (the resisters) in the process

and to analyze why they might be resistant. Ask


■ Why might people resist this change?

■ Is their resistance justified?

■ What can be done to prevent or overcome this


The context in which the change will take place is

another factor to consider when assessing resist-

ance to change (Lichiello & Madden, 1996). This

includes the amount of change occurring at the

same time, the organizational climate, the environ-

ment surrounding the organization, and past histo-

ry of change in the organization. Is there goodwill

toward change because it has gone well in the past?

Or have the changes gone badly, generating ill will

and resistance to additional change (Maurer,

2008)? There may be external pressure to change

because of the competitive nature of the health-

care market in the community. In other situations,

government regulations may make it difficult to

bring about a desired change.

Almost everything you have learned about

effective leadership is useful in planning the imple-

mentation of change: communicating the vision,

motivating people, involving people in decisions

that affect them, dealing with conflict, eliciting

cooperation, providing coordination, and fostering

teamwork. People have to be moved out of their

comfort zone to unfreeze the situation and get

them ready to change (Flower & Guillaume, 2002).

Consider all these things when formulating a plan

to implement a proposed change, then act on them

in the next step: implementing the change.

Implementing the Change

You are finally ready to embark on the journey that

has been carefully planned. Consider the following


■ Magnitude: Is it a major change that affects almost everything people do, or is it a minor one?

■ Complexity: Is this a difficult change to make? Does it require much new knowledge and skill?

How much time will it take to acquire them?

■ Pace: How urgent is this change? Can it be done gradually, or must it be implemented all at once?

■ Stress: Is this the only change that is taking place, or is it just one of many taking place?

How stressful are these changes? How can you

help people keep their stress at tolerable levels?

A simple change, such as introducing a new

thermometer, may be planned, implemented, and

integrated easily into everyone’s work routine. A

complex change, such as introducing a medication

Design the Change

Plan the Implementation

Implement the Change

Integrate the Change

Figure 8.3 Four phases of planned change.

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110 unit 2 | Working Within the Organization

error reduction system, may require experimenta-

tion with the new system, feedback on what works

and what does not, and revising the plan several

times before the system really works.

Some discomfort is likely to occur with almost

any change, but it is important to keep it within

tolerable limits. Exert pressure to make people pay

attention to the change process, but do not exert so

much pressure that they are overstressed by it. In

other words, you want to raise the heat enough to

get them moving but not so much that they boil

over (Heifetz & Linsky, 2002).

Integrating the Change

Finally, after the change has been made, make sure

that everyone has moved into a new comfort zone.

Ask yourself:

■ Is the change well integrated into everyday


■ Are people comfortable with it?

■ Is it well accepted? Is there any residual resis-

tance that could still undermine full integration

of the change?

It usually takes some time before a change is fully

integrated into everyday routines (Hunter, 2004). As

Kotter noted, change “sticks” when, instead of being

the new way to do something, it has become “the

way we always do things around here” (1999, p. 18).

Personal Change

The focus of this chapter is on leading others

through the process of change. However, choosing

to change is also an important part of your own

development as a leader. Hart and Waisman (2005)

compare personal change with the story of the

caterpillar and the butterfly:

Caterpillars cannot fly. They have to crawl or climb to f ind their food. Butterflies, on the other hand, can soar above an obstacle. They also have a different perspective on their world because they can fly. It is not easy to change from a caterpillar to a butterfly. Indeed, the transition (metamorphosis) may be quite uncomfortable and involves some risk. Are you ready to become a butterfly?

The process of personal change is similar to the

process described throughout this chapter: first rec-

ognize the need for change, then learn how to do

things differently, and then become comfortable

with the “new you” (Guthrie & King, 2004). A

more detailed step-by-step process is given in

Table 8-2. You might, for example, decide that you

need to stop interrupting people when they speak

with you. Or you might want to change your lead-

ership style from laissez-faire to participative.

Would a small change be easier to accomplish

than the radical change in your leadership style?

Perhaps not. Deutschman (2005) reports research

that indicates radical change might be easier to

accomplish because the benefits are evident much

more quickly. An extreme example: many people

could avoid a second coronary bypass or angioplasty

by changing their lifestyle, yet 90% do not do so.

Deutschman compares the typical advice (exercise,

stop smoking, eat healthier meals) with Dean

Ornish’s radical vegetarian diet (only 10% of calories

from fat). After 3 years, 77% of the patients who

went through this extreme change had continued

these lifestyle changes. Why? Ornish suggests

several reasons: (1) after several weeks, people felt a

change—they could walk or have sex without pain;

(2) information alone is not enough—the emotional

aspect is dealt with in support groups and through

meditation, relaxation, yoga, and aerobic exercise;

and (3) the motivation to pursue this change is

redefined—instead of focusing on fear of death, which

many find too frightening, Ornish focuses on the joy

of living, feeling better, and being active without pain.

The traditional approach to change is turned on

its head in this approach: radical change appears

easier to accomplish than a minor change, and peo-

ple are not stressed but feel better making the

change. Deutschman’s five commonly accepted

myths about change that have been refuted by new

insights from research summarize this approach

(Table 8-3).

It remains to be seen whether these new insights

on changing behavior will be useful in the work-

place as well.


Change is an inevitable part of living and working.

How people respond to change, the amount of

stress it causes, and the amount of resistance it

provokes can be influenced by leadership. Handled

well, most changes can become opportunities for

professional growth and development rather than

just additional stressors with which nurses and

their clients have to cope.

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chapter 8 | People and the Process of Change 111

table 8-2

Which Stage of Change Are You In? While studying how smokers quit the habit, Dr. James Prochaska, a psychologist at the University of Rhode Island, developed

a widely influential model of the “stages of change.” What stage are you in? See if any of the following statements sound


Typical Statement Stage Risks

Adapted from Deutschman’s Which Stage of Change Are You In? “Typical statements” adapted from Stages of Change: Theory and Practice by Michael

Samuelson, executive director of the National Center for Health Promotion.
















You are in denial. You probably feel coerced by

other people who are trying to make you

change. But they are not going to shame you

into it—their meddling will backfire.

Feeling righteous because of your good

intentions, you could stay in this stage for

years. But you might respond to the emotional

persuasion of a compelling leader.

This “rehearsal” can become your reality. Some

85% of people who need to change their

behavior for health reasons never get to this

stage or progress beyond it.

It is an emotional struggle. It is important to

change quickly enough to feel the short-term

benefits that give a psychic lift and make it

easier to stick with the change.

Relapse. Even though you have created a new

mental pathway, the old pathway is still there

in your brain, and when you are under a lot of

stress, you might fall back on it.

“As far as I’m concerned, I don’t have any

problems that need changing.”

“I guess I have faults, but there’s nothing that

I really need to change.”

“I’ve been thinking that I wanted to change

something about myself.”

“I wish I had more ideas on how to solve my


“I have decided to make changes in the next

2 weeks.”

“I am committed to join a fitness club by the

end of the month.”

“Anyone can talk about changing. I’m actually

doing something about it.”

“I am doing okay, but I wish I was more


“I may need a boost right now to help me

maintain the changes I’ve already made.”

“This has become part of my day, and I feel it

when I don’t follow through.”

table 8-3

Five Myths About Changing Behavior Myth Reality

1. Crisis is a powerful impetus for change. Ninety percent of patients who have had coronary bypasses do not sustain

changes in the unhealthy lifestyles, which worsens their severe heart

disease and greatly threatens their lives.

2. Change is motivated by fear. It is too easy for people to go into denial of the bad things that might

happen to them. Compelling positive visions of the future are a much

stronger inspiration for change.

3. The facts will set us free. Our thinking is guided by narratives, not facts. When a fact does not fit

people’s conceptual “frames”—the metaphors used to make sense of the

world—people reject the fact. Also, change is best inspired by emotional

appeals rather than factual statements.

4. Small, gradual changes are always Radical, sweeping changes are often easier because they yield benefits

easier to make and sustain. quickly.

5. People cannot change because Brains have extraordinary “plasticity,” meaning that people can continue

the brain becomes “hardwired” early in life. learning complex new things throughout life—assuming they remain

truly active and engaged.

Adapted from Deutschman’s Fact Take: Five Myths About Changing Behavior. Deutschman, A. (2005/May). Change or die. Fast Company, 94, 52–62.

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112 unit 2 | Working Within the Organization

Study Questions

1. Why is change inevitable? What would happen if no change at all occurred in health care?

2. Why do people resist change? Why do nursing staff members seem particularly resistant to change?

3. How can leaders overcome resistance to change?

4. Describe the process of implementing a change from beginning to end. Use an example from your

clinical experience to illustrate this process.

Case Study to Promote Critical Reasoning

A large health-care corporation recently purchased a small, 50-bed rural nursing home. A new

director of nursing was brought in to replace the former one, who had retired after 30 years. The

new director addressed the staff members at the reception held to welcome him. “My philosophy is

that you cannot manage anything that you haven’t measured. Everyone tells me that you have all

been doing an excellent job here. With my measurement approach, we will be able to analyze

everything you do and become more efficient than ever.” The nursing staff members soon found

out what the new director meant by his measurement approach. Every bath, episode of inconti-

nence care, feeding of a resident, or trip off the unit had to be counted, and the amount of time

each activity required had to be recorded. Nurse managers were required to review these data with

staff members every week, questioning any time that was not accounted for. Time spent talking

with families or consulting with other staff members was considered time wasted unless the staff

member could justify the “interruption” in his or her work. No one complained openly about the

change, but absenteeism rates increased rapidly. Personal day and vacation time requests soared.

Staff members nearing retirement crowded the tiny personnel office, overwhelming the single staff

member with their requests to “tell me how soon I can retire with full benefits.” The director of

nursing found that shortage of staff was becoming a serious problem and that no new applications

were coming in, despite the fact that this rural area offered few good job opportunities.

1. What evidence of resistance to change can you find in this case study?

2. What kind of resistance to change did the staff members exhibit?

3. If you were a staff nurse at this facility, how do you think you would have reacted to this change in


4. Why did staff members resist this change?

5. What could the director of nursing do to increase acceptance of this change? What could the nurse

managers and staff nurses do?

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chapter 9 Delegation of Client Care

OBJECTIVES After reading this chapter, the student should be able to: ■ Define the term delegation.

■ Define the term unlicensed assistive personnel.

■ Understand the legal implications of making assignments to other health-care personnel.

■ Recognize barriers to successful delegation.

■ Make appropriate assignments to team members.

■ Explain the various nursing care delivery models.


Introduction to Delegation

Definition of Delegation


The Nursing Process and Delegation

Coordinating Assignments

The Need for Delegation

Safe Delegation

Criteria for Delegation

Task-Related Concerns





Relationship-Oriented Concerns


Learning Opportunities



Staff Preferences

Barriers to Delegation

Experience Issues

Licensure Issues

Legal Issues and Delegation

Quality-of-Care Issues

Assigning Work to Others

Models of Care Delivery

Functional Nursing

Team Nursing

Total Client Care

Primary Nursing



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116 unit 2 | Working Within the Organization

Linda is a new graduate and has just f inished her orientation. She works from 7 p.m. to 7 a.m. on a busy, monitored neuroscience unit. The client census is 48, making this a full unit. Although there is an associate nurse manager for the shift, Linda is the charge nurse. Her responsibilities include receiving and transcribing orders, contacting physicians with any information or requests, accessing laboratory reports from the computer, reviewing them and giv- ing them to the appropriate staff members, checking any new medication orders and placing them in the appropriate medication administration records, relieving the monitor technician for dinner and breaks, and assigning staff to dinner and breaks. When Linda comes to work, she discovers that one registered nurse (RN) called in sick. She has two RNs and three unlicensed assistive personnel (UAP) for staff. She panics and wants to refuse to take report. After a discussion with the charge nurse from the previous shift, she realizes that not taking report is not an option. She sits down to evaluate the acu- ity of the clients and the capabilities of her staff.

Introduction to Delegation

Delegation is not a new concept. In her Notes on Nursing, Florence Nightingale (1859) clearly stated: “Don’t imagine that if you, who are in

charge, don’t look to all these things yourself, those

under you will be more careful than you are....” She

continued by directing, “But then again to look to

all these things yourself does not mean to do them

yourself. If you do it, it is by so much the better

certainly than if it were not done at all. But can you

not insure that it is done when not done by your-

self? Can you insure that it is not undone when

your back is turned? This is what being in charge

means. And a very important meaning it is, too.

The former only implies that just what you can do

with your own hands is done. The latter that what

ought to be done is always done. Head in charge

must see to house hygiene, not do it herself ” (p. 17).

Definition of Delegation

By definition, delegation is the reassigning of

responsibility for the performance of a job from

one person to another (American Nurses

Association [ANA], 1996). RNs maintain account-

ability for supervising those to whom tasks are del-

egated (ANA, 2005). Although the responsibility

for the task is transferred, the accountability for the

process or outcome of the task remains with the

delegator, or the person delegating the activity.

Nightingale referred to this delegation responsibil-

ity when she inferred that the “head in charge” does

not necessarily carry out the task but still sees that

it is completed.

An assignment is not the same as delegation.

In an assignment, power is not transferred.

Assignments refer to practical or routine functions

that are part of a job description or client needs.

For example, the team leader assigns three clients

to the licensed practical nurse (LPN). That is part

of the job description for the LPN. However, giv-

ing medications to all the clients on the team is a

delegated responsibility.

According to the ANA, specific overlying prin-

ciples remain firm regarding delegation. These

include the following:

■ The nursing profession delineates the scope of

nursing practice.

■ The nursing profession identifies and supervises

the necessary education, training, and use of

ancillary roles concerned with the delivery of

direct client care.

■ The RN assumes responsibility and accountabil-

ity for the provision of nursing practice.

■ The RN directs care and determines the

appropriate utilization of any ancillary personnel

involved in providing direct client care.

■ The RN accepts assistance from ancillary nurs-

ing personnel in delivering nursing care for the

client (ANA, 2005, p. 6).

Nurse-related principles are also designated by the

ANA. These are important when considering what

tasks may be delegated and to whom. These princi-

ples are:

■ The RN has the duty to be accountable for

personal actions related to the nursing process.

■ The RN considers the knowledge and skills of

any ancillary personnel to whom aspects of care

are delegated.

■ The decision to delegate or assign is based on

the RN’s judgment regarding the following: the

condition of the client; the competence of the

members of the nursing team; the amount of

supervision that will be required of the RN if a

task is delegated.

■ The RN uses critical thinking and professional

judgment when following the Five Rights of

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chapter 9 | Delegation of Client Care 117

Delegation delineated by the National Council

of State Boards of Nursing (NCSBN) (Box 9-1).

■ The RN recognizes that a relational aspect exists

between delegation and communication.

Communication needs to be culturally appropri-

ate, and the individual receiving the communi-

cation should be treated with respect.

■ Chief nursing officers are responsible for

creating systems to assess, monitor, verify, and

communicate continuous competence require-

ments in areas related to delegation.

■ RNs monitor organizational policies, procedures,

and job descriptions to ensure they are in

compliance with the nurse practice act, consult-

ing with the state board of nursing as needed

(ANA, 2005, p. 6).

Delegation may be direct or indirect. Direct delega- tion is usually “verbal direction by the RN delegator regarding an activity or task in a specific nursing

care situation” (ANA, 1996, p. 15). In this case, the

RN decides which staff member is capable of per-

forming the specific task or activity. Indirect delega- tion is “an approved listing of activities or tasks that have been established in policies and procedures of

the health care institution or facility” (ANA, 1996,

p. 15). The ANA also differentiated the delegation

of a task from the assignment of a task. Although

the terms are often used interchangeably, according

to the ANA (1996), assignment is the “downward

or lateral transfer of both the responsibility and the

accountability of an activity from one person to

another.” When one RN “delegates” to another RN,

that RN, based on knowledge and skill, may be

responsible and accountable. UAP may also be

assigned, rather than “delegated,” a task. For exam-

ple, UAP have the knowledge and skills required for

some routine tasks (Ellis & Hartley, 2004).

The recent changes occurring in the health-care

environment continue to modify the scope of nurs-

ing practice and the activities delegated to UAP. A

main concern in almost all health-care settings is

that UAP are performing inappropriate functions

that belong within the legal realm of nursing

(ANA, 2002).

Permitted tasks vary from institution to institu-

tion. For example, a certified nursing assistant

(CNA) performs specific activities designated by the

job description approved by the particular health-

care institution. Although the institution delineates

tasks and activities, this does not mean that the RN

cannot decide to assign other personnel in specific

situations. Take the following example:

Ms. Ross was admitted to the neurological unit from the neuroscience intensive care unit. She suf- fered a grade II subarachnoid hemorrhage 2 weeks ago and has a left hemiparesis. She has diff iculty with swallowing and receives tube feedings through a percutaneous endoscopic gastrostomy (PEG) tube; however, she has been advanced to a pureed diet. She needs assistance with personal care, toileting, and feeding. A physical therapist comes twice a day to get her up for gait training; otherwise, the physi- cian wants her in a chair as much as possible.

Assessing this situation, the RN might consider

assigning an LPN to this client. The swallowing

problems place the client at risk for aspiration,

which means that feeding may present a problem.

There is a potential for injury. The LPN is capable

of managing the PEG tube feeding. While assist-

ing with bathing, the LPN can perform range-

of-motion exercises to all the client’s extremities

and assess her skin for breakdown. The LPN also

knows the appropriate way to assist the client in

transferring from the bed to the chair. The RN may

not assign an individual to perform a task or activ-

ity not specified in that person’s job description

or within the scope of practice, such as allowing

a nursing assistant to administer medications or

perform certain types of dressing changes.


Do not confuse delegation with supervision.

Supervision is more direct and requires directly

overseeing the work or performance of others.

Supervision includes checking with individuals

throughout the day to see what activities have been

completed and what may still need to be finished.

For example, a nursing assistant has been assigned

to take all the vital signs on the unit and give the

morning baths to eight clients. Three hours into

the morning, she is far behind. At this point, it is

box 9-1

The Five Rights of Delegation 1. Right task

2. Right circumstances

3. Right person

4. Right direction/communication

5. Right supervision/evaluation

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118 unit 2 | Working Within the Organization

important that the RN discover why. Perhaps one

of the clients required more care than expected, or

the nursing assistant needed to do an errand off the

floor. Reevaluation of the assignment may be nec-

essary. When one RN works with another, then

supervision is not needed. This is a collaborative

relationship and includes consulting and giving

advice when needed.

Individuals who supervise others also delegate

tasks and activities. Chief nursing officers often

delegate tasks to associate directors. This may

include record reviews, unit reports, or client

acuities. Certain administrative tasks, such as staff

scheduling, may be delegated to another staff

member, such as an associate manager. The chief

nursing officer remains accountable for ensuring

the activities are completed.

Supervision sometimes entails more direct

evaluation of performance, such as performance

evaluations and discussions regarding individual

interactions with clients and other staff members.

Regardless of where you work, you cannot

assume that only those in the higher levels of the

organization delegate work to other people. You,

too, will be responsible at times for delegating some

of your work to other nurses, to technical person-

nel, or to another department. Decisions associated

with this responsibility often cause some difficulty

for new nurses. Knowing each person’s capabilities

and job description can help you decide which

personnel can assist with a task.

The Nursing Process and Delegation

Before deciding who should care for a particular

client, the nurse must assess each client’s particular

needs, set client-specific goals, and match the skills

of the person assigned with the tasks that need to

be accomplished (assessment). Thinking this through before delegating helps prevent problems

later (plan). Next, the nurse assigns the tasks to the appropriate person (implementation). The nurse must then oversee the care and determine whether

client care needs have been met (evaluation). It is also important for the nurse to allow time for feed-

back during the day. This enables all personnel to

see where they are and where they want to go.

Often, the nurse must first coordinate care for

groups of clients before being able to delegate tasks

to other personnel. The nurse also needs to consider

his or her own responsibilities. This includes assisting

other staff members with setting priorities, commu-

nicating clearly, clarifying instructions, and reassess-

ing the situation.

In 1995 the NCSBN published a paper address-

ing the issue of delegation. The NCSBN developed

a concept called the Five Rights of Delegation (see

Box 9-1), similar to the five rights regarding

medication administration. In 2006 the NCSBN,

along with the ANA, prepared a joint statement on

delegation that clarified the profession’s practice

guidelines and the legal requisites for delegation.

Before being able to delegate tasks and activities to

other individuals, however, the nurse must under-

stand the needs of each client.

Coordinating Assignments

One of the most difficult tasks for new nurses to

master is coordinating daily activities. Often, you

have clients for whom you provide direct care, and

you must supervise the work of others, such as non-

nurse caregivers, LPNs, or vocational nurses.

Although care plans, critical (or clinical) pathways,

concept maps, and computer information sheets are

available to help identify client needs, these items

do not provide a mechanism for coordinating the

delivery of care. To do this, personalized work-

sheets can be developed that prioritize tasks to per-

form for each client. Using the worksheets helps

the nurse identify tasks that require the knowledge

and skill of an RN and those that can be carried out

by UAP.

On the worksheet, tasks are prioritized on the

basis of client need, not nursing convenience. For

example, an order states that a client is to receive

continuous tube feedings. Although it may be con-

venient for the nurse to fill the feeding container

with enough supplement to last 6 hours, it is not

good practice and not safe for the client. Instead,

the nurse should plan to check the tube feeding

every 2 hours.

As for Linda at the beginning of the chapter, a

worksheet can help her determine who can do

what. First, she needs to decide what particular

tasks she must do. These include receiving and

transcribing orders; contacting physicians with

information or requests; accessing laboratory

reports from the computer, reviewing them, and

giving them to the appropriate staff members; and

checking any new medication orders and placing

them in the medication administration records.

Another RN may be able to relieve the monitor

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chapter 9 | Delegation of Client Care 119

technician for dinner and breaks, and a second RN

may be able to assign staff to dinner and breaks.

Next, Linda needs to look at the needs of each

client on the unit and prioritize them. She is now

ready to delegate to her staff effectively.

Some activities must be done at a certain time,

and their timing may be out of one’s control.

Examples include medication administration and

clients who need special preparation for a sched-

uled procedure. The following are some tips for

organizing work on personalized worksheets to

help establish client priorities (Tappen, Weiss, &

Whitehead, 2004):

■ Plan your time around these activities.

■ Do high-priority activities first.

■ Determine which activities are best done in a


■ Remember that you are responsible for activities

delegated to others.

■ Consider your peak energy time when schedul-

ing optional activities.

This list acts as a guideline for coordinating client

care. The nurse needs to use critical thinking skills

in the decision-making process. Remember that

this is one of the ANA nurse-related principles of

delegation (ANA, 2005). For example, activities

that are usually clustered include bathing, changing

linen, and parts of the physical assessment. Some

clients may not be able to tolerate too much activ-

ity at one time. Take special situations into consid-

eration when coordinating client care and deciding

who should carry out some of the activities.

Remember, however, that even when you delegate,

you remain accountable.

Figure 9.1 is an example of a personalized work-

sheet. (See Chapter 11, Time Management, for a

complete discussion.)

The Need for Delegation

The 1990s brought rapid change to the health-care

environment. Several forces came together at one

time, including the nursing shortage, health-care

reform, an increased need for nursing services, and

demographic trends. These changes continue to

have an impact on the delivery of nursing care,

requiring institutions to hire other personnel to

assist nurses with client care (Zimmerman, 1996).

Health-care institutions often use UAP to per-

form certain client care tasks (Habel, 2001;

Hansten & Jackson, 2004; Huber, Blegan, &

McCloskey, 1994). As the nursing shortage

becomes more critical, there is a greater need for

institutions to recruit the services of UAPs (ANA,

2002). A survey conducted by the American

Hospital Association revealed that 97% of hospi-

tals currently employ some type of UAP. Because a

high percentage of institutions employ these per-

sonnel, many nurses believe they know how to

work with and safely delegate tasks to them. This

is not the case. Therefore, many nursing organiza-

tions have developed definitions for UAP and cri-

teria regarding their responsibilities. The ANA

defines UAP as follows:

Unlicensed assistive personnel are individuals who are trained to function in an assistive role to the registered nurse in the provision of patient/client care activities as delegated by and under the supervision of the registered professional nurse. Although some of these people may be certi- f ied (e.g., certif ied nursing assistant [CNA]), it is important to remember that certif ication differs from licensure. When a task is delegated to an unlicensed person, the professional nurse remains personally responsible for the outcomes of these activities (ANA, 2005).

As work on the UAP issue is ongoing, the ANA

has recently updated its position statements to

define direct and indirect patient care activities that

may be performed by UAP. Included in these

updates are specific definitions regarding UAP and

technicians and acceptable tasks.

Use of the RN to provide all the care a client

needs may not be the most efficient or cost-effective

use of professional time. More hospitals are moving

away from hiring LPNs and utilizing all RN

staffing with UAP. For this reason, the nursing focus

is directed at diagnosing client care needs and car-

rying out complex interventions.

The ANA cautions against delegating nursing

activities that include the foundation of the nursing

process and that require specialized knowledge,

judgment, or skill (ANA, 1996, 2002, 2005). Non-

nursing functions, such as performing clerical or

receptionist duties, taking trips or doing errands off

the unit, cleaning floors, making beds, collecting

trays, and ordering supplies, should not be carried

out by the highest paid and most educated member

of the team. These tasks are easily delegated to

other personnel.

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120 unit 2 | Working Within the Organization

Safe Delegation

In 1990 the NCSBN adopted a definition of delega-

tion, stating that delegation is “transferring to a com-

petent individual the authority to perform a selected

nursing task in a selected situation” (p. 1). In its

publication Issues (1995), the NCSBN again presented this definition. Likewise, the ANA Code for Nurses

(1985) stated, “The nurse exercises informed judg-

ment and uses individual competence and qualifica-

tions as criteria in seeking consultation, accepting

responsibilities, and delegating nursing activities to

Nurse/Team _____________________________________________DNR 8607/Code 99

Patient Room # ______ Name _________________ Age ________________________



Diet _________Fluids: PO __________ IV__________ Type _____________________

Restrictions: BR _______ BRP ______OOB/Chair______ Ambulate with assist ______

Activity ________________________________________________________________

Assessment ____________________________________________________________


1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

4. ____________________________________________________________________

5. ____________________________________________________________________


1. Vital signs: Temp _____ Pulse _______ AHR______ BP ______ Parameters ________

2. Cardiac Monitor: Rhythm_____________________ Rate ______________________

3. Neurologic Status _____________________________________________________

4. CMS: __________________________ Traction:______________________________

Figure 9.1 Personalized patient worksheet.

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chapter 9 | Delegation of Client Care 121

others” (p. 1). In 2005, the ANA defined delegation

as “the transfer of responsibility for the performance

of an activity from one individual to another while

retaining accountability for the outcome” (p. 4). To

delegate tasks safely, nurses must delegate appropri-

ately and supervise adequately.

In 1997 the NCSBN developed a Delegation

Decision-Making Grid. This grid is a tool to help

nurses delegate appropriately. It provides a scoring

instrument for seven categories that the nurse

should consider when making delegation decisions.

The categories for the grid are listed in Box 9-2.

Scoring the components helps the nurse evalu-

ate the situations, the client needs, and the health-

care personnel available to meet the needs. A low

score on the grid indicates that the activity may be

safely delegated to personnel other than the RN,

and a high score indicates that delegation may not

be advisable. Figure 9.2 shows the Delegation

Decision-Making Grid. The grid is also available

on the NCSBN Web site at ncsbn.com

Nurses who delegate tasks to UAP should eval-

uate the activities being considered for delegation

(Keeney, Hasson, & McKenna, 2005). The

American Association of Critical Care Nurses

(AACN) (1990) recommended considering five

factors, which are listed in Box 9-3, in making a

decision to delegate.

It is the responsibility of the RN to be well

acquainted with the state’s nurse practice act and

regulations issued by the state board of nursing

regarding UAP (ANA, 2005). State laws and regu-

lations supersede any publications or opinions set

forth by professional organizations. As stated earlier,

the NCSBN provides criteria to assist nurses

with delegation.

LPNs are trained to perform specific tasks, such

as basic medication administration, dressing

changes, and personal hygiene tasks. In some states,

the LPN, with additional training, may start and

monitor intravenous (IV ) infusions and administer

certain medications.

Criteria for Delegation

The purpose of delegation is not to assign tasks to

others that you do not want to do yourself. When

you delegate to others effectively, the result is you

have more time to perform the tasks that only a

professional nurse is permitted to do.

In delegating, the nurse must consider both the

ability of the person to whom the task is delegated and the fairness of the task to the individual and the team (Tappen, Weiss, & Whitehead, 2004). In

other words, both the task aspects of delegation (Is this a complex task? Is it a professional respon-

sibility? Can this person do it safely?) and the

interpersonal aspects (Does the person have time to do this? Is the work evenly distributed?) must be


The ANA (2005) has specified tasks that RNs

may not delegate because they are specific to the

discipline of professional nursing. These activities

include (Boysen & Fischer, 2000):

■ Initial nursing and follow-up assessments if

nursing judgment is indicated

■ Decisions and judgments about client outcomes

■ Determination and approval of a client plan of


■ Interventions that require professional nursing

knowledge, decisions, or skills

■ Decisions and judgments necessary for the

evaluation of client care

Task-Related Concerns

The primary task-related concern in delegating

work is whether the person assigned to do the task

has the ability to complete it. Team priorities and

efficiency are also important considerations.


To make appropriate assignments, the nurse needs

to know the knowledge and skill level, legal defi-

nitions, role expectations, and job description

for each member of the team. It is equally impor-

tant to be aware of the different skill levels of

box 9-2

Seven Components of the Delegation Decision-Making Grid

• Level of client acuity

• Level of unlicensed assistive personnel capability

• Level of licensed nurse capability

• Possibility for injury

• Number of times the skill has been performed by the

unlicensed assistive personnel

• Level of decision making needed for the activity

• Client’s ability for self-care

Adapted from the National Council of State Boards of Nursing. Delegation

Decision-Making Grid. National State Boards of Nursing, Inc., 1997


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122 unit 2 | Working Within the Organization

Elements for Review

Client A

Client B

Client C

Client D


Level of Client Stability

Level of UAP Competence

Level of Licensed Nurse Competence

Potential for Harm


Level of Decision Making

Ability for Self-Care

Describe activity/task:

Score the client’s level of stability: 0. Client condition is chronic/stable/predictable 1. Client condition has minimal potential for change 2. Client condition has moderate potential for change 3. Client condition is unstable/acute/strong potential for change

Score the UAP competence in completing delegated nursing care activities in the defined client population: 0. UAP - expert in activities to be delegated, in defined population 1. UAP - experienced in activities to be delegated, in defined

population 2. UAP - experienced in activities, but not in defined population 3. UAP - novice in performing activities and in defined population

Score the licensed nurse’s competence in relation to both knowledge of providing nursing care to a defined population and competence in implementation of the delegation process: 0. Expert in the knowledge of nursing needs/activities of defined

client population and expert in the delegation process 1. Either expert in knowledge of needs/activities of defined client

population and competent in delegation or experienced in the needs/activities of defined client population and expert in the delegation process

2. Experienced in the knowledge of needs/activities of defined client population and competent in the delegation process

3. Either experienced in the knowledge of needs/activities of defined client population or competent in the delegation process

4. Novice in knowledge of defined population and novice in delegation

Score the potential level of risk the nursing care activity has for the client (risk is probability of suffering harm): 0. None 1. Low 2. Medium 3. High

Score based on how often the UAP has performed the specific nursing care activity: 0. Performed at least daily 1. Performed at least weekly 2. Performed at least monthly 3. Performed less than monthly 4. Never performed

Score the decision making needed, related to the specific nursing care activity, client (both cognitive and physical status), and client situation: 0. Does not require decision making 1. Minimal level of decision making 2. Moderate level of decision making 3. High level of decision making

Score the client’s level of assistance needed for self-care activities: 0. No assistance 1. Limited assistance 2. Extensive assistance 3. Total care or constant attendance

Total Score

Figure 9.2 Delegation decision-making grid.

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chapter 9 | Delegation of Client Care 123

caregivers within each discipline because ability

differs with each level of education. Additionally,

individuals within each level of skill possess their

own strengths and weaknesses. Prior assessment

of the strengths of each member of the team will

assist in providing safe and efficient care to

clients. Figure 9.3 outlines the skills of various

health-care personnel.

People should not be assigned a task that they

are not skilled in or knowledgeable to perform,

regardless of their professional level. People are

often reluctant to admit they cannot do something.

Instead of seeking help or saying they are not com-

fortable with a task, they may avoid doing it, delay

starting it, do only part of it, or even bluff their way

through it, a risky choice in health care.

Regardless of the length of time individuals

have been in a position, employees need orientation

when assigned a new task. Those who seek assis-

tance and advice are showing concern for the team

and the welfare of their clients. Requests for assis-

tance or additional explanations should not be

ignored, and the person should be praised, not

criticized, for seeking guidance (Tappen, Weiss, &

Whitehead, 2004).


The work of a busy unit rarely ends up going as

expected. Dealing with sick people, their families,

physicians, and other team members all at the same

time is a difficult task. Setting priorities for the day

should be based on client needs, team needs, and

organizational and community demands. The val-

ues of each may be very different, even opposed.

These differences should be discussed with team

members so that decisions can be made based on

team priorities.

One way to determine patient priorities is to base

decisions on Maslow’s hierarchy of needs. Maslow’s

hierarchy is frequently used in nursing to provide a

framework for prioritizing care to meet client needs.

The basic physiological needs come first because

they are necessary for survival. For example, oxygen

and medication administration, IV fluids, and enter-

al feedings are included in this group.

Identifying priorities and deciding the needs to

be met first help in organizing care and in deciding

which other team members can meet client needs.

For example, nursing assistants can meet many

hygiene needs, allowing licensed personnel to

administer medications and enteral feedings in a

timely manner.


Efficiency means that all members of the team

know their jobs and responsibilities and work

together like gears in a well-built clock. They mesh

together and keep perfect time.

Five Factors for Determining if Client Care Activity Should Be Delegated

• Potential for harm to the patient

• Complexity of the nursing activity

• Extent of problem solving and innovation required

• Predictability of outcome

• Extent of interaction

Adapted from American Association of Critical Care Nurses (AACN). (1990).

Delegation of Nursing and Non-Nursing Activities in Critical Care: A

Framework for Decision-Making. Irvine, CA: AACN.

LPN Skills

Vital signs Some IV medication (depending on state Nurse Practice Act and institution)

Physical care

Ancillary Personnel

Patient Care Needs

PT OT Nutrition Speech


Feeding Hygiene Physical care

RN Skills

Assessment IV medications Blood administration Planning care Physician orders Teaching

Figure 9.3 Diagram of delegation decision-making grid.

box 9-3

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124 unit 2 | Working Within the Organization

The current health-care delivery environment

demands efficient, cost-effective care. Delegating

appropriately can increase efficiency and save

money. Likewise, incorrect delegation can decrease

efficiency and cost money. When delegating tasks

to individuals who cannot perform the job, the RN

must often go back to perform the task.

Although institutions often need to “float” staff

to other units, maintaining continuity, if at all pos-

sible, is important. Keeping the same staff members

on the unit all the time, for example, allows them to

develop familiarity with the physical setting and

routines of the unit as well as the types of clients the

unit services. Time is lost when staff members are

reassigned frequently to different units. Although

physical layouts may be the same, client needs, unit

routines, use of space, and availability of supplies are

often different. Time spent to orient reassigned staff

members takes time away from delivery of client

care. However, when staff members are reassigned,

it is important for them to indicate their skill level

and comfort in the new setting. It is just as impor-

tant for the staff members who are familiar with the

setting to identify the strengths of the reassigned

person and build on them.


Appropriateness is another task-related concern.

Nothing can be more counterproductive than, for

example, floating a coronary care nurse to labor and

delivery. More time will be spent teaching the nec-

essary skills than on safe mother-baby care.

Assigning an educated, licensed staff member to

perform non-nursing functions to protect safety is

also poor use of personnel.

Relationship-Oriented Concerns

Relationship-oriented concerns include fairness,

learning opportunities, health concerns, compati-

bility, and staff preferences.


Fairness means distributing the workload evenly in

terms of both the physical requirements and the

emotional investment in providing health care. The

nurse who is caring for a dying client may have less

physical work to do than another team member,

but in terms of emotional care to the client and

family, he or she may be doing double the work of

another staff member.

Fairness also means considering equally all

requests for special consideration. The quickest way

to alienate members of a team is to be unfair. It is

important to discuss with team members any deci-

sions that have been made that may appear unfair

to any one of them. Allow the team members to

participate in making decisions regarding assign-

ments. Their participation will decrease resentment

and increase cooperation. In some health-care

institutions, team members make such decisions as

a group.

Learning Opportunities

Including assignments that stimulate motivation,

learning, and assisting team members to learn new

tasks and take on new challenges is part of the role

of the RN.


Some aspects of caregiving jobs are more stressful

than others. Rotating team members through the

more difficult jobs may decrease stress and allow

empathy to increase among the members. Special

health needs, such as family emergencies or special

physical problems of team members, also need to

be addressed. If some team members have difficul-

ty accepting the needs of others, the situation

should be discussed with the team, bearing in mind

the employee’s right to privacy when discussing

sensitive issues.


No matter how hard you may strive to get your team

to work together, it just may not happen. Some peo-

ple work together better than others. Helping peo-

ple develop better working relationships is part of

team building. Creating opportunities for people to

share and learn from each other increases the over-

all effectiveness of the team.

As the leader, you may be forced to intervene in

team member disputes. Many individuals find it

difficult to work with others they do not like person-

ally. It sometimes becomes necessary to explain that

liking another person is a plus but not a necessity in

the work setting and that personal problems have no

place in the work environment. For example:

Laura had been a labor and delivery room supervi- sor in a large metropolitan hospital for 5 years before she moved to another city. Because a position similar to the one she left was not available, she became a

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chapter 9 | Delegation of Client Care 125

staff nurse at a small local hospital. The hospital had just opened its new birthing center. The f irst day on the job went well. The other staff members seemed cordial. As the weeks went by, however, Laura began to have problems getting other staff to help her. No one would offer to relieve her for meals or a break. She noticed that certain groups of staff members always went to lunch together but that she was never invited to join them. She attempted to speak to some of the more approachable coworkers, but she did not get much information. Disturbed by the situation, Laura went to the nurse manager. The nurse man- ager listened quietly while Laura related her experi- ences. She then asked Laura to think about the last staff meeting. Laura realized that she had alienated the staff during the meeting because she had said repeatedly that in “her hospital ” things were done in a particular way. Laura also realized that, instead of asking for help, she was in the habit of demanding it. Laura and the nurse manager discussed the diff icul- ties of her changing positions, moving to a new place, and trying to develop both professional and social ties. Together, they came up with several solutions to Laura’s problem.

Staff Preferences

Considering the preferences of individual team

members is important but should not supersede

other criteria for delegating responsibly. Allowing

team members to always select what they want to

do may cause the less assertive members’ needs to

be unmet.

It is important to explain the rationale for deci-

sions made regarding delegation so that all team

members may understand the needs of the unit or

organization. Box 9-4 outlines basic rights for pro-

fessional health-care team members. Although

written originally for women, the concepts are

applicable to all professional health-care providers.

Barriers to Delegation

Many nurses, particularly new ones, have difficulty

delegating. The reasons for this include experience

issues, licensure issues, and quality-of-care issues.

Experience Issues

Many nurses received their education during the

1980s, when primary care was the major delivery

system. These nurses lacked the education and skill

needed for delegation (Mahlmeister, 1999). Nurses

educated before the 1970s worked in settings with

LPNs and nursing assistants, where they routinely

delegated tasks. However, client acuity was lower

and the care less complex. Older nurses have con-

siderable delegation experience and can be a

resource for younger nurses.

The added responsibility of delegation creates

some discomfort for nurses. Many believe they are

unprepared to assume this responsibility, especially

in deciding the competency of another person. To

decrease this discomfort, nurses need to participate

in establishing guidelines for UAP within their

institution. The ANA Position Statements on

Unlicensed Assistive Personnel address this.

Table 9-1 lists the direct and indirect client care

activities that may be performed by UAP.

Licensure Issues

The current health-care environment requires

nurses to delegate. Many nurses voice concerns

about the personal risk regarding their licensure if

they delegate inappropriately. The courts have usu-

ally ruled that nurses are not liable for the negli-

gence of other individuals, provided that the nurse

delegated appropriately. Delegation is within the

scope of nursing practice. The art and skill of dele-

gation are acquired with practice.

Legal Issues and Delegation

State nurse practice acts establish the legal bound-

aries for nursing practice. Professional nursing

organizations define practice standards, and the

policies of the health-care institution create job

descriptions and establish policies that guide appro-

priate delegation decisions for the organization.

box 9-4

Basic Entitlements of Individuals in the Workplace

Professionals in the workplace are entitled to:

• Respect from others in the work setting

• A reasonable and equitable workload

• Wages commensurate with the job

• Determine his or her own priorities

• Ask for what he or she wants

• Refuse without guilt

• Make mistakes and be accountable for them

• Give and receive information as a professional nurse

• Act in the best interest of the client

• Be human

Adapted from Chevernet, M. (1988). STAT: Special Techniques in Assertiveness

Training for Women in Healthcare Professions, 2nd ed. St. Louis, Mo.: Mosby.

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126 unit 2 | Working Within the Organization

Inherent in today’s health-care environment is

the safety of the client. The quality of client care

and the delievery of safe and effective care are cen-

tral to the concept of delegation. RNs are held

accountable when delegating care activities to oth-

ers. This means that they have an obligation to

intervene whenever they deem the care provided is

unsafe or unethical. It is also important to realize

that a delegated task may not be “sub-delegated.”

In other words, if the RN delegated a task to the

LPN, the LPN cannot then delegate the task to the

UAP, even if the LPN has decided that it is within

the abilities of that particular UAP. There may be

legal implications if a client is injured as a result of

inappropriate delegation. Take the following case:

In Hicks v. New York State Department of Health, a nurse was found guilty of patient neglect because of her failure to appropriately train and supervise the UAP working under her. In this particular situation, a security guard discovered an elderly nursing home client in a totally dark room undressed and covered with urine and fecal materi- al. The client was partially in his bed and partially restrained in an overturned wheelchair. The court found the nurse guilty on the following: the nurse failed to assess whether the UAP had delivered proper care to the client, and this subsequently led to the inadequate delivery of care (1991).

Quality-of-Care Issues

Nurses have expressed concern over the quality of

client care when tasks and activities are delegated

to others. Remember Nightingale’s words earlier in

the chapter, “Don’t imagine that if you, who are in

charge, don’t look to all these things yourself, those

under you will be more careful than you are.” She

added that you do not need to do everything

yourself to see that it is done correctly. When you

delegate, you control the delegation. You decide to

whom you will delegate the task. Remember that

there are levels of acceptable performance and that

not every task needs to be done perfectly.

Assigning Work to Others

Assigning work can be difficult for several reasons:

1. Some nurses think they must do everything


2. Some nurses distrust subordinates to do things


3. Some nurses think that if they delegate all the

technical tasks, they will not reinforce their

own learning.

4. Some nurses are more comfortable with the

technical aspects of client care than with the

more complex issues of client teaching and

discharge planning.

Families and clients do not always see professional

activities. Rather, they see direct client care

(Keeney, Hasson, McKenna, & Gillen, 2005).

Nurses believe that when they do not participate

directly in client care, they do not accomplish any-

thing for the client. The professional aspects of

nursing, such as planning care, teaching, and dis-

charge planning, help to promote positive out-

comes for clients and their families. When working

with LPNs, knowing their scope of practice helps

in making delegation decisions.

Models of Care Delivery

Functional nursing, team nursing, total client care,

and primary nursing are models of care delivery that

developed in an attempt to balance the needs of the

client with the availablity and skills of nurses. Both

table 9-1

Direct and Indirect Client Care Activities Direct Client Care Activities Indirect Client Care Activities

Assisting with feeding and drinking Providing a clean environment

Assisting with ambulation Providing a safe environment

Assisting with grooming Providing companion care

Assisting with toileting Providing transportation for noncritical clients

Assisting with dressing Assisting with stocking nursing units

Assisting with socializing Providing messenger and delivery services

Adapted from American Nurses Association. (2002). Position Statement on Utilization of Unlicensed Assistive Personnel.

Washington, DC: American Nurses Association.

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chapter 9 | Delegation of Client Care 127

delegation and communication skills are essential to

successfully follow through with any given model of

care delivery.

Functional Nursing

Functional nursing or task nursing evolved during

the mid-1940s due to the loss of RNs who left

home to serve in the armed forces during the

Second World War. Prior to the war, RNs com-

prised the majority of hospital staffing. Because of

the lack of nurses to provide care at home, hospitals

used more LPNs or licensed vocational nurses and

UAP to care for clients.

When implementing functional nursing, the

focus is on the task and not necessarily holistic

client care. The needs of the clients are categorized

by task, and then the tasks are assigned to the “best

person for the job.” This method takes into consi-

deration the skill set and licensure scope of practice

of each caregiver. For example, the RN would per-

form and document all assessments and administer

all IV medications; the LPN or LVN would

adminster treatments and perform dressing

changes. UAP would be responsible for meeting

hygiene needs of clients, obtaining and recording

vital signs, and assisting in feeding clients. This

method is efficient and effective; however, when

implemented, continuity in client care is lost. Many

times, re evaluation of client status and follow-up

does not occur, and a breakdown in communication

among staff occurs.

Team Nursing

Team nursing grew out of functional nursing; nurs-

ing units often resort to this model when appropri-

ate staffing is unavailable. A group of nursing

personnel or a team provides care for a cluster of

clients. The manner in which clients are divided

varies and depends on several issues: the layout of

the unit, the types of clients on the unit, and the

number of clients on the unit. The organization of

the team is based on the number of available staff

and the skill mix within the group.

An RN assumes the role of the team leader. The

team may consist of another RN, an LPN, and UAP.

The team leader directs and supervises the team,

which provides client care. The team knows the con-

dition and needs of all the clients on the team.

The team leader acts as a liason between the

clients and the health-care provider/physician.

Responsibilities include formulating a client plan

of care, transcribing and communicating orders and

treatment changes to team members, and solving

problems of clients and/or team members. The

nurse manager confers with the team leaders,

supervises the client care teams and, in some insti-

tutions, conducts rounds with the health-care


For this method to be effective, the team leader

needs strong delegation and communication skills.

Communication among team members and the

nurse manager avoids duplication of efforts and

decreases competition for control of assignments

that may not be equal based on client acutity and

the skills sets of team members.

Total Client Care

During the 1920s total client care was the original

model of nursing care delivery. Much nursing was

in the form of private duty nursing, in which nurses

cared for clients in homes and in hospitals. Schools

of nursing located in hospitals provided students

who staffed the nursing units and delivered care

under the watchful eyes of nursing supervisors and

directors. In this model, one RN assumes the

responsibility of caring for one client. This includes

acting as a direct liason among the client, family,

health-care provider, and other members of the

health-care team. Today, this model is seen in high

acuity areas such as critical care units, postanesthe-

sia recovery units, and in labor and delivery units.

This model requires RNs to engage in non-nursing

tasks that might be assumed by individuals without

the educational level of an RN.

Primary Nursing

In the 1960s nursing care delivery models started

to move away from team nursing and placed the

RN in the role of giving direct client care. The cen-

tral principle of this model is to distribute nursing

decision making to the nurses caring for the client.

As the primary nurse, the RN devises, implements,

and is responsible for the nursing care of the client

during the time the client remains on the nursing

unit. The primary nurse along with associate nurs-

es gives direct care to the client.

In its ideal form, primary nursing requires an

all-RN staff. Although this model provides conti-

nuity of care and nursing accountability, staffing is

difficult and expensive. Some view it as ineffective

as many tasks that consume the time of the RN

could be carried out by other personnel.

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128 unit 2 | Working Within the Organization


The concept of delegation is not new. The delega-

tion role is essential to the RN-LPN and RN-UAP

relationship. Personal organizational skills are a

prerequisite to delegation. Before the nurse can

delegate tasks to others, he or she needs to under-

stand individual client needs. Using worksheets

and Maslow’s hierarchy helps the nurse understand

these individual client needs, set priorities, and

identify which tasks can be delegated to others.

Using the Delegation Decision-Making Grid helps

the nurse delegate safely and appropriately.

It is also important the nurse be aware of the

capabilities of each staff member, the tasks that may

be delegated, and the tasks that the RN needs to per-

form. When delegating, the RN uses professional

judgment in making decisions. Professional judg-

ment is directed by the state nurse practice act and

national standards of nursing. Institutions develop

their own job descriptions for UAP and other health-

care professionals, but institutional policies cannot

contradict the state nurse practice act. Although the

nurse delegates the task or activity, he or she remains

accountable for the delegated decision.

Understanding the concept of delegation helps

the new nurse organize and prioritize client care.

Knowing the staff and their capabilities simplifies

delegation. Utilizing staff members’ capabilities

creates a pleasant and productive working environ-

ment for everyone involved. Understanding delega-

tion and proper application of delegation principles

is needed in the implementation of the various

nursing practice models.

Study Questions

1. What are the responsibilities of the professional nurse when delegating tasks to an LPN or UAP?

2. What factors need to be considered when delegating tasks?

3. What is the difference between the delegation and the assignment of a task?

4. What are the nurse manager’s legal responsibilities in supervising UAP?

5. If you were the nurse manager, how would you have handled Laura’s situation?

6. How would you have handled the situation if you were Linda?

7. Bring the client census from your assigned clinical unit to class. Using the Delegation Decision-

Making Grid, decide which clients you would assign to the personnel on the unit. Give reasons for

your decision.

8. What type of nursing delivery model is implemented on your assigned clinical unit? Give examples

of the roles of the personnel engaged in client care to support your answer.

Case Study to Promote Critical Reasoning

Julio works at a large teaching hospital in a major metropolitan area. This institution services the

entire geographical region, including indigent clients, and, because of its reputation, administers

care to international clients and individuals who reside in other states. Like all health-care

institutions, this one has been attempting to cut costs by using more UAP. Nurses are often floated

to other units. Lately, the number of indigent and foreign clients on Julio’s unit has increased. The

acuity of these clients has been quite high, requiring a great deal of time from the nursing staff.

Julio arrived at work at 6:30 a.m., his usual time. He looked at the census board and discovered

that the unit was filled, and Bed Control was calling all night to have clients discharged or

transferred to make room for several clients who had been in the emergency department since the

previous evening. He also discovered that the other RN assigned to his team called in sick. His

team consists of himself, two UAP, and an LPN who is shared by two teams. He has eight clients

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chapter 9 | Delegation of Client Care 129

References American Association of Critical Care Nurses (AACN). (1990).

Delegation of Nursing and Non-Nursing Activities in Critical Care: A Framework for Decision Making. Irvine, Calif.: AACN.

American Nurses Association (ANA). (1985). Code for Nurses. Washington, DC: ANA.

American Nurses Association (ANA). (1996). Registered Professional Nurses and Unlicensed Assistive Personnel. Washington, DC: ANA.

American Nurses Association (ANA). (2002). Position Statements on Registered Nurse Utilization of Unlicensed Assistive Personnel. Washington, DC: ANA.

American Nurses Association (ANA). (2005). Principles for Delegation. Washington, DC: ANA.

Boysen, R., & Fischer, C. (2000). Delegation/practice boundaries. South Dakota State University College of Nursing. Retrieved July 29, 2002, from learn.sdstate. edu/nursing/ DelegationModule2

Chevernet, M. (1988). STAT: Special Techniques in Assertiveness Training for Women in Healthcare Professions, 2nd ed. St. Louis, Mo.: Mosby.

Ellis, J.R., & Hartley, C.L. (2004). Nursing in Today’s World. Philadelphia: Lippincott, Williams & Wilkins.

Habel, M. (Winter 2001). Delegating nursing care to unlicensed assistive personnel. Continuing Education for Florida Nurses, 39–54.

Hansten, R.I, & Jackson, M. (2004). Clinical Delegation Skills: A Handbook for Professional Practice. Sudbury, Mass.: Jones & Bartlett.

Hicks v. New York State Department of Health. (1991). 570 N.Y.S. 2d 395 (A.D. 3 Dept).

Huber, D., Blegan, M., & McCloskey, J. (1994). Use of nursing assis- tants: Staff nurse opinions. Nursing Management, 25(5), 64–68.

Keeney, S., Hasson, F., McKenna, H., & Gillen, P. (2005). Health care assistants: The view of managers of health care agencies on training and employment. Journal of Nursing Management, 13(1), 83–92.

Keeney, S., Hasson, F., & McKenna, H. (2005). Nurses’, midwives’, and patients’ perceptions of trained health care assistants. Journal of Advanced Nursing, 50(4), 345–355.

Mahlmeister, L. (1999). Professional accountability and legal liability for the team leader and charge nurse. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 28, 300–309.

National Council of State Boards of Nursing. (1990). Concept Paper on Delegation. Chicago: NCSBN.

National Council of State Boards of Nursing. (1995). Delegation: Concepts and decision-making process. Issues (December), 1–2.

National Council of State Boards of Nursing. (1997). Delegation Decision-Making Grid. Chicago: NCSBN.

National Council of State Boards of Nursing. (2007). The five rights of delegation. Retrieved November 30, 2008, from www.ncsbn.org/Joint_statement.pdf

Nightingale, F. (1859). Notes on Nursing: What It Is and What It Is Not. London: Harrison and Sons. (Reprint 1992. Philadelphia: JB Lippincott.)

Tappen, R., Weiss, S.A., & Whitehead, D.K. (2004). Essentials of Leadership and Management. Philadelphia: FA Davis.

Zimmerman, P.G. (1996). Delegating to assistive personnel. Journal of Emergency Nursing, 22, 206–212.

on his team: two need to be readied for surgery, including preoperative and postoperative teaching,

one of whom is a 35-year-old woman scheduled for a modified radical mastectomy for the

treatment of breast cancer; three are second-day postoperative clients, two of whom require

extensive dressing changes, are receiving IV antibiotics, and need to be ambulated; one postopera-

tive client who is required to remain on total bedrest, has a nasogastric tube to suction as well as a

chest tube, is on total parenteral nutrition and lipids, needs a central venous catheter line dressing

change, has an IV, is taking multiple IV medications, and has a Foley catheter; one client who is

ready for discharge and needs discharge instruction; and one client who needs to be transferred to a

subacute unit, and a report must be given to the RN of that unit. Once the latter client is trans-

ferred and the other one is discharged, the emergency department will be sending two clients to the

unit for admission.

1. How should Julio organize his day? Set up an hourly schedule.

2. What type of client management approach should Julio consider in assigning staff appropriately?

3. If you were Julio, which clients and/or tasks would you assign to your staff? List all of them, and

explain your rationale.

4. Using the Delegation Decision-Making Grid, make staff and client assignments.

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chapter 10 Quality and Safety

OBJECTIVES After reading this chapter, the student should be able to: ■ Discuss the history of quality and safety within the U.S.

health-care system.

■ Analyze historical, social, political, and economic trends affecting the nursing profession and the health-care delivery system.

■ Explain the importance of quality improvement (QI) for the nurse, patient, organization, and health-care delivery system.

■ Discuss the role of the nurse in continuous quality improve- ment (CQI) and risk management.

■ Examine factors contributing to medical errors and evidence-based methods for the prevention of medical errors.

■ Explain the use of technology to enhance and promote safe patient care, educate patients and consumers, evaluate health-care delivery, and enhance the nurse’s knowledge base.

■ Describe the effects of communication on patient-centered care, interdisciplinary collaboration, and safety.

■ Promote the role of the nurse in the contemporary health-care environment.


History and Overview

Historical Trends and Issues

The IOM and the Committee on the Quality of Health Care in America

Quality in the Health-Care System


Using CQI to Monitor and Evaluate Quality of Care

QI at the Organizational and Unit Levels

Strategic Planning

Structured Care Methodologies

Critical Pathways

Aspects of Health Care to Evaluate




Risk Management

The Economic Climate in the Health-Care System

Economic Perspective

Regulation and Competition

Nursing Labor Market

Defining and Identifying the Nursing Shortage

Factors Contributing to the Nursing Shortage

Safety in the U.S. Health-Care System

Types of Errors

Error Identification and Reporting

Developing a Culture of Safety

Organizations, Agencies, and Initiatives Supporting Quality and Safety in the Health-Care System

Government Agencies

Health-Care Provider Professional Organizations

Nonprofit Organizations and Foundations

Quality Organizations

Integrating Initiatives and Evidenced-Based Practices into Patient Care

Health-Care System Reform

Role of Nursing in System Reform

The ANA’s Agenda

Influence of Nursing



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132 unit 2 | Working Within the Organization

History and Overview

You are entering professional nursing at a time

when issues pertaining to quality and safety of the

U.S. health-care system have come to the forefront

in the delivery of health care. Considering the

complexity of the decisions you make every day in

managing patient care at the bedside, it may be easy

to dismiss the theory that you must also consider

quality and safety within the health-care system.

However, each day as a professional registered

nurse (RN), you will participate in activities to sup-

port quality and safety initiatives at the bedside,

within your organization, and as part of the health-

care system. First, this chapter identifies trends

and issues that have brought quality and safety to

the forefront.

Historical Trends and Issues

The rapidly changing health-care delivery system

is driven by many forces (Baldwin, Conger,

Maycock, & Ableggen, 2002; Davis, 2001; Elwood,

2007; Ervin, Bickes, & Schim, 2006; Menix, 2000)

that are influencing the current movement toward

improved quality and safety. Some of these forces

include economics, societal demographics and

diversity, regulation and legislation, technology,

health-care delivery and practice, and environment

and globalization.

Economics. U.S health-care delivery has been affected by many economic trends and issues.

Businesses, government, and the media decry the

cost of health care within the United States when

compared with that of other developed nations

( Jackson, 2006; Kersbergen, 2000). The cost of

research and the cost to develop new treatments

and technology are rising. Nurses need to be pre-

pared to support consumers with a thorough

knowledge of quality, accountability, and cost-

effectiveness (AACN, 1997). Educated consumers

will expect safe, quality care with associated satis-

faction and health outcomes. Improvements in

quality and safety will reduce costs (Cronenwett et

al., 2007; Institute of Medicine [IOM], 2003a).

Societal demographics and diversity. Increased numbers of racial and ethnic groups /will influence

health-care delivery (Billings & Halsted, 2005;

Elwood 2007; Heller, Oros, & Durney-Crowley,

2000). Increased numbers of elderly people,

increased lifespan, and improvements in technology

mean an emphasis on specialized geriatric care.

Both the elderly and ethnic minorities are at-risk

populations who suffer disadvantages in access,

payment, and quality of care (U.S. Department of

Health & Human Services, 2001).

Regulation and legislation. The diverse interests of consumers, insurance companies, government,

and regulation affect health-care legislation. For

health-care leaders and providers of care, unprece-

dented challenges will continue despite the atten-

tion that quality and safety has received during the

evolution of the existing health-care system.

Technology. The use of technology will improve cost, clinical outcomes, quality, and safety (IOM,

2003a). Nursing practice must accommodate this

health-care delivery trend with the inclusion of

concepts in interdisciplinary collaboration, patient-

focused systems, and information literacy (Booth,

2006). Additionally, nurses must utilize technology

and informatics to incorporate evidenced-based

practices for improved quality and safety in the

health-care delivery system.

Technology also produces advancements in dis-

ease treatments, especially in the areas of genetics

and genomics, and all professionals must integrate

these areas into practice ( Jenkins & Calzone,

2007). Advances in genetics and genomics lead to

breakthroughs in the treatments of a variety of

genetic disorders, QI, and outcomes in clinical

practice often related to pharmacotherapeutics

(Trossman, 2006).

Health-care delivery and practice. Health-care professionals should be prepared to provide safe,

quality care in all settings, including acute care and

community settings. Nurses and other health-care

professionals need the knowledge, skills, attitudes,

and competencies to function in a variety of set-

tings and the ability to support the needs of the

elderly (Ervin, Bickes, & Schim, 2006; Heller,

Oros, Durney-Crowley, 2000).

The integration of evidenced-based practice will

serve to improve quality and safety for patients, as

it will improve collaboration and interdisciplinary

teamwork (Brady et al., 2001; IOM, 2003a;

O’Neill, 1998). Both the IOM (2003a) and the

Pew Health Professions Commission (O’Neill,

1998) identified the need for the health-care deliv-

ery system and its professionals to improve collab-

oration and to work in an interdisciplinary team to

improve quality and safety.

Environment and globalization. The emergence of a global economy, the ease of travel, and

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chapter 10 | Quality and Safety 133

advances in communication technology affect the

movement of people, money, and disease (Heller,

Oros, & Durney-Crowley, 2000; Kirk, 2002).

Global warming and climate change have been

linked to the emergence of new drug-resistant

organisms, an increase in vector-borne and water-

borne disease, and migration of affected popula-

tions. Safe, quality health care will need to confront

the challenges of increasing multiculturalism,

potential for pandemic, and the effect of climate

change and pollution on health.

In addition, many health-care professionals,

government agencies, and supporting organizations

have contributed to the evolution of quality and

safety within the health-care system. The

Historical Timeline (Table 10-1) highlights signif-

icant organizations and initiatives of importance to

quality and safety.

table 10-1

Historical Timeline 1896 Nurses Associated Alumnae of the United States and Canada formed, later called the American Nurses Association


1906 Food and Drug Act signed, which began the regulation of food and drugs to protect consumers

1918 American College of Surgeons founded, which initiated minimum standards for hospitals and on-site hospital

inspections for adherence to standards

1930s Employers began offering health benefits, and the first commercial insurance companies arose

1945 Quality management principles developed by Edward Deming were applied successfully to industries such as

manufacturing, government, and health care

1951 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) founded; currently referred to as the

Joint Commission (JC)

1955 Social Security Act passed; hospitals that had volunteered for accreditation by JCAHO were approved for

participation in Medicare and Medicaid

1966 Quality of health-care services defined in the literature

1970 IOM established as a nonprofit adviser to the nation to improve health in the national academies

1979 National Committee on Quality Assurance (NCQA) established

1986 National Center of Nursing Research founded at the National Institutes of Health (NIH)

1989 Agency for Healthcare Research and Quality (AHRQ) established

1990 NCQA began accrediting managed care organizations by using data from Health Plan Employer Data and

Information Set (HEDIS)

1990 Institute of Healthcare Improvement (IHI) founded

1991 Nursing’s Agenda for Health Care Reform published by the ANA

1996 National Patient Safety Foundation (NPSF) founded; JC established Sentinel Event Policies

1996 IOM launched three-part initiative to study health-care system quality

1998 IOM National Roundtable on Health Care Quality released Consensus Statement

1999 IOM published To Err is Human: Building a Safer Health System

2001 IOM published Crossing the Quality Chasm: A New Health System for the 21st Century

2001 IOM published Envisioning the National Health Care Quality Report

2001 ANA’s National Database for Nursing Quality Indicators (NDNQI) demonstrated the positive impact of the

appropriate mix of nursing staff on patient outcomes

2001 JC mandated hospital-wide patient safety standards

2003 IOM published Priority Areas for National Action: Transforming Health Care Quality, which established priority

areas for national action to improve quality of care and outcomes (Box 10-1)

2003 JC established first set of National Patient Safety Goals (NPSG)

2003 IOM published Health Professions Education: A Bridge to Quality

2004 IOM published Keeping Patients Safe: Transforming the Work Environment of Nurses

2004 IOM published Patient Safety: Achieving a New Standard of Care

2005 ANA updated its Health Care Agenda, urging system reform

2006 IOM published Preventing Medication Errors: Quality Chasm Series

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134 unit 2 | Working Within the Organization

The IOM and the Committee on the Quality of Health Care in America

The IOM is a private, nonprofit organization char-

tered in 1970 by the U.S government. The IOM’s

role is to provide unbiased, expert health and scien-

tific advice for the purpose of improving health.

The result of the IOM’s work supports government

policy making, the health-care system, health-care

professionals, and consumers.

In 1998 the IOM National Roundtable on

Health Care Quality released Statement on Quality of Care (Donaldson, 1998), which urged health-care leaders to make urgent changes in the U.S. health-

care system. The Roundtable reached consensus in

four areas regarding the U.S. health-care system:

1. Quality can be defined and measured;

2. Quality problems are serious and extensive;

3. Current approaches to QI are inadequate; and

4. There is an urgent need for rapid change.

This IOM statement launched today’s move-

ment to improve quality and safety for the 21st

century U.S. health-care system.

In 1998 the IOM charged the Committee on

the Quality of Health Care in America to develop

a strategy to improve health-care quality in the

coming decade (IOM, 2000). The Committee

completed a systematic review and critique of liter-

ature that highlighted and quantified severe short-

comings in the heath-care system. Its work led to

the series of reports that serves as the foundation

and strategy for health system reform (Box 10-2).

Two in particular, To Err is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), provide a framework

upon which the 21st-century health-care system is

being built.

To Err is Human—discussed later in this chapter— quantified unnecessary death in the U.S. health-

care system and placed emphasis on system failures

as the foundation for errors and mistakes.

According the report, it is the flawed systems in

patient care that often leave the door open for

human error. The report made a series of eight rec-

ommendations in four areas (Box 10-3) that aimed

to decreased errors by at least 50% over 5 years. The

goal of the recommendations was “for the external

environment to create sufficient pressure to make

errors costly to health-care organizations and

providers, so they are compelled to take action to

improve safety” (IOM, 2000, p. 4). The recommen-

dations sparked pubic interest in health-care quality

and safety and caused prompt responses by the

government and national quality organizations.

Crossing the Quality Chasm addressed broad quality issues in the U.S. health-care system. The report indi-

cated that the health-care system is fundamentally

flawed with “gaps,” and it proposed a system-wide

box 10-1

Institute of Medicine Priority Areas (IOM, 2003b).

• Asthma

• Cancer screening

• Care coordination

• Children with special

care needs

• Diabetes

• End-of-life issues

• Frail elderly

• Health literacy

• Hypertension

• Immunizations

• Ischemic heart disease

• Major depression

• Nosocomial infections

• Obesity

• Pain control in advanced


• Pregnancy and childbirth

• Self-management

• Severe, persistent mental illness

• Stroke

• Tobacco dependence in adults

box 10-2

IOM Quality Reports (IOM, 2006) • Crossing the Quality Chasm: The IOM Quality Health Care

Initiative (1996)

• To Err Is Human: Building a Safer Health System (2000)

• Crossing the Quality Chasm: A New Health System for the

21st Century (2001)

• Envisioning the National Health Care Quality Report (2001)

• Priority Areas for National Action: Transforming Health Care

Quality (2003b)

• Leadership by Example: Governmental Roles (2003)

• Health Professions Education: A Bridge to Quality (2003a)

• Patient Safety: Achieving a New Standard of Care (2003)

• Keeping Patients Safe: Transforming the Work Environment

for Nurses (2004)

• Academic Health Centers: Leading Change in the 21st

Century (2004)

• Preventing Medication Errors: Quality Chasm Series (2006)

box 10-3

Focus Areas of To Err is Human Recommendations (IOM, 2000)

• Enhance knowledge and leadership regarding safety.

• Identify and learn from errors.

• Set performance standards and expectations for safety.

• Implement safety systems within health-care organ-


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chapter 10 | Quality and Safety 135

strategy and action plans to redesign the health-care

system. The report stated that the gaps between actu-

al care and high-quality care could be attributed to

four key inter-related areas in the health-care system:

the growing complexity of science and technology, an

increase in chronic conditions, a poorly organized

delivery system of care, and constraints on exploiting

the revolution in information technology. With the

overarching goal of improving the health-care system

by closing identifiable gaps, the report made 13 rec-

ommendations, some of which are in Box 10-4.

Additionally, the report addressed the importance of

aligning and designing health-care payer systems,

professional education, and the health-care environ-

ment for quality enhancements, improved outcomes

in care, and use of best practices.

As a professional nurse, you have a responsibility

to acknowledge the complexity and deficits of the

health-care system. In managing patient care, you

must continually consider the impact of the system

on the care you provide and participate in the qual-

ity and safety initiatives at the bedside, in your unit,

and within your organization to promote quality

and safety within the system.

Quality in the Health-Care System

The IOM defines quality as “the degree to which health services for individuals and populations

increase the likelihood of desired health outcomes

and are consistent with current and professional

knowledge” (IOM, 2001, p. 232). This definition is

used by U.S. organizations and many international

health-care organizations, and it is the basis for

nursing management of patient care. Box 10-5 elab-

orates on this definition by outlining six primary

aims of health care.


QI activities have been part of nursing care since

Florence Nightingale evaluated the care of soldiers

during the Crimean War (Nightingale & Barnum,

1992). To achieve quality health care, QI activities

use evidence-based methods for gathering data and

achieving desired results.

QI usually involves common characteristics

(McLaughlin & Caluzny, 2006, p 3):

■ A link to key elements of the organization’s

strategic plan

■ A quality council consisting of the institution’s

top leadership

■ Training programs for all levels of personnel

■ Mechanisms for selecting improvement oppor-


■ Formation of process improvement teams

■ Staff support for process analysis and redesign

■ Personnel policies that motivate and support

staff participation in process improvement

QI is called by many names: quality assurance,

FADE, PDSA, total quality management (TQM),

Six Sigma, and CQI. Regardless of the term used, QI

is a structured organizational process for involving

personnel in planning and executing a continuous

flow of improvements to provide quality health care

that meets or exceeds expectations (McLaughlin &

Kaluzny, 2006, p. 3). The following sections focus

on CQI.

box 10-4

Ten Rules to Govern Health-Care Reform for the 21st Century (IOM, 2001, p. 61)

• Care is based on a continuous healing relationship

• Care is provided based on patient needs and values

• Patient is source of control of care

• Knowledge is shared and free-flowing

• Decisions are evidence-based

• Safety as a system property

• Transparency is necessary; secrecy is harmful

• Anticipate patient needs

• Waste is continually decreased

• Cooperation between health-care providers

box 10-5

Six Aims for Improving Quality in Health-Care (IOM, 2001, p. 39).

Health care should be:

1. Safe: Avoiding injuries to patients from the care that is

intended to help them

2. Effective: Providing services based on scientific

knowledge to all who could benefit and refraining from

providing services to those not likely to benefit

(avoiding underuse and overuse)

3. Patient-centered: Providing care that is respectful of

and responsive to individual patient preferences, needs,

and values and ensuring that patient values guide all

clinical decisions

4. Timely: Reducing waits and sometimes harmful delays

for those who receive and those who give care

5. Efficient: Avoiding waste, in particular that of

equipment, supplies, ideas, and energy

6. Equitable: Providing care that does not vary in quality

because of characteristics such as gender, ethnicity,

geographic location, and socioeconomic status

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136 unit 2 | Working Within the Organization

Using CQI to Monitor and Evaluate Quality of Care

Continuous quality improvement (CQI) is a process of identifying areas of concern (indicators),

continuously collecting data on these indicators,

analyzing and evaluating the data, and implement-

ing needed changes. When one indicator is no

longer a concern, another indicator is selected.

Common indicators include, for example, number

of falls, medication errors, and infection rates.

Indicators can be identified by the accrediting

agency or by the facility itself. The purpose of CQI

is to improve the capability continuously of every-

one involved in providing care, including the

organization itself. CQI aims to avoid a blaming

environment and attempts to provide a means to

improve the entire system.

CQI relies on collecting information and analyz-

ing it. The time frame used in a CQI program can

be retrospective (evaluating past performance, often

called quality assurance), concurrent (evaluating cur- rent performance), or prospective (future-oriented,

collecting data as they come in). The procedures

used to collect data depend on the purpose of the

program. Data may be obtained by observation, per-

formance appraisals, patient satisfaction surveys,

statistical analyses of length-of-stay and costs, sur-

veys, peer reviews, and chart audits (Huber, 2000).

In the CQI framework, data collection is every-

one’s responsibility. Collecting comprehensive, accu-

rate, and representative data is the first step in the

CQI process. You may be asked to brainstorm your

ideas with other nurses or members of the interdis-

ciplinary team, complete surveys or checklists, or

keep a log of your daily activities. How do you

administer medications to groups of patients? What

steps are involved? Are the medications always avail-

able at the right time and in the right dose, or do you

have to wait for the pharmacy to bring them to the

floor? Is the pharmacy technician delayed by emer-

gency orders that must be processed? Looking at the

entire process and mapping it out on paper in the

form of a flowchart may be part of the CQI process

for your organization (Fig. 10.1).

QI at the Organizational and Unit Levels

Strategic Planning

Leaders and managers are so often preoccupied

with immediate issues that they lose sight of their

ultimate objectives. Quality cannot be found at the

unit level if the organization is not focusing on

quality issues. To stay on track, an organization

needs a strategic plan. A strategic plan is a short, visionary, conceptual document that:

■ Serves as a framework for decisions or for secur-

ing support/approval

■ Provides a basis for more detailed planning

■ Explains the business to others in order to

inform, motivate, and involve

Assign Responsibilities

Identify Vital Areas

Define Scope of Care

Evaluate Performance and Outcomes

Recommend and Implement Actions

Evaluate Degree of Improvement

Analyze Area in Terms of:

Aspects Standards Indicators


Measure Actual Performance and

Measure Patient Outcomes

Figure 10.1 Unit level QI process. (Adapted from Hunt, D.V. [1992]. Quality in America: How to Implement a Competitive Quality Program. Homewood, IL: Business One Irwin; and Duquette, A.M. [1991]. Approaches to monitoring practice: Getting started. In Schroeder, P. [ed.]. Monitoring and Evaluation in Nursing. Gaithersburg, MD: Aspen.)

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chapter 10 | Quality and Safety 137

■ Assists benchmarking and performance


■ Stimulates change and becomes the building block

for the next plan (planware.org/strategy.htm)

During the strategic planning process, the organi-

zation develops or reviews its vision, mission state-

ment, and corporate values. A group develops

business objectives and key strategies to meet these

objectives. In order to do this, a SWOT analysis is

done—a review of the organization’s Strengths,

Weaknesses, Opportunities, and Threats. Key

strategies are identified, and action plans are devel-

oped. The organization’s mission, goals, and strate-

gic plan ultimately drive the outcomes and QI plan

for that organization. Be proactive, and participate

in the process. Ask your nurse manager if there are

opportunities for the staff to participate in the

planning process.

Issues related to QI may also come out of the

strategic planning process. Quality issues are not

often apparent to senior managers. Staff members

at the unit level can often identify quality issues

because they are the ones who can feel the impact

when quality is lacking. Once a process that needs

improvement is identified, an interdisciplinary

team is organized whose members have knowledge

of the identified process. The team members meet

to identify and analyze problems, discuss solutions,

and evaluate changes. The team clarifies the cur-

rent knowledge of the process; it identifies causes

for variations in the process and works to unify the

process. Box 10-6 identifies questions that team

members might ask as they work on the QI plan.

Structured Care Methodologies

Most agencies have tools for tracking outcomes.

These tools are called structured care methodologies (SCMs). SCMs are interdisciplinary tools to “iden-

tify best practices, facilitate standardization of care,

and provide a mechanism for variance tracking,

quality enhancement, outcomes measurement, and

outcomes research” (Cole & Houston, 1999, p. 53).

SCMs include guidelines, protocols, algorithms,

standards of care, critical pathways, and order sets.

■ Guidelines. Guidelines first appeared in the 1980s as statements to assist health-care

providers and patients in making appropriate

health-care decisions. Guidelines are based on

current research strategies and are often devel-

oped by experts in the field. The use of guidelines

is seen as a way to decrease variations in practice.

■ Protocols. Protocols are specific, formal docu- ments that outline how a procedure or interven-

tion should be conducted. Protocols have been

used for many years in research and specialty

areas but have been introduced into general

health care as a way to standardize approaches

to achieve desired outcomes. An example in

many facilities is a chest pain protocol.

■ Algorithms. Algorithms are systematic proce- dures that follow a logical progression based on

additional information or patient responses to

treatment. They were originally developed in

mathematics and are frequently seen in

emergency medical services. Advanced cardiac

life support algorithms are now widely used in

health-care agencies.

■ Standards of care. Standards of care are often discipline-related and help to operationalize

patient care processes and provide a baseline for

quality care. Lawyers often refer to a discipline’s

standards of care in evaluating whether a patient

has received appropriate services.

■ Critical (or clinical) pathways. A critical path- way outlines the expected course of treatment

for patients with similar diagnoses. The critical

pathway should orient the nurse easily to the

patient outcomes for the day. In some institu-

tions, nursing diagnoses with specific time

frames are incorporated into the critical path-

way, which describes the course of events that

lead to successful patient outcome within the

diagnosis-related group (DRG)–defined time

frame. For the patient with an uncomplicated

box 10-6

Questions the Team Needs to Ask 1. Who are our customers, stakeholders, markets?

2. What do they expect from us?

3. What are we trying to accomplish?

4. What changes do we think will make an improvement?

5. How and when will we pilot-test our predicted


6. What do we expect to learn from the pilot test?

7. What will we do with negative results? positive results?

8. How will we implement the change?

9. How will we measure success?

10. What did we learn as a team from this experience?

11. What changes would we make for the future?

Adapted from McLaughlin, C., & Kaluzny, A. (2006). Continuous Quality

Improvement in Health Care: Theory, Implementations, and Applications.

3rd ed. Massachusetts: Jones & Bartlett.

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138 unit 2 | Working Within the Organization

myocardial infarction (MI), a proposed course of

events leading to a successful patient outcome

within the 4-day DRG-defined time frame

might be as follows (Doenges, Moorhouse, &

Geissler, 1997): (1) Patient states that chest pain

is relieved; (2) ST- and T-wave changes resolve

and pulse oximeter reading is greater than

90%; patient has clear breath sounds; (3) Patient

ambulates in hall without experiencing extreme

fatigue or chest pain; (4) Patient verbalizes

feelings about having an MI and future fears;

(5) Patient identifies effective coping strategies;

(6) Ventricular dysfunction, dysrhythmia, or

crackles resolved

SCMs may be used alone or together. A patient

who is admitted for an MI may have care planned

using a critical pathway for an acute MI, a heparin

protocol, and a dysrhythmia algorithm. In addition,

the nurses may refer to the standards of care in

developing a traditional nursing care plan.

SCMs can improve physiological, psychological,

and financial outcomes. Services and interventions

are sequenced to provide safe and effective out-

comes in a designated time and with most effective

use of resources. They also give an interdisciplinary

perspective that is not found in the traditional

nursing care plan. Computer programs allow

health-care personnel to track variances (differ-

ences from the identified standard) and use these

variances in planning QI activities.

The use of SCMs does not take the place of the

expert nursing judgment. The fundamental pur-

pose of the SCM is to assist health-care providers

in implementing practices identified with good

clinical judgment, research-based interventions,

and improved patient outcomes. Data from SCMs

allow comparisons of outcomes, development of

research-based decisions, identification of high-

risk patients, and identification of issues and prob-

lems before they escalate into disasters. Do not be

afraid to learn and understand the different SCMs.

Critical Pathways

Critical pathways are clinical protocols involving all disciplines. They are designed for tracking a

planned clinical course for patients based on aver-

age and expected lengths of stay. Financial out-

comes can be evaluated from critical pathways by

assessing any variances from the proposed length of

stay. The health-care agency can then focus on

problems within the system that extend the length

of stay or drive up costs because of overutilization

or repetition of services. For example:

Mr. J. was admitted to the telemetry unit with a diagnosis of MI. He had no previous history of heart disease and no other complicating factors such as diabetes, hypertension, or elevated cholesterol levels. His DRG-prescribed length of stay was 4 days. He had an uneventful hospitalization for the f irst 2 days. On the third day, he complained of pain in the left calf. The calf was slightly reddened and warm to the touch. This condition was diagnosed as thrombophlebitis, which increased his length of hos- pitalization. The case manager’s review of the events leading up to the complaints of calf pain indicated that, although the physician had ordered compression stockings for Mr. J., the stockings never arrived, and no one followed through on the order. The variances related to his proposed length of stay were discussed with the team providing care, and measures were instituted to make sure that this oversight would not occur again.

Critical pathways provide a framework for com-

munication and documentation of care. They are

also excellent teaching tools for staff members

from various disciplines. Institutions can use criti-

cal pathways to evaluate the cost of care for differ-

ent patient populations (Capuano, 1995; Crummer

& Carter, 1993; Flarey, 1995; Lynam, 1994).

Most institutions have adopted a chronological,

diagrammatic format for presenting a critical pathway.

Time frames may range from daily (day 1,

day 2, day 3) to hourly, depending on patient needs.

Key elements of the critical pathway include discharge

planning, patient education, consultations, activities,

nutrition, medications, diagnostic tests, and treat-

ment (Crummer & Carter, 1993). Table 10-2

is an example of a critical pathway. Although orig-

inally developed for use in acute care institutions,

critical pathways can be developed for home care

and long-term care. The patient’s nurse is usually

responsible for monitoring and recording any devi-

ations from the critical pathway. When deviations

occur, the reasons are discussed with all members

of the health-care team, and the appropriate

changes in care are made. The nurse must identify

general trends in patient outcomes and develop

plans to improve the quality of care to reduce the

number of deviations. Through this close monitor-

ing, the health-care team can avoid last-minute

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chapter 10 | Quality and Safety 139

surprises that may delay patient discharge and can

predict lengths of stay more effectively.

Aspects of Health Care to Evaluate

A CQI program can evaluate three aspects of

health care: the structure within which the care is

given, the process of giving care, and the outcome

of that care. A comprehensive evaluation should

include all three aspects (Brook, Davis, &

Kamberg, 1980; Donabedian, 1969, 1977, 1987).

When evaluation focuses on nursing care, the inde-

pendent, dependent, and interdependent functions

of nurses may be added to the model (Irvine, 1998).

Each of these dimensions is described here, and

their interrelationship is illustrated in Table 10-3.


Structure refers to the setting in which the care is given and to the resources (human, financial,

and material) that are available. The following

structural aspects of a health-care organization can

be evaluated:

■ Facilities. Comfort, convenience of layout, acces- sibility of support services, and safety

■ Equipment. Adequate supplies, state-of-the-art equipment, and staff ability to use equipment

■ Staff. Credentials, experience, absenteeism, turnover rate, staff-patient ratios

■ Finances. Salaries, adequacy, sources

Although none of these structural factors alone

can guarantee quality care, they make good care

more likely. A higher level of nurses each shift and

a higher proportion of RNs are associated with

shorter lengths of stay; higher proportions of RNs

are also related to fewer adverse patient outcomes

(Lichtig, Knauf, & Milholland, 1999; Rogers

et al., 2004).


Process refers to the activities carried out by the health-care providers and all the decisions made

while a patient is interacting with the organization

(Irvine, 1998). Examples include:

■ Setting an appointment

■ Conducting a physical assessment

■ Ordering a radiograph and magnetic resonance

imaging scan

■ Administering a blood transfusion

■ Completing a home environment assessment

■ Preparing the patient for discharge

■ Telephoning the patient post discharge

Each of these processes can be evaluated in terms

of timeliness, appropriateness, accuracy, and com-

pleteness (Irvine, 1998). Process variables include

psychosocial interventions, such as teaching and

counseling, and physical care measures. Process also

includes leadership activities, such as interdiscipli-

nary team conferences. When process data are col-

lected, a set of objectives, procedures, or guidelines

is needed to serve as a standard or gauge against

which to compare the activities. This set can be

highly specific, such as listing all the steps in a

catheterization procedure, or it can be a list of

objectives, such as offering information on breast-

feeding to all expectant parents or conducting

weekly staff meetings.

The American Nurses Association (ANA)

Standards of Care are process standards that

answer the question: What should the nurse be

doing, and what process should the nurse follow to

ensure quality care?


An outcome is the result of all the health-care providers’ activities. Outcome measures evaluate

the effectiveness of nursing activities by answering

such questions as: Did the patient recover? Is the

family more independent now? Has team function-

ing improved? Outcome standards address indica-

tors such as physical and mental health; social and

physical function; health attitudes, knowledge,

and behavior; utilization of services; and customer

satisfaction (Huber, 2000).

The outcome questions asked during an evalua-

tion should measure observable behavior, such as

the following:

■ Patient: Wound healed; blood pressure within

normal limits; infection absent

■ Family: Increased time between visits to the

emergency department; applied for food stamps

■ Team: Decisions reached by consensus; atten-

dance at meetings by all team members

Some of these outcomes, such as blood pressure or

time between emergency department visits, are eas-

ier to measure than other, equally important out-

comes, such as increased satisfaction or changes in

attitude. Although the latter cannot be measured as

precisely, it is important to include the full spectrum

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140 unit 2 | Working Within the Organization

table 10-2

Sample Critical Pathway: Heart Failure, Hospital; ELOS 4 Days Cardiology or Medical Unit

ND and Categories of Care Day 1 _____ Day 2 _____ Day 3 _____ Day 4 _____

Decreased cardiac

output R/T:

Decreased myocardial

contractility, altered

electrical conduction,

structural changes

Fluid volume excess

R/T compromised







Diagnostic studies


Participate in actions

to reduce cardiac



understanding of

fluid/food restrictions



ECG, echo, Doppler

ultrasound, stress

test, cardiac scan


ABGs/pulse oximeter

Cardiac enzymes






Liver function studies

Serum glucose

Albumin/total protein

Thyroid studies

Digoxin level (as



Display VS within

acceptable limits;


controlled; pulse

oximetry within

acceptable range

Meet own self-care

needs with

assistance as



understanding of

general condition

and health-care


Breathing sounds


Urinary output


Weight loss (reflecting

fluid loss)

Cardiac rehabilitation

Occupational therapist

(for ADLs)

Social services

Home care

Echo-Doppler (if not

done day 1) or other

cardiac scans

Cardiac enzymes (if ↑)



PT/aPTT (if taking anti-


→ Dysrhythmias

controlled or absent

Free of signs of

respiratory distress



increase in activity


Plan for lifestyle/

behavior changes

Breath sounds clear

Balanced I&O

Edema resolving

Community resources




PT/aPTT (as indicated)

Repeat digoxin level (if


→ →

Plan in place to meet

postdischarge needs

Weight stable or

continued loss if

edema present

2208_Ch10_131-156.qxd 11/6/09 5:59 PM Page 140

table 10-2

Sample Critical Pathway: Heart Failure, Hospital; ELOS 4 Days Cardiology or Medical Unit—cont’d

ND and Categories of Care Day 1 _____ Day 2 _____ Day 3 _____ Day 4 _____



Medication allergies:

Patient education

Additional nursing


Apical pulse,

heart/breath sounds


Cardiac rhythm

(telemetry) q4h

BP, P, R q2h until

stable, q4h

Temp q8h

I&O q8h

Weight qAM

Peripheral edema q8h

Peripheral pulses q8h

Sensorium q8h

DVT check qd

Response to activity

Response to



IV diuretic

ACEI, ARB, vasodialtors,

beta blocker

IV/PO potassium


PO/cutaneous nitrates

Morphine sulfate

Daytime/hs sedation



Stool softener/laxative

Orient to unit/room

Review advance


Discuss expected






Bed/chair rest

Assist with physical





care per protocol

Supplemental O 2

Cardiac diet

→ q8h

→ → → → → → → → →

→ PO →

→ → → → → →

→ Cardiac education per


Review medications:

Dose, times, route,

purpose, side effects

Progressive activity


Skin care

→ BPR/ambulate as tolerated, cardiac


→ →

→ bid

→ D/C

→ → → → bid → bid → bid → → →

→ →

→ D/C → → → D/C → → PO or D/C

→ Signs/symptoms to

report to health-care


Plan for home-care


→ Up ad lib/graded program

→ D/C if able →

→ → D/C → → qd → D/C → D/C → → →

→ →

→ →

→ D/C →

→ Provide written

instructions for

home care

Schedule for follow-up


→ (send home)

CP = critical path; ELOS = estimated length of stay; ND = nursing diagnosis.

Doenges, M.E., Moorhouse, M.F., and Geissler, A.C. (2010). Nursing Care Plans: Guidelines for Individualizing Patient Care, ed. 8. Philadelphia: FA Davis, with permission.

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142 unit 2 | Working Within the Organization

of biological, psychological, and social aspects

(Strickland, 1997). For this reason, considerable

effort has been put into identifying the patient out-

comes that are affected by the quality of nursing

care. For example, the ANA identified 10 quality

indicators in acute care that are likely to relate to the

availability and quality of professional nursing serv-

ices in hospitals. Across the United States, data are

being collected from nursing units using these qual-

ity indicators.

A major problem in using and interpreting out-

come measures is that outcomes are influenced by

many factors. For example, the outcome of patient

teaching done by a nurse on a home visit is affected

by the patient’s interest and ability to learn, the

quality of the teaching materials, the presence or

absence of family support, information (which may

conflict) from other caregivers, and the environ-

ment in which the teaching is done. If the teaching

is successful, can the nurse be given full credit for

the success? If it is not successful, who has failed?

It is necessary to evaluate the process as well as

the outcome to determine why an intervention

such as patient teaching succeeds or fails. A com-

prehensive evaluation includes all three aspects:

structure, process, and outcome. However, it is

much more difficult to gather and monitor out-

come data than to measure structure or process.

Risk Management

An important part of CQI is risk management, a process of identifying, analyzing, treating, and eval-

uating real and potential hazards. The Joint

Commission ( JC) recommends the integration of

a quality control/risk management program to

maintain continuous feedback and communication.

To plan proactively, an organization must identify

real or potential exposures that might threaten it.

As a nurse, it is your responsibility to report adverse

incidents to the risk manager, according to your

organization’s policies and procedures. In many

states, this is a legal requirement.

Risk events are categorized according to severity.

Although all untoward events are important,

not all carry the same severity of outcomes

(Benson-Flynn, 2001).

1. Service occurrence. A service occurrence is an unexpected occurrence that does not result in

a clinically significant interruption of services

and that is without apparent patient or employee

injury. Examples include minor property or

equipment damage, unsatisfactory provision

of service at any level, or inconsequential inter-

ruption of service. Most occurrences in this

category are addressed within the patient

complaint process.

2. Serious incident. A serious incident results in a clinically significant interruption of therapy or

service, minor injury to a patient or employee,

or significant loss or damage of equipment or

property. Minor injuries are usually defined as

needing medical intervention outside of hospital

admission or physical or psychological damage.

3. Sentinel events. A sentinel event is an unex- pected occurrence involving death or serious/

permanent physical or psychological injury, or

the risk thereof. The phrase, “or the risk there-

of ” includes any process variation for which a

recurrence would carry a significant chance of a

serious adverse outcome. Such events are called

sentinel because they signal the need for imme-

diate investigation and response. When a sen-

tinel event occurs, appropriate individuals

table 10-3

Dimensions of QI in Nursing: Examples Independent Function Dependent Function Interdependent Function

Structure Pressure ulcer risk assessment High-speed automatic dial-up system Nursing case management

form available puts nurses in touch with physicians model of care adopted on

rapidly rehabilitation unit

Process Assesses risk for development Order to increase dosage of pain Communicates with therapists

of pressure ulcer and medication obtained and about need for customized

implements preventive measures processedwithin 1 hour wheelchair

Outcome Skin intact at discharge Relief from pain Able to enter narrow doorway

to bathroom unassisted

Adapted from Irvine, D. (1998). Finding value in nursing care: A framework for quality improvement and clinical evaluation. Nursing Economics, 16(3),


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chapter 10 | Quality and Safety 143

within the organization must be made aware of

the event; they must investigate and understand

the causes of the event; and they must make

changes in the organization’s systems and

processes to reduce the probability of such an

event in the future (jcaho.org/ptsafety_frm.html).

The subset of sentinel events that is subject to

review by JC includes any occurrence that meets

any of the following criteria:

■ The event has resulted in an unanticipated death

or major permanent loss of function, not related

to the natural course of the patient’s illness or

underlying condition.

■ The event is one of the following (even if the out-

come was not death or major permanent loss of

function): suicide of a patient in a setting where

the patient receives around-the-clock care (e.g.,

hospital, residential treatment center, crisis

stabilization center), infant abduction or discharge

to the wrong family, rape, hemolytic transfusion

reaction involving administration of blood or

blood products having major blood group incom-

patibilities, surgery on the wrong patient or

wrong body part (jcaho.org/ptsafety_frm.html)

Adhering to nursing standards of care as well as the

policies and procedures of the institution greatly

decreases the nurse’s risk. Common areas of risk for

nursing include:

■ Medication errors

■ Documentation errors and/or omissions

■ Failure to perform nursing care or treatments


■ Errors in patient safety that result in falls

■ Failure to communicate significant data to

patients and other providers (Swansburg &

Swansburg, 2002)

Risk management programs also include attention

to areas of employee wellness and prevention of

injury. Latex allergies, repetitive stress injuries,

carpal tunnel syndrome, barrier protection for

tuberculosis, back injuries, and the rise of antibiotic-

resistant organisms all fall under the area of risk

management (Huber, 2000).

Adhering to standards of care and exercising the

amount of care that a reasonable nurse would

demonstrate under the same or similar circumstances

can protect the nurse from litigation. Understanding

what actions to take when something goes wrong is

imperative. The main goal is patient safety. Reporting

and remediation must occur quickly (Huber, 2000).

Once an incident has occurred, you must com-

plete an incident report immediately. The incident

report is used to collect and analyze data for future

determination of risk. The report should be accu-

rate, objective, complete, and factual. If there is

future litigation, the plaintiff ’s attorney can sub-

poena the report. The report should be prepared in

only a single copy and never placed in the medical

record (Swansburg & Swansburg, 2002). It is kept

with internal hospital correspondence.

Nurses have a responsibility to remain educated

and informed and to become active participants in

understanding and identifying potential risks to

their patients and to themselves. Ignorance of the

law is no excuse. Maintaining a knowledgeable,

professional, and caring nurse-patient relationship

is the first step in decreasing your own risk.

The Economic Climate in the Health-Care System

For many years, decisions about care were based

primarily on providing the best quality care, what-

ever the cost. As the economic support for health

care is challenged, however, health-care providers

are pressured to seek methods of care delivery that

achieve quality outcomes at lower cost.

Economic Perspective

The economic perspective is rooted in three funda-

mental observations:

1. Resources are scarce. Due to scarce resources, three choices result:

■ The amount to be spent on health-care services

and the composition of those services

■ The methods for producing those services

■ The method of distribution of health care,

which influences the equity with which these

services are distributed

2. Resources have alternative uses. As a result of this scarcity, the choice to expend resources in

one area eliminates the use of those same

resources in another area. If more nursing

homes are going to be built, for example, then

there will be fewer hospitals, less housing, less

education, or other uses of those same


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144 unit 2 | Working Within the Organization

3. Individuals want different services or have different preferences. Some people choose alternative treatment modalities such as

acupuncture, herbal therapy, or massage therapy

rather than traditional health care. Health-care

services are marketed extensively.

Regulation and Competition

During the past three decades, federal and state

governments have attempted to restrain the cost of

health care by focusing. Regulation attempts to control cost through government actions; competi- tion uses market forces. Competition can drive aspects of health care through consumers,

providers, and suppliers. Among the attempts to

control cost were:

1. Medicare Prospective Payment System (PPS). In 1983 the federal government changed its

method of paying hospitals for treating

Medicare patients. Instead of paying for actual

costs, the PPS pays hospitals a fixed, predeter-

mined sum for a particular admission. If a hos-

pital can provide the service at a cost below the

fixed amount, it pockets the difference. If more

resources and money are used than the prede-

termined amount, the hospital incurs a loss.

2. DRGs. Tied to the PPS, DRGs are the patient classification systems by which the Medicare

PPS determines payment. Each of the

495 DRGs represents a particular case type.

3. Managed care. Managed care is a system of health care that combines the financing and

delivery of health services into a single entity.

Currently, more than 75% of people with pri-

vate health insurance are enrolled in managed

care plans. Managed care plans are seen as cost-

saving alternatives to traditional fee-for-service

delivery systems. Through provider networks

and selective provider contracting, they attempt

to control resource use and health-care costs

(Chang, Price, & Pfoutz, 2001). Figure 10.2

depicts the current factors increasing and

containing health-care costs.

4. Cost sharing. With rising health-care costs, employers purchasing health plans have begun

to shift some of the increase cost in premiums,

prescriptions, and specialty services to employ-

ees. Higher cost for consumers and shifting

financial burdens have left more Americans

without health-care coverage.

5. Medical savings accounts (MSA). As a regula- tory tool, MSAs are a cost-sharing method for

incentivizing consumers to plan and share in

the cost of their own health-care expenditures.

Money that would normally be spent on

health-care premiums by the employer-

consumer is deposited into an MSA. Accounts

created under the Medicare Modernization

Act of 2003 are the property of the employee-

consumer, giving more choice into how and

where the money is spent. The account is tax-

deferred until it is used for allowable health-

related spending as in high-deductable health

plans and tax-deferred plans. Other types of

consumer-directed plans exist, such as the

flexible spending account, health reimburse-

ment account, and medical saving accounts, all

of which have stipulations for use.

Factors Increasing Costs

• Expansion of national economy

• General inflation

• Aging population

• Growth of third-party payments

• Employer-provided health insurance

• Tax deduction for medical expenses

• Increased costs of labor and equipment

• Expansion of medical technology and products

• Malpractice insurance and litigation

Factors Containing Costs

• Federal economic stabilization program

• Voluntary effort hospital regulation program

• State-level health-care payment programs

• Medicare prospective payment system (PPS) with payments of fixed amount per admission

• Diagnostic-related groups (DRGs) for hospital payments

• Resource-based relative value scale (RBRVS) for physician payments

• Managed care plans

Figure 10.2 Factors affecting the cost of health care. (From Chang, C.F., Price, S.A., & Pfoutz, S.K. [2001]. Economics and Nursing: Critical Professional Issues. Philadelphia: FA Davis, p. 79.)

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chapter 10 | Quality and Safety 145

6. Single-Payer/National Health Coverage. A single-payer system aims to decrease the cost

of care by eliminating third-party insurers,

costly overhead, and bureaucracy while provid-

ing coverage for all. Plans may offer choices to

consumers regarding providers, hospitals, and

specialty services, and physicians and hospitals

are paid through negotiates, fee-for-service, or

salary. Costs are controlled through budgeting,

bulk purchasing, and negotiation (Physicians

for a National Health Plan, 2008).

Proponents of a single-payer system cite lower costs

per capita while ensuring access to care for all

Americans. Opponents cite that the possible trade-

off for decreased cost and improved access leads to

increased mortality, poorer outcomes of care, limited

to no-cost savings, and loss of control by consumers

(National Center for Policy Analysis, 2008).

The intended effects of regulation and competi-

tion are to decrease cost. Despite the variety of

attempts over the years to drive down costs, they

continue to go up, imposing a heavy burden on

consumers or employers (Center for Studying

Health System Change, 2008). However, improved

quality and safety prevent unnecessary deaths and

errors that contribute to the high cost of care

(IOM, 2000; IOM 2003a). The U.S. government,

consumers, providers, and organizations have a

vested interest in controlling health-care expendi-

tures and in preventing waste while maintaining

quality care.

Nursing Labor Market

RNs comprise 77% of the nurse workforce, and

almost 60% of RNs are employed by hospitals. The

nationwide unemployment rate for RNs is only 1%.

Vacancy rates nationwide are reported at anywhere

from 13% to 20% and are rising. A serious nursing

shortage is here, and it will continue until at least

2020. The demand for nurses is expected to

increase even more dramatically as the baby

boomers reach their 60s, 70s, and beyond. From

now until 2030, the population age 65 years and

older will double.

Def ining and Identifying the Nursing Shortage

The nursing shortage is defined simply as a supply-

demand issue. Unfortunately, the current nursing

shortage is more complex and severe than previous

shortages in terms of the available supply, the

demand from employers, and the new graduate

pipeline for RNs.

■ Supply of existing RNs. The total supply of U.S. RNs is estimated at 2.9 million and is pro-

jected to remain the same though 2020. The

supply of active RNs, including those who are

licensed, working, or seeking employment as an

RN, is projected be 2.1–2.3 million from 2000

to 2020 (U.S. Department of Health and

Human Services [HRSA], 2006).

■ New graduate supply pipeline. Nursing program graduation and NCLEX-RN pass rates affect

supply. The American Association of Colleges of

Nursing (AACN) reported an increase in bac-

calaureate level–entry enrollments, up by 5.4% in

2006 (AACN, 2008). According to the National

Council of State Boards of Nursing (2008), first-

time candidates for nursing licensure in 2007

numbered 200,209, with a pass rate of 69.4%.

However, HRSA (2006) projected that U.S.

nursing programs must graduate 90% more nurs-

es to meet the U.S. demands for nurses (p. 2).

■ Demand from employers. The Bureau of Labor Statistics predicts the RN job to be among the

top 10 in growth rate (U.S. Department of

Labor, 2008). Total job openings for RNs will

exceed 1.1.million, including new job growth

and replacement of retiring nurses.

In a survey of over 5000 community hospitals, the

American Hospital Association (2007) reported

116,000 RN vacancies as of December 2006. The

effects of these vacancies contribute to decreased

employee and patient satisfaction and increased hiring

of foreign-educated nurses. The majority of urban

hospital emergency departments reported capacity

issues and spend time on by-pass or diversion due to

a lack of properly staffed critical care beds.

In 2002 more than 100,000 new RNs were

hired; the majority were foreign-born nurses and

nurses over age 50 returning to the workforce in

tough economic times. Although the new hires and

a sharp increase in RN salaries are positive, the cur-

rent nursing shortage is far from over.

Factors Contributing to the Nursing Shortage

Many complex factors have led to and continue to

contribute to the current critical nursing shortage:

■ High acuity, increasing age of patients in hospitals. Medically complex patients require

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146 unit 2 | Working Within the Organization

skilled nursing care. The number of aging baby

boomers will significantly increase the demands

on the health-care systems and increase the

needs for RNs.

■ Increased demand for nurses. As health care moves to a variety of community settings, only

the most acute patients remain in the hospital.

The transfer of less acute patients to nursing

homes and community settings creates addition-

al job opportunities. Research supporting

improved patient outcomes when patient care is

provided by RNs as opposed to unlicensed per-

sonnel will also increase demand for RNs.

■ Aging nursing workforce. In 2000, fewer than one in three RNs was younger than 40 years of

age. The percentage of nurses age 40–49 years is

currently more than 35%.

In March 2004 the average age of the RN popula-

tion was 46.8 years of age, up from 45.2 in 2000.

The RN population under the age of 30 dropped

from 9% of the nursing population in 2000 to 8%

in 2004 (AACN, 2008).

■ Job dissatisfaction. Staffing levels, heavy workloads, increased use of overtime, lack of

sufficient support staff, and salary discrepancies

between nurses and other health-care profes-

sionals have contributed to growing dissatisfac-

tion and lower retention of nurses. Many

facilities are now using workplace issues and

incentives as a retention strategy.

■ Reduction in and shortage of nursing faculty. As retirements for faculty continue, the shortage

of faculty continues to affect the number of

students admitted to nursing programs. In

2007 nursing programs reported more than

750 open nursing faculty positions (AACN,

2008). In addition, nursing programs turned

away over 40,000 qualified nursing applicants,

in part, due to the shortage of nursing faculty

(AACN, 2008).

■ The need to control spiraling health-care costs,

along with the issues of supply and demand for

nursing services will continue. According to the

ANA, more than 40% of nurses graduate initially

from associate-degree nursing programs. You,

personally, will be affected by trends in health-

care delivery, but you can also be a major voice

in decision making (Nelson, 2002). As in the

past, cost control and demand for nursing

services will most likely involve changing nurse

staffing, the model of care, and professional

nursing practice (Ritter-Teitel, 2002).

Safety in the U.S. Health-Care System

Patient safety is the prevention of harm caused by

errors. The IOM defines errors as “the failure of a

planned action to be completed as intended (e.g.,

error of execution) or the use of a wrong plan to

achieve an aim (e.g., error of planning) (IOM,

2000, p. 57). It is important to note that errors are

unintentional and that not all errors lead to an

adverse event causing harm or death.

Types of Errors

To Err is Human (2000) relied on the work of Leape et al. (1993) to categorize types of errors

(Box 10-7). After categorizing types of errors,

Leape and colleagues found that 70% of all errors

were preventable.

Human errors can occur for many reasons. Skill- based errors can be slips or lapses when the actions taken by the provider were not what was intended

(Duke University Medical Center, 2005). An

example of rule-based error is an experienced nurse

administering the wrong medication by picking up

the wrong syringe.

box 10-7

Types of Errors (IOM, 2000, p. 36) Diagnostic

Error or delay in diagnosis

Failure to employ indicated tests

Use of outmoded tests or therapy

Failure to act on results of monitoring or testing


Error in the performance of an operation, procedure, or test

Error in administering the treatment

Error in the dose or method of using a drug

Avoidable delay in treatment or in responding to an abnor-

mal test

Inappropriate (not indicated) care


Failure to provide prophylactic treatment

Inadequate monitoring or follow-up of treatment


Failure of communication

Equipment failure

Other system failure

Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Preventing medical

injury. Qual Rev Bull. 19(5):144–149, 1993.

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chapter 10 | Quality and Safety 147

Not all errors lead to patient harm or to an

adverse event. Each type of event can be studied to

glean data used to improve safety.

■ Near miss. A near miss is an error that results in no harm or very minimal patient harm (IOM,

2000, p. 87). Near misses are useful in identify-

ing and remedying vulnerabilities in a system

before harm can occur.

■ Adverse event. An adverse event is injury to a patient caused by medical management rather

than an underlying condition of the patient

(IOM, 2000). The IOM reports have highlight-

ed the prevalence of errors, especially preventa-

ble adverse events. Adverse events have been

classified into four types (see Box 10-7).

■ Accident. An accident is an event that involves damage to a defined system that disrupts the

ongoing or future output of that system.

Accidents occur when multiple systems fail and

tend to be unplanned or unforeseen. Accidents

provide information about systems.

Error Identification and Reporting

Nurses are on the front line in identifying and

reporting errors. However, many errors are not

reported or go undetected. Providers and organiza-

tions may fear blame or punishment for mistakes

or errors.

Developing a Culture of Safety

To achieve safe patient care, a culture of safety must exist. Organizations and senior leadership must

drive change to develop a culture of safety—a

blame-free environment in which reporting of

errors is promoted and rewarded. A culture of

safety promotes trust, honesty, openness, and trans-

parency. Teamwork and involvement of the patient

contribute to promoting a culture of safety. When

a culture of safety exists, individual providers do

not fear reprisal and are not blamed for identifying

or reporting errors. Reported errors provide data

and information necessary to understand why or

how the error occurred, thus improving care and

preventing harm.

Event-reporting systems hold organizations

accountable and lead to improved safety. Mandatory

reporting systems are operated by regulatory agen-

cies and have a strong focus on errors associated

with serious harm or death. As of 2005, 24 states

had either mandatory or voluntary reporting

systems (Rosenthal & Booth, 2005). In addition,

the Food and Drug Administration (FDA) man-

dates reporting of serious harm or death (adverse

events) related to drugs and medical devices. Failure

to report mandatory requirements may lead to fines,

withdrawal of participation in clinical trials, or loss

of licensure to operate.

The Joint Commission relied on root cause analysis from each sentinel event. Root cause analy- sis is the process of learning from consequences.

The consequences can be desirable, but most root

cause analysis deals with adverse consequences. An

example of a root cause analysis is a review of a

medication error, especially one resulting in a death

or severe complications. Principles of root cause

analysis include:

1. Determine what influenced the consequences,

i.e., determine the necessary and sufficient

influences that explain the nature and the mag-

nitude of the consequences.

2. Establish tightly linked chains of influence.

3. At every level of analysis, determine the neces-

sary and sufficient influences.

4. Whenever feasible, drill down to root causes.

5. Know that there are always multiple root causes.

The Joint Commission also developed the

International Center for Patient Safety, which

establishes National Patient Safety Goals each year

and publishes Sentinel Event Strategies. Box 10-8

box 10-8

Joint Commission International Center for Patient Safety

1. Sets patient safety standards

2. Implements and oversees sentinel event policy and

advisory group

3. Publishes Sentinel Event Alert newsletter and quality

check reports

4. Sets yearly national patient safety goals

5. Developed the universal protocol related to surgical


6. Evaluates organizations’ monitoring of quality of care


7. Conducts patient safety research

8. Provides patient safety resources

9. Supports the Speak Up program

10. Involved with patient safety coalitions and legislative


Adapted from Joint Commission on Accreditation of Healthcare

Organizations (JCAHO), accessed November 26, 2005, from


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148 unit 2 | Working Within the Organization

describes the work of the International Center for

Patient Safety. These tools developed by the Joint

Commission offer health-care organizations goals

and strategies to prevent harm and death based on

what has been learned from sentinel events.

Organizations, Agencies, and Initiatives Supporting Quality and Safety in the Health-Care System

The ongoing movement to improve quality and

safety has led to the development of governmental

and private organizations (see Box 10-9) in addition

to those mentioned in the historical perspective

at the beginning of this chapter. These organiza-

tions and agencies currently monitor, evaluate,

accredit, influence, research, finance, and advocate

for quality within the health delivery system. Each

organization works inside and outside the system

to drive change leading to improved health out-

comes and improved system quality. Each organi-

zation works within its mission to address various

characteristics of the health-care system or to

address patient needs. Some organizations serve

multiple roles beyond their primary mission.

Government Agencies

Federal and state-level government agencies pro-

vide tools and resources for improving quality and

safety within the U.S. health-care system.

Government agencies also oversee regulation,

licensure, and mandatory and voluntary reporting


Within the U.S. Department of Health and

Human Services (HHS) reside multiple agencies

that support quality and safety. HHS is the U. S.

government’s principal agency for protecting the

health of all Americans and providing essential

human services, including health care (HHS, 2008).

HHS works closely with state and local govern-

ments to meet the nation’s health and human needs.

In addition to administering Medicare and

Medicaid, the Center for Medicare and Medicaid

(CMS) administers quality initiatives intended “to

assure quality health care for all Americans through

accountability and public exposure” (CMS, 2008).

Initiatives include:

■ MedQIC. This initiative aims to ensure each

Medicare recipient receives the appropriate level

of care. MedQIC is a community-based QI

program that provides tools and resources to

box 10-9

Organizations and Agencies Supporting Quality and Safety

Government Agencies

• U.S. Department of Health and Human Services


• Food and Drug Administratoin (FDA) http://www.fda.gov/

• Initiatives: Medwatch and Sentinel Initiative

• Health Resources and Services Administration (HRSA)


• Initiatives: Health Information Technology and National

Practitioner Database

• Center for Medicare and Medicaid Services (CMS) http://


• Initiatives: Hospital Quality Initiative, MedQIC, American

Health Quality Association (AHQA),

• Agency for Healthcare Research and Quality (AHRQ)


• Initiatives: Health IT, Improving Health Care Quality,

Medical Errors and Patient Safety, Measuring Quality

• VA National Center for Patient Safety http://www.


Health-Care Provider Professional Organizations

• American Nurses Association http://nursingworld.org/

• Initiative: National Database of Nursing Quality

Indicators (NDNQI)

• Association of Perioperative Registered Nurses (AORN)


• Initiative: Patient Safety First and AORN Toolkits

• American Hospital Association (AHA)


• Initiative: AHA Quality Center

• Association of Academic Health Centers


• Priorities: Health Profession Workforce and Health Care


Non-Profit Organizations, Foundations, and Research

• The Leapfrog Group http://www.leapfroggroup.org/

• Kaiser Family Foundation http://www.kff.org/

• Markel Foundation-Connecting for Health http://www.


• Robert Wood Johnson Foundation-Quality Equality in

Healthcare http://www.rwjf.org/qualityequality/


• National Patient Safety Foundation http://www.


• The Commonwealth Fund http://www.commonwealthfund.


Quality Organizations

• Institute for Healthcare Improvement (IHI) http://


• The Joint Commission http://www.jointcommission.org/

• National Committee for Quality Assurance (NCQA) http://


• National Quality Forum http://www.qualityforum.org/

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■ AHRQ Quality Indicators. Set of quality indi- cators used by organizations to highlight

potential quality concerns, identify areas that

need further study and investigation, and track

changes over time

The U. S. Department of Defense (DoD) and the

Veterans Health Administration (VHA) have

taken leadership positions in developing tools,

resources, and programs aimed at improving safety,

promoting change, and promoting a culture of safety

within the DoD and VHA. The VHA National

Center for Patient Safety developed a toolkit for

fall prevention and management, tools for escape

and elopement management, and cognitive aids for

root cause analysis and health failure mode and

effect analysis.

Health-Care Provider Professional Organizations

Professional organizations directly address the mis-

sions and concerns regarding quality and safety of

the professionals they represent. Each organization

offers programs, access to evidence-based practices,

toolkits, and newsletters to aid their members in

driving quality within their own practice and


The vital quality and safety initiative of the

ANA is the National Database of Nursing Quality

Indicators (NDNQI), a database of unit-specific

nurse-sensitive information collected at hospitals.

Data are collected and evaluated to improve quality.

The indicators reflect the structure, process, and

outcomes of nursing care and lead to improved

quality and safety at the bedside. The ANA also

has a strong focus on safe nurse staffing levels to

promote safe, quality patient care.

Nonprof it Organizations and Foundations

With few exceptions, nonprofit organizations and

foundations are generally focused on consumer

education, policy development, and research to

improve quality and safety within the health-care

system. Many organizations serve multiple mis-

sions. The Kaiser Family Foundation (2005) has a

strong emphasis on U.S. and international nonpar-

tisan health policy and health policy research. Self-

funded research and public opinion polling on

topics related to quality and safety in the health-

care system contribute to policy and legislation


chapter 10 | Quality and Safety 149

encourage changes in processes, structures, and

behaviors within the health-care community.

■ Post–Acute Care Reform Plan. CMS is exam- ining post-acute transfers with the aim of reduc-

ing care fragmentation and unsafe transitions.

■ Hospital Quality Initiative. This is a major ini- tiative aimed at improving quality of care at the

provider and organization level. Organizations

provide data through public reporting of quality

measures that translate information to assist

consumers in health decisions. This initiative cre-

ates a uniform set of quality measurement by

which consumers can compare organizations and

by which organizations can benchmark progress

toward achieving goals in specified areas of care,

such as acute myocardial infarct, congestive heart

failure, pneumonia, and postsurgical infections.

These data feed the Hospital Compare Web site (www.hospitalcompare.hhs.gov). Organizations

are incentivized to participate with an offering of

increased reimbursement.

Also under the HHS is the Agency for Healthcare

Research and Quality (AHRQ), which is the lead

federal agency charged with improving the quality,

safety, efficiency, and effectiveness of health care for

all Americans (HHS, 2008). Through multiple ini-

tiatives, the support of research, and evidence-

based decision-making, the AHRQ aims to fulfill

its mission:

■ Health IT. A multifaceted initiative that includes (a) research support of $260 million in grants and

contracts to support and stimulate investment

in health information technology (IT); (b) the

newly created AHRQ National Resource Center,

which provides technical assistance and research

funding to aid technology implementation within

communities; and (c) learning laboratories at

more than 100 hospitals nationwide to develop

and test health IT applications

■ National Quality Measures Clearinghouse (NQMC). Web-accessible database provides access to evidence-based quality measures and

measure sets; NQMC provides access for

obtaining detailed information on quality

measures and to further their dissemination,

implementation, and use in order to inform

health-care decisions

■ Medical Errors and Patient Safety. Web site providing access to evidence-based tools and

resources for consumers and providers

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150 unit 2 | Working Within the Organization

Also having a multifaceted mission, the

renowned Robert Wood Johnson Foundation

(RWJF) serves multiple missions and seeks to

improve health and health care for all Americans.

RWJF’s success comes from leveraging partner-

ships and its endowment to “building evidence and

producing, synthesizing and distributing knowl-

edge, new ideas and expertise” (RWJF, 2008) in

eight program areas. RWJF is responsible for

sucessfully funded projects and research that

improve quality and safety for all Americans.

The Leapfrog Group is a nonprofit organiza-

tion interested in improving safety, quality, and

affordability of health care through incentives and

rewards to those who use and pay for health care

(Leapfrog Group, 2007). With a focus on reducing

preventable medical mistakes, the Leapfrog Group

touted their benefits to improve safety and quality

to consumers and business owners with three leaps: (a) improve transparency by reporting hospital

survey results addressing quality and safety indica-

tors; (b) incentivize better quality and safety

performance; and (c) collaborate with other orga-

nizations to improve quality and safety. To date,

there is limited evidence that the Leapfrog Group

has effectively improved quality or safety.

Limitations to success may be in part because too

few hospitals have participated in the surveys and

too few consumers have used the available infor-

mation to make health decisions; however, there is

an indication that, with time, participation could

improve with adjustments in strategy by the

Leapfrog Group (Galvin, Delbanco, Milstein, &

Belden, 2005).

Quality Organizations

Each of the quality organizations strives to improve

system-wide quality for Americans through a vari-

ety of programs and methods.

The National Committee for Quality Assurance

(NCQA) was established in 1990 to accredit health

plans and certify organizations. Its success in sup-

porting quality and safety resides in its Health

Effectiveness Data and Information Set (HEDIS).

Over 90% of U.S. health plans use HEDIS to

measure performance. HEDIS allows for con-

sumers and employers to evaluate health plans

using data from HEDIS as a report card of the

plan’s success.

JC was established in 1951 with a focus on

structural measures of quality, assessment of the

physical plant, number of patient beds per nurse,

credentialing of service providers, and other

standards for each department. This system of

evaluation has given way to a more process- and

outcome-focused model: CQI. Today, the JC

accredits more than 19,000 health-care organiza-

tions. Evaluation of nursing services is an impor-

tant part of the accreditation. JC–accredited

agencies are measured against national standards

set by health-care professionals. Hospitals,

health-care networks, long-term care facilities,

ambulatory care centers, home health agencies,

behavioral health-care facilities, and clinical

laboratories are among the organizations seeking

JC accreditation. Although accreditation by the

JC is voluntary, Medicare and Medicaid reim-

bursement cannot be sought by organizations not

accredited by JCAHO.

Integrating Initiatives and Evidenced-Based Practices Into Patient Care

As you familiarize yourself with each of these

organizations and their respective initiatives, con-

sider how they will affect the management of

patient care. Your responsibility as a professional

RN is to acknowledge their presence, understand

and value their importance, and participate in your

facility-adopted initiatives and evidence-based

practices. Additionally, as a leader and manager, you

will be expected to drive changes based upon

endeavors of many of these organizations, agencies,

and initiatives ensuring that quality and safety con-

tinue to improve.

Health-Care System Reform

Eighty-two percent of Americans believe the U.S.

health-care system is in need of either fundamental

change or complete rebuilding (How, Shih, Lau,

& Shoen, 2008). Americans want leadership to

address quality, cost, coverage, and access. The

debate rests on how best to achieve necessary reform.

The IOM report proposed five core compe-

tencies (Box 10-10) in which all health-care

professionals will need to be effective as providers

and leaders in the 21st-century health-care


By integrating these competencies into

21st-century health profession education, you can

begin to support health-care reform while managing

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chapter 10 | Quality and Safety 151

patient care. As a practicing professional, you can use

the competencies to guide future professional devel-

opment and ensure positive impact on health-care

reform while improving quality and safety.

Role of Nursing in System Reform

The ANA’s Agenda

In 1989, taking a leadership position regarding

health-care reform, the ANA began to address

concerns regarding quality, safety, and cost of care

as well as the potential health-care reform within

the United States Working with more than 60

nursing and health-care organizations, the ANA

published Nursing’s Agenda for Health Care Reform (ANA, 1991). This document was positioned as its

blueprint for reform.

Building on the ANA’s report from 1991, the

ANA’s Health Care Agenda (ANA, 2005) describes the organization’s policy on health system reform.

This policy includes four basic principles:

1. Health care is a basic human right. A restruc-

tured health-care system should include univer-

sal access to essential services.

2. The development of health policies that incor-

porate the IOM’s six aims of health care will

save money.

3. The health-care system must be reshaped and

redirected away from the overuse of expensive,

technology-driven, acute, hospital-based

services in the model we now have to one

in which a balance is struck between high-

technology treatment and community-based

and preventive services, with emphasis on

the latter.

4. The ANA supports a single-payer health-care

system (ANA, 2005, p. 2).

Although updated in 2008, the ANA’s policy still

maintains the same four principles.

Influence of Nursing

Nurses are empowered through self-determination,

meaning, competence, and impact (Whitehead,

Weiss, & Tappen, 2007, p. 71). Additionally, nurses

play vital roles in collective bargaining and decision

making within their organizations, empowered

through professional organization such as the

ANA (see Chapter 5).

Nurses are respected and trusted health-care

professionals. To influence change in the health-

care system, professional nurses must first acknowl-

edge power within the profession and recognize

their central role in health care. To be effective,

nurses must leverage their professional expertise

and the trust and respect they have garnered. It is

critical that nurses speak up and seek an active role

in shaping health-care reform:

■ Become informed. Research topics of interest to you and your practice. Rely on the Internet and your professional organizations as resources

for current policy and legislative topics.

■ Plan. After selecting a topic, prepare your plan: gather facts and figures that will support your

ideas and position. Outline them, and address

your audience in person, on paper, or via the

Web. The most influential people are prepared

and believe in their topic.

■ Take action. Shape public opinion by the method of your choice. Start small, and build

box 10-10

Core Competencies for Health Professionals (IOM, 2003a, p. 4) Provide patient-centered care. Identify, respect, and care about patients; differences, values, preferences, and expressed

needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate

patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion

of healthy lifestyles, including a focus on population health.

Work in interdisciplinary teams. Cooperate, collaborate, communicate, and integrate care in teams to ensure that care is

continuous and reliable.

Employ evidence-based practice. Integrate best research with clinical expertise and patient values for optimum care, and

participate in learning and research activities to the extent feasible.

Apply quality improvement. Identify errors and hazards in care; understand and implement basic safety design principles,

such as standardization and simplification; continually understand and measure quality of care in terms of structure, process,

and outcomes in relation to patient and community needs; and design and test interventions to change processes and

systems of care with the objective of improving quality.

Utilize informatics. Communicate, manage knowledge, mitigate error, and support decision making using information


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152 unit 2 | Working Within the Organization

your impact. (1) Write a letter to your represen-

tative (local, state, federal), ANA leadership or

state-level delegate, the editor of your local

newspaper, or to the editor of your favorite

nursing journal/magazine. (2) Attend a meeting

where your topic will be addressed in a public

forum or at a professional gathering. Meet the

people who are influential, and share your ideas

or learn from others. (3) Vote for candidates and

officers in your professional organizations and

within the government. (4) Visit your represen-

tative (local, state, federal) or ANA leadership

or state-level delegate to share your ideas.

(5) Volunteer. Ask what you can do to help.

(6) Testify before decision-making bodies.


Pressure from quality organizations, consumers,

payers, and providers has caused the focus in the

health-care system to shift from patient care to

issues of cost and quality. Experts indicate that

quality promotes decreased costs and increased sat-

isfaction. This is an opportunity for nurses to

become more professional and empowered to

organize and manage patient care so that it is safe,

efficient, and of the highest quality. Begin early in

your career to participate actively in QI initiatives.

Regardless of the care model used or the indicators

selected, focus attention on the following in patient

care delivery (Hansten & Washburn, 2001, p. 24D):

1. Think critically. Use your creative, intuitive, logical, and analytical processes continually in

working with patients.

2. Plan and report outcomes. Emphasizing results is a necessary part of managing resources in

today’s cost-conscious environment. Focusing

on the outcomes moves the nurse out of the

mindset of focusing just on tasks.

3. Make introductory rounds. Begin each shift with the health-care team members introduc-

ing themselves, describing their roles, and pro-

viding patients updates.

4. Plan in partnership with the patient. In conjunc- tion with the introductory rounds, spend a few

minutes early in the shift with each patient,

discussing shift objectives and long-term goals.

This event becomes the center of the nursing

process for the shift and ensures that the patient

and nurse are working toward the same outcomes.

5. Communicate the plan. Avoid confusion among members of the team by communicat-

ing the intended outcomes and the important

role that each member plays in the plan.

6. Evaluate progress. Schedule time during the shift quickly to evaluate outcomes and the

progress of the plan and to make revisions as


Study Questions

1. How have historical, social, political, and economic trends affected your practice? Give specific

examples and their implications.

2. What problems have you identified during your clinical experiences that could be considered issues

to be addressed using CQI?

3. What SCMs have you seen implemented in practice? Which ones might you use to assist you in

planning care? If you have not seen any, ask the nurse manager what is used on the unit.

4. Review the section in this chapter on risk management. In what areas of risk do you feel you are

the most vulnerable? How will you work on correcting your risk?

5. Discuss the role of the nurse in CQI and risk management.

6. Based on patient safety goals for the current year, what will you do to ensure adherence to these goals?

7. What are evidence-based practices that promote quality and safety within the health-care system?

8. Describe how regulatory agencies and accrediting agencies affect patient care and outcomes at the


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chapter 10 | Quality and Safety 153

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Case Study to Promote Critical Reasoning

The director of CQI has called a meeting of all the staff members on your floor. Based on last

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that of patients for the first half of the year. She has requested that the staff identify members who

wish to be CQI team members looking at this problem. You, the staff nurse, have volunteered to be

a member of the team. The team will consist of the diabetes educator, a patient-focused care

assistant, a pharmacist, and you.

1. Why were these people selected for the team?

2. What data need to be collected to evaluate this situation?

3. What are the potential outcomes for patients with uncontrolled diabetes?

4. Develop a flowchart of a typical hospital stay for a patient with uncontrolled diabetes.

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chapter 11 Time Management

OBJECTIVES After reading this chapter, the student should be able to: ■ Describe personal perceptions of time.

■ Discuss the rationale for good time management skills.

■ Set short- and long-term personal career goals.

■ Analyze activities at work using a time log.

■ Incorporate time management techniques into clinical practice.

■ Organize work to make more effective use of available time.

■ Set limits on the demands made on one’s time.

■ Create a personal calendar using a computerized calendar system.


The Tyranny of Time

How Do Nurses Spend Their Time?

Organizing Your Work

Setting Your Own Goals


Long-Term Planning Systems

Schedules and Blocks of Time

Filing Systems

Setting Limits

Saying No

Eliminating Unnecessary Work

Streamlining Your Work

Avoiding Crisis Management

Keeping a Time Log

Reducing Interruptions

Categorizing Activities

Finding the Fastest Way

Automating Repetitive Tasks

The Rhythm Model for Time Management



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158 unit 2 | Working Within the Organization

Coming onto the unit, Celia, the evening charge nurse, already knew that a hectic day was in progress. Scattered throughout the unit were clues from the past 12 hours. Two patients on emergency department stretchers had been placed outside obser- vation rooms already occupied by patients who were admitted the previous day in critical condition. Stationed in the middle of the hall was the code cart, with its drawers opened and electrocardiograph paper cascading down the sides. Approaching the nurses’ station, Celia found Guillermo buried deep in paperwork. He glanced at her with a face that had exhaustion written all over it. His f irst words were, “Three of your RNs called in sick. I called staff ing for additional help, but only one is available. Good luck!” Celia surveyed the unit, looked at the number of staff members available, and reviewed the patient acuity level of the unit. She decided not to let the sit- uation upset her. She would take charge of her own time and reallocate the time of her staff. She began to reorganize her staff mentally according to their capabilities and alter the responsibilities of each member. Having taken steps to handle the problem, Celia felt ready to begin the shift.

Business executives, managers, students, and nurses

know that time is a valuable resource. Time cannot

be saved and used later, so it must be used now and

wisely. As a new nurse, you may at times find your-

self sinking in the “quicksand” of a time trap, know-

ing what needs to be done but just not having the

necessary time to do it (Ferrett, 1996). In today’s

fast-paced health-care environment, time manage-

ment skills are critical to a nurse’s success. Learning

to take charge of your time and to use it effectively

and efficiently is the key to time management

(Gonzalez, 1996). Many nurses believe they never

have enough time to accomplish their tasks. Like

the White Rabbit in Alice in Wonderland, they are constantly in a rush against time. Time manage-

ment, simply, is organizing and monitoring time so

that patient care tasks can be scheduled and imple-

mented in a timely and organized fashion (Bos &

Vaughn, 1998).

The Tyranny of Time

Newton stated that time was absolute and that it

occurred whether the universe was there or not.

Einstein theorized that time has no independent

existence apart from the order of events by which

people measure it (Smith, 1994). It really does not

matter which theory is correct because, for nurses,

their professional and personal lives are guided

by time.

How often do you look at your watch during the

day? Do you divide your day into blocks of time?

Do you steal a quick glance at the clock when you

come home after putting in a full day’s work? Do

you mentally calculate the amount of time left to

complete the day’s tasks of grocery shopping, driv-

ing in a car pool, making dinner, and leaving again

to take a class or attend a meeting? Calendars,

clocks, watches, newspapers, television, and radio

remind people of their position in time. Perception

of time is important because it affects people’s use

of time and their response to time (Box 11-1).

Computers complete operations in a fraction of

a second, and speeds can be measured to the

nanosecond. Time clocks that record the minute

employees enter and leave work are commonplace,

and few excuses for being late are really considered

acceptable. Timesheets and schedules are part of

most health-caregivers’ lives. Staff members are

box 11-1

Time Perception Webber (1980) collected a number of interesting tests of

people’s perception of time. You may want to try several

of these:

• Do you think of time more as a galloping horseman or a

vast motionless ocean?

• Which of these words best describes time to you: sharp,

active, empty, soothing, tense, cold, deep, clear, young,

or sad?

• Is your watch fast or slow? (You can check it with the


• Ask a friend to help you with this test. Go into a quiet

room without any work, reading material, radio, food,

or other distractions. Have your friend call you after

10–20 minutes have elapsed. Try to guess how long

you were in that room.

Webber test results interpreted. A person who has a circular

concept of time would compare time with a vast ocean.

A galloping horseman would be characteristic of a linear

conception of time, emphasizing speed and forward

motion. A person oriented to a fast tempo and achievement

would describe time as clear, young, sharp, active,

or tense rather than empty, soothing, sad, cold, or deep.

These same fast-tempo people are likely to have fast

watches and to overestimate the amount of time that they

sat in a quiet room.

Adapted from Webber, R.A. (1980). Time Is Money! Tested Tactics That

Conserve Time for Top Executives. New York: Free Press.

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chapter 11 | Time Management 159

expected to follow precisely set schedules and meet

deadlines for almost everything, from distributing

medications to completing reports on time. Many

agencies produce vast quantities of computer-

generated data that can be analyzed to determine

the amount of time spent on various activities.

Several fallacies exist regarding time manage-

ment. One of the foremost is that time can be man-

aged like other resources. Time is finite. There are

only 24 hours in a day, so the amount of time avail-

able cannot be controlled, only how it is used

(Brumm, 2004). Individual personality, culture,

and environment interact to influence human

perceptions of time (Matejka & Dunsing, 1988).

Everybody has an internal tempo (Chappel, 1970).

Some internal tempos are quicker than others.

Environment also affects the way people respond to

time. A fast-paced environment influences most peo-

ple to work at a faster pace, despite their internal

tempo. For individuals with a slower tempo, this

pace can cause discomfort. If you are high-

achievement–oriented, you are likely to have already

set some career goals for yourself and to have a men-

tal schedule of deadlines for reaching these goals (“go

on to complete my bachelor of science in nursing in

4 years; a master of science in nursing in 6 years”).

Many health-care professionals are linear, fast-

tempo, achievement-oriented people. Simply

working at a fast pace, however, is not necessarily

equivalent to achieving a great deal. Much energy

can be wasted in rushing around and stirring things

up but actually accomplishing very little. This

chapter looks at ways in which you can use your

time and energy wisely to accomplish your goals.

How Do Nurses Spend Their Time?

Nurses are the largest group of health-care profes-

sionals. Because of the number of nurses needed and

the shift variations, attention concerning the effi-

ciency and effectiveness of their time management is

needed. Efficient nurses deliver care in an organized

manner that makes best use of time, resources, and

effort. Effective care improves a situation.

Today’s labor market for skilled health-care pro-

fessionals remains tight. Institutions face new chal-

lenges, not of “trimming the fat, but compensate

[sic] for loss of muscle” (Baldwin, 2002, p. 1).

Current shortages of nurses, radiology technicians,

pharmacists, and other health-care specialists show

all the signs of a long-term problem. Health-care

institutions need to change their thinking on how to

manage work. Most are looking toward technology

to help cope with staffing shortages (Baldwin, 2002).

For example:

A new graduate worked in a medical intensive care unit from 7 a.m. to 3 p.m. and rotated every third week to 11 p.m. to 7 a.m., working 7 days straight before getting 2 days off. It was not diff icult to remain awake during the entire shift the f irst night on duty, but each night thereafter staying awake became increasingly diff icult. After taking and recording the 2 a.m. vital signs, the new graduate inevitably fell asleep at the nurses’ station. He was so tired that he had to check and recheck patient med- ications and other procedures for fear of making a fatal error. He became so anxious over the possibility of injuring someone that sleep during the day became impossible. Because of his obsession with rechecking his work, he had diff iculty completing tasks and was always behind at the end of the shift (of course, napping did not help his time management).

A number of studies have examined how nurses use

their time, especially nurses in acute care. For exam-

ple, a study by Arthur Andersen found that only

35% of nursing time is spent in direct patient care

(including care planning, assessment teaching, and

technical activities). Lundgren and Segesten (2001)

found that this increases to 50% when an all-RN

staff is involved in patient care delivery, as the nurses

spent less time supervising non-nursing personnel.

Documentation accounts for another 20% of

nursing time. The remainder of time is spent on

transporting patients, processing transactions,

performing administrative responsibilities, and

undertaking hotel services (Brider, 1992).

Categories may change from study to study, but

the amount of time spent on direct patient care is

usually less than half the workday. As hospitals

continue to reevaluate the way they deliver health

care, nurses are finding themselves more involved

with tasks that are not directly patient-related,

such as determining quality improvement, devel-

oping critical pathways, and so forth. These are

added to their already existing patient care func-

tions. The critical nursing shortage compounds

this problem. The result is that, in some cases,

nurses are able to meet only the highest-priority

patient needs, particularly in certain clinical set-

tings such as short-stay units or ambulatory care

centers (Curry, 2002).

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160 unit 2 | Working Within the Organization

Any change in the distribution of time spent on

various activities can have a considerable impact on

patient care and on the organization’s bottom line.

Prescott (1991) offered the following example:

If more unit management responsibilities could be shifted from nurses to non-nursing personnel, about 48 minutes per nurse shift could be redirected to patient care. In a large hospital with 600 full-time nurses, the result would be an additional 307 hours of direct patient care per day. Calculating the results of this time-saving strategy in another way shows an even greater impact: the changes would con- tribute the equivalent of the work of 48 additional full-time nurses to direct patient care.

Many health-care institutions are considering inte-

grating units with similar patient populations and

having them managed by a non-nurse manager,

someone with business and management expertise,

not necessarily nursing skills. However, as a group,

nurses respect managers who have nursing expertise

and who are able to perform as nurses. They believe

that a nurse-manager has a greater understanding of

both patient and professional staff needs. To address

these service concerns, many educational institu-

tions have developed dual graduate degrees com-

bining nursing and management.

Organizing Your Work

Setting Your Own Goals

It is difficult to decide how to spend your time

because there are so many tasks that need time. A

good first step is to take a look at the situation,

and get an overview. Then ask yourself, “What are

my goals?” Goals help clarify what you want and

give you energy, direction, and focus. Once you

know where you want to go, set priorities. This is

not an easy task. Remember Alice’s conversation

with the Cheshire Cat in Lewis Carroll’s Alice in Wonderland:

“Would you tell me please, which way I ought to go from here?” asked Alice.

“That depends a good deal on where you want to go to,” said the Cat.

“I don’t care where,” said Alice. “Then it doesn’t matter which way you go,” said

the Cat (Carroll, 1907).

How can you get somewhere if you do not know

where you want to go? It is important to explore

your personal and career goals. This can help you

make decisions about the future.

This concept can be applied to daily activities as

well as help in career decisions. Ask yourself ques-

tions about what you want to accomplish over a

particular period. Personal development skills

include discipline, goal setting, time management

and organizational skills, self monitoring, and a

positive attitude toward the job (Bos & Vaughn,

1998). Many of the personal management and

organizational skills related to the workplace focus

on time management and scheduling. Most new

nurses have the skills required to perform the job

but lack the personal management skills necessary

to get the job done, specifically when it comes to

time management.

To help organize your time, set both short- and

long-term goals. Short-term goals are those that

you wish to accomplish within the near future.

Setting up your day in an organized fashion is a

short-term goal, as is scheduling a required medical

errors or domestic violence course.

Long-term goals are those you wish to complete

over a long time. Advanced education and career

goals are examples. A good question to ask yourself

is, “What do I see myself doing 5 years from now?”

Every choice you make requires a different alloca-

tion of time (Moshovitz, 1993).

Alinore, a licensed practical nurse returning to school to obtain her associate’s degree in nursing, faced a multitude of responsibilities. A wife, a mother of two toddlers, and a full-time staff mem- ber at a local hospital, Alinore suddenly found herself in a situation in which there just were not enough hours in a day. She became convinced that becoming a registered nurse was an unobtainable goal. When asked where she wanted to be in 5 years, she answered, “At this moment, I think, on an island in Tahiti!” Several instructors helped Alinore devel- op a time plan. First, she was asked to list what she did each day and how much time each task required. This list included basic child care, driving children to and from day care, shopping, cooking meals, cleaning, hours spent in the classroom, study hours, work hours, and time devoted to leisure. Once this was established, she was asked which tasks could be allocated to someone else (e.g., her husband), which tasks could be clustered (e.g., cooking for several days at a time), and which tasks could be shared. Alinore’s husband was willing to assist with car pools, grocery

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chapter 11 | Time Management 161

shopping, and cleaning. Previously, Alinore never asked him for help. Cooking meals was clustered: Alinore made all the meals in 1 day and then froze and labeled them to be used later. This left time for other activities. Alinore graduated at the top of her class and subsequently completed her BSN. She became a clinical preceptor for other associate degree nursing students on a pediatric unit in a county hospital. She never did get to Tahiti, though.

Employers pay nurses for their time. Does that

mean that nurses “sell” their time? If so, then nurs-

es “own” their time. Looking at time from this per-

spective changes the point of view about time, as

nurses then manage their own time to accomplish

patient care tasks.

Time management means handling time with a

measure of proficiency. Therefore, time manage-

ment means meeting patient care needs skillfully

during a nursing shift (Navuluri, 2001). Organizing

work eliminates extra steps or serious delays in

completing it. Organizing also reduces the amount

of time spent in activities that are neither produc-

tive nor satisfying.

Working on the most difficult tasks when you

have the most energy decreases frustration later in

the day when you may be more tired and less effi-

cient. To begin managing your time, develop a

clear understanding of how you use your time. Creating a personal time inventory helps you

estimate how much time you spend on typical

activities. Keeping the inventory for a week gives

a fairly accurate estimate of how you spend your

time. The inventory also helps identify “time

wasters” (Gahar, 2000).

MacKenzie (1990) identified 20 of the biggest

time wasters. Some of these come directly from the

work environment, whereas others are personal char-

acteristics. To avoid time wasters, take control. It is

important to prevent endless activities and other

people controlling you (American Bar Association

Career Resource Center, n.d.). Every day, set priori-

ties to help you meet your goals. Ten frequent activ-

ities that infringe on time are in Box 11-2.


One of the most useful organizers is the “to do” list.

You can make this list either at the end of every day

or at the beginning of each day before you do any-

thing else. Some people say they do it at the end of

the day because something always interferes at the

beginning of the next day. Do not include routine

tasks because they will make the list too long and

you will do them without the extra reminder.

If you are a team leader, place the unique tasks

of the day on the list: team conference, telephone

calls to families, discussion of a new project, or in-

service demonstration of a new piece of equip-

ment. You may also want to arrange these tasks in

order of their priority, starting with those that

must be done that day. Ask yourself the following

questions regarding the tasks on the list

(Moshovitz, 1993):

■ What is the relative importance of each of these


■ How much time will each task require?

■ When must each task be completed?

■ How much time and energy have to be devoted

to these tasks?

If you find yourself postponing an item for several

days, decide whether to give it top priority the next

day or drop it from the list as an unnecessary task.

The list should be in a user-friendly form: on

your electronic organizer, in your pocket, or on a

clipboard. Checking the list several times a day

quickly becomes a good habit. Computerized

calendar-creator programs help in setting priori-

ties and guiding daily activities. Many of these

are found on the Internet or intranet of an insti-

tution. These programs can be set to appear on

the desktop when you turn on your computer to

give an overview of the day, week, or month. This

calendar acts as an automated to-do list. Your

daily list may become your most important time

manager (Box 11-3).

box 11-2

Ten Frequent Activities That Infringe on Time

• Managing by crisis

• Telephone calls

• Poor planning

• Taking on too much

• Unexpected visitors

• Improper delegation

• Disorganization

• Inability to say no

• Procrastinating

• Meetings

Adapted from the ABA Career Resource Center, http://www.abanet.org/


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162 unit 2 | Working Within the Organization

Long-Term Planning Systems

At the beginning of the semester, students are told

the examination dates and when papers will be due.

Many students find it helpful to enter the dates on

a semester-long calendar so they can be seen at a

glance. Then the students can see when clusters of

assignments are due at the same time. This allows

for advance planning or perhaps requests to change

dates or get extensions.

Personal digital assistants (PDAs), or hand-held

organizers, have become quite popular. These

devices allow both short-term and long-term

scheduling. PDAs permit storing of personal notes

and reminders, contact data, Internet access, and

other program files. Hand-held devices permit syn-

chronization with personal computers and

Internet-based calendars.

Schedules and Blocks of Time

Without some type of schedule, you are more likely

to drift through a day or bounce from one activity to

another in a disorganized fashion. Assignment

sheets, worksheets, flow sheets, and critical pathways

are all designed to help you plan patient care and

schedule your time effectively. The critical pathway

is a guide to recommended treatments and optimal

patient outcomes (see Chapter 10). Assignment sheets indicate the patients for whom each staff member is

responsible. Worksheets are then created to organize the daily care that must be given to the assigned

patients (see Chapter 9 for examples of worksheets).

Flow sheets are lists of items that must be recorded for each patient.

Effective worksheets and flow sheets schedule

and organize the day by providing reminders of

various tasks and when they need to be done. The

danger in using them, however, is that the more

they divide the day into discrete segments, the

more they fragment the work and discourage a

holistic approach. If a worksheet becomes the focus

of attention, the perspective of the whole and of the

individuals who are your patients may be lost.

Some activities must be done at a certain time.

These activities structure the day or week to a great

extent, and their timing may be out of your control.

However, in every job there are tasks that can be

done whenever you want to do them, as long as

they are done.

In certain nursing jobs, reports and presenta-

tions are often required. For these activities, you

may need to set aside blocks of time during which

you can concentrate on the task. Trying to create

and complete a report in 5- or 10-minute blocks of

time is unrealistic. By the time you reorient yourself

to the project, the time allotted is over, and nothing

has been accomplished. Setting aside large blocks

of time to do complex tasks is much more efficient.

Consider energy levels when beginning a big

task. Start when levels are high and not at, say, 4:00

in the afternoon if that is when you find yourself

winding down (Baldwin, 2002). For example, if you

are a morning person, plan your demanding work

in the morning. If you get energy spurts later in the

morning or early afternoon, plan to work on larger

or heavier tasks at that time. Nursing shifts may be

designed in 8-, 10-, or 12-hour blocks. Many nurses

working the night shifts (11 p.m. to 7 a.m. or

7 p.m. to 7 a.m.) find they have more energy a

little later into their shift rather than at the begin-

ning, whereas nurses working the day shifts (7 a.m.

to 3 p.m. or 7 a.m. to 7 p.m.) find they have the

most energy at the beginning of their shift. Also,

learn to delegate tasks that do not require profes-

sional nursing skills.

Some people go to work early to have a block of

uninterrupted time. Others take work home with

them for the same reason. This extends the work-

day and cuts into leisure time. The higher your

stress level, the less effective you will be on the

job—do not bring your work home with you. You

need some time off to recharge your batteries

(Turkington, 1996).

Filing Systems

Filing systems are helpful for keeping track of

important papers. All professionals need to main-

tain copies of licenses, certifications, continuing

education credits, and current information about

their specialty area. Keeping these organized in an

easily retrievable system saves time and energy

when you need to refer to them. Using color-coded

box 11-3

Determining How to Maximze Your Time • Set goals.

• Make a schedule.

• Write a to-do list.

• Revise and modify the to-do list; do not throw it out.

• Identify time-wasting behaviors.

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chapter 11 | Time Management 163

folders is often helpful. Each color holds docu-

ments that are related to one another. For example,

all continuing education credits might be placed in

a blue folder, anything pertaining to licensure in a

yellow folder, and so on.

Setting Limits

To set limits, it is necessary to identify your objec-

tives and then arrange the actions needed to meet

them in order of their priority (Haynes, 1991;

Navuluri, 2001). The focus of time management

exists on two levels: temporal and spatial. Nurses

need to focus on patient care needs during the shift

(temporal) or within the boundaries of the working

environment (spatial).

Saying No

Saying no to low-priority demands on your time is

an important but difficult part of setting limits.

Assertiveness and determination are necessary for

effective time management. Learn to say no tact-

fully at least once a day (Hammerschmidt &

Meador, 1993). Patient care is a team effort.

Effective time management requires you to look at

other members of the team who may be able to

take on the task.

The wisdom of time management is that you

may have to let others help you while never giving

up ownership of your time. In other words,

although supervisors and managers tell you what to

do, how you accomplish this remains up to you

(Navuluri, 2001). Is it possible to say no to your

supervisor or manager? It may not seem so at first,

but many requests are negotiable. Requests some-

times are in conflict with career goals. Rather than

sit on a committee in which you have no interest,

respectfully decline, and volunteer for one that

holds promise for you as well as meets the needs of

your unit.

Can you refuse an assignment? Your manager

may ask you to work overtime or to come in on

your scheduled day off, but you can decline. You

may not refuse to care for a group of patients or to

take a report because you think the assignment is

too difficult or unsafe. You may, however, discuss

the situation with your supervisor and, together,

work out alternatives. You can also confront the

issue of understaffing by filing an unsafe staffing

complaint. Failure to accept an assignment may

result in accusations of abandonment.

Some people have difficulty saying no.

Ambition keeps some people from declining any

opportunity, no matter how overloaded they are.

Many individuals are afraid of displeasing others

and therefore feel obligated to take on continuous-

ly all types of additional assignments. Still others

have such a great need to be needed that they con-

tinually give of themselves, not only to patients but

also to their coworkers and supervisors. They fail to

stop and replenish themselves, and then they

become exhausted. Remember, no one can be all

things to all people at all times without creating

serious guilt, anger, bitterness, and disillusionment.

“Anyone who says it’s possible has never tried it”

(Turkington, 1996, p. 9).

Eliminating Unnecessary Work

Some work has become so deeply embedded in

one’s routines that it appears essential, although it

is really unnecessary. Some nursing routines fall

into this category. Taking vital signs, giving baths,

changing linens, changing dressings, performing

irrigations, and doing similar basic tasks are more

often done according to schedule rather than

according to patient need, which may be much

more or much less often than the routine specifies.

Some of these tasks may appropriately be delegated

to others:

■ If patients are ambulatory, bed linens may not

need to be changed daily. Incontinent and

diaphoretic patients need to have fresh linens

more frequently. Not all patients need a com-

plete bed bath every day. Elderly patients have

dry, fragile skin; giving them good mouth, facial,

and perineal care may be all that is required on

certain days. This should be included in the

patient’s care plan.

■ Much paperwork is duplicative, and some is alto-

gether unnecessary. For example, is it necessary

to chart nursing interventions in two or three

places on the patient record? Charting by excep-

tion, flow sheets, and computerized records are

attempts to eliminate some of these problems.

■ Socialization in the workplace is an important

aspect in maintaining interpersonal relation-

ships. When there is a social component to

interactions in a group, the result is usually

positive. However, too much socialization can

reduce productivity. Use judgment in deciding

when socializing is interfering with work.

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164 unit 2 | Working Within the Organization

You may create additional work for yourself without

realizing it. How often do you walk back down the

hall to obtain equipment when it all could have

been gathered at one time? How many times do you

walk to a patient’s room instead of using the inter-

com, only to find that you need to go back to where

you were to get what the patient needs? Is the staff

providing personal care to patients who are well

enough to meet some of these needs themselves?

Streamlining Your Work

Many tasks cannot be eliminated or delegated,

but they can be done more efficiently. There are

many sayings in time management that reflect the

principle of streamlining work. “Work smarter, not

harder” is a favorite one that should appeal to

nurses facing increasing demands on time. “Never

handle a piece of paper more than once” is a more

specific one, reflecting the need to avoid procrasti-

nation in your work. “A stitch in time saves nine”

reflects the extent to which preventive action saves

time in the long run.

Avoiding Crisis Management

Crisis management occurs when people procrasti-

nate or do not pay attention to their intuitions. The

key to avoiding crises is to anticipate possible prob-

lems and intervene before they become overwhelm-

ing. As a new nurse, it may be difficult to anticipate

everything; however, there are some things that you

can do by organizing your day. Several methods of

working smarter and not harder are:

■ Gather materials, such as bed linen, for all of

your patients at one time. As you go to each

room, leave the linen so that it will be there

when you need it.

■ While giving a bed bath or providing other per-

sonal care, perform some of the aspects of the

physical assessment, such as taking vital signs,

skin assessment, and parts of the neurological

and musculoskeletal assessment. Prevention is

always a good idea.

■ If a patient does not “look right,” do not ignore

your intuition. The patient is probably having a


■ If you are not sure about a treatment or medica-

tion, ask before you proceed. It is usually less

time-consuming to prevent a problem than it is

to resolve one.

■ When you set aside time to do a specific task

that has a high priority, stick to your schedule,

and complete it.

■ Do not allow interruptions while you are com-

pleting paperwork, such as transcribing orders.

What else can you do to streamline your work? A

few general suggestions follow, but the first one, a

time log, can assist you in developing others unique

to your particular job. If you complete the log cor-

rectly, a few surprises about how you really spend

your time are almost guaranteed.

Keeping a Time Log

Perception of time is elastic. People do not accurate-

ly estimate the time they spend on any particular

task; people cannot rely on their memories for accu-

rate information about how they spend their time.

The time log is an objective source of information.

Most people spend a much smaller amount of their

time on productive activities than they estimate.

Once you see how large amounts of your time are

spent, you will be able to eliminate or reduce the

time spent on nonproductive or minimally produc-

tive activities (Drucker, 1967; Robichaud, 1986).

For example, many nurses spend a great deal of

time searching for or waiting for missing medications,

equipment, or supplies. Before beginning patient care,

assemble all the equipment and supplies you will

need, and check the patient’s medication drawer

against the medication administration record so you

can order anything that is missing before you begin.

Figure 11.1 is an example of a time log in which

you enter your activities every half hour. This

means that you will have to pay careful attention to

what you are doing so that you can record it accu-

rately. Do not postpone record-keeping; do it every

30 minutes. A 3-day sample may be enough for you

to see a pattern emerging. It is suggested that you

repeat the process again in 6 months, both because

work situations change and to see if you have made

any long-lasting changes in your use of time.

Reducing Interruptions

Everyone experiences interruptions. Some of these

are welcome and necessary, but too many interfere

with your work. A phone call from the laboratory

with a critical value is a necessary interruption.

Hobbs (1987) stated that necessary interruptions are

not time wasters. Middle-level managers are inter-

rupted every 8 minutes, and senior managers suffer

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chapter 11 | Time Management 165



























Activities Comments

Figure 11.1 Time log. (Adapted from Robichaud, A.M. [1986]).

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166 unit 2 | Working Within the Organization

interruptions every 5 minutes. Patient-care managers—

nurses—seem to be interrupted every minute.

Interruptions need to be kept to a minimum or elim-

inated, if possible. Closing the door to a patient’s

room may reduce interruptions. You may have to ask

visitors to wait a few minutes before you can answer

their questions, although you must remain sensitive

to their needs and return to them as soon as possible.

There is nothing wrong about asking a col-

league who wants your assistance to wait a few

minutes if you are engaged in another activity.

Interruptions that occur when you are trying to

pour medications or make calculations can cause

errors. Physicians and other professionals often

request nursing attention when nurses are involved

with patient-care tasks. Find out if an unlicensed

person may help. If not, ask the physician to wait,

stating that you will be more than glad to help as

soon as you complete what you are doing. Be cour-

teous, but be firm; you are busy also.

Categorizing Activities

Clustering certain activities helps eliminate the

feeling of bouncing from one unrelated task to

another. It also makes your caregiving more holis-

tic. You may, for example, find that documentation

takes less time if you do it while you are still with

the patient or immediately after seeing a patient.

The information is still fresh in your mind, and you

do not have to rely on notes or recall. Many health-

care institutions have switched to computerized

charting, with the computers placed at the bedside.

This setup assists in documenting care and inter-

ventions while the nurse is still with the patient.

Also, try to follow a task through to completion

before beginning another.

Finding the Fastest Way

Many time-consuming tasks can be done more effi-

ciently by automation. Narcotic delivery systems that

deliver the correct dose and electronically record the

dose, the name of the patient, and the name of the

health-care personnel removing the medication are

being used in many institutions. This system saves

staff time in documentation and in performing a

narcotic count at the end of each shift. Bar coding is

another method used by health-care institutions. Bar

coding allows for scanning certain types of patient

data, decreasing the number of paper chart entries

(Baldwin, 2002; Meyer, 1992).

Efficient systems do not have to be complex.

Using a preprinted color-coded sticker system

helps identify patients who must be without food

or fluids (NPO) for tests or surgery, those who

require 24-hour urine collections, or those who

require special cultures. The information need not

be written or entered repeatedly if stickers are used.

Everyone talks about the amount of time wasted

by physicians, nurses, and other clinicians in looking

for such things as patient charts, equipment, and

even patients. Erica Drazen, vice president of First

Consulting Group in Lexington, Massachusetts,

suggested using more sophisticated wireless tech-

nology, similar to the car tracking systems used by

law enforcement. Tiny transmitters can be activated

from a central point to locate the items or individ-

uals. Using electronic medical record systems

decreases the amount of time spent looking for

patient records. By using approved access codes,

health-care personnel can obtain information from

anywhere within the institution. This also mini-

mizes time spent on paper charting.

Automating Repetitive Tasks

Developing techniques for repetitive tasks is simi-

lar to finding the fastest method, but it focuses on

specific tasks that are repeated again and again,

such as patient teaching.

Many patients come to the hospital or ambula-

tory center for surgery or invasive diagnostic tests

for same-day treatment. This does not give nurses

much teaching time. Using videotapes and pam-

phlets as teaching aids can reduce the time needed

to share the information, allowing the nurse to be

available to answer individual questions and create

individual adaptations. Many facilities are using

these techniques for cardiac rehabilitation, preoper-

ative teaching, and infant care instruction.

Computer-generated teaching and instruction

guides permit patients to take the information

home with them. This can decrease the number of

phone calls requiring repetition of information.

The Rhythm Model for Time Management

Navuluri (2001) looked at time management in

terms of a Rhythm Model—a PQRST pattern:

Prioritize, Question, Recheck, Self-reliance, Treat.

By prioritizing, you can accomplish the most

important tasks first. Questioning permits you to

look at events and tasks in terms of effectiveness,

efficiency, and efficacy. Rechecking unfinished

tasks quickly helps you to manage your time

efficiently. Self-reliance allows you to know the

difference between events that are within your

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chapter 11 | Time Management 167

control and those that are not, as well as realizing

your limitations. No one knows better what you

are capable of doing than you. Treats are part of

life. It is okay to take a break or time out. It is

important because doing so permits you to

ref resh. Table 11-1 summarizes the Rhythm

Model for Time Management.


Time can be your best friend or worst enemy,

depending on your perspective and how you man-

age it. It is important to identify how you feel

about time and to assess your own time manage-

ment skills. Nursing requires that numerous activ-

ities be performed within what often seems to be

very brief periods. Remember that there are only

so many hours in the day. Knowing this can create

stress. No one works well “under pressure.” Learn

to delegate. Learn to say, “I would really like to

help you; can it wait until I finish this?” Learn to

say no. Most of all, learn how to make the most of

your day by working effectively and efficiently.

Finally, remember that 8 hours should be desig-

nated as sleep time and several more as personal

or leisure (“time off ”) time.

table 11-1

The Rhythm Model for Time Management PRIORITIZE List tasks in order of importance.

Remember that some tasks must occur at specific times, whereas others can occur at any time.

Emergencies take precedence.

Identify events controlled by you and events controlled by others.

Use critical thinking skills to assign priorities.


EFFECTIVENESS Did the task produce the desired outcome?

EFFICIENCY How can I accomplish the plan with the least expenditure of time?

Is there a way to break this down into simpler tasks?

EFFICACY Do I have the skill and ability to obtain the desired effect?

RECHECK Mentally and physically recheck an unfinished or delegated task.

SELF-RELIANCE Identify those tasks that are within your control and those that are not.

Use critical thinking skills and adaptability to revise priorities.

“Go with the flow.”

TREAT Treat yourself to a break when you can.

Treat yourself to time off.

Treat yourself to an educational experience: Commit yourself to excellence.

Treat others courteously and with respect.

Study Questions

1. Develop a personal time inventory. Identify your time wasters. How do you think you can eliminate

these activities?

2. Create your own patient care worksheet. How does this worksheet help you organize your clinical day?

3. Keep a log of your clinical day. Which activities took the most time? Why? Which activities took

the least time? What situations interfered with your work? What could you do to reduce the inter-


4. Identify a task that is done repeatedly in your clinical area. Think of a new, more efficient way to do

that task. How could you implement this new routine? How could you evaluate its efficiency?

5. Consider how many interruptions you had during the day. How did you handle them? How did

they interfere in your time management?

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168 unit 2 | Working Within the Organization

Case Study to Promote Critical Reasoning

Antonio was recently hired as a team leader for a busy cardiac step-down unit. Nursing responsibilities

of the team leader, in addition to patient care, include meeting daily with team members, reviewing

all admissions and discharges for acuity and length of stay, and documenting all patients who

exceed length of stay and the reasons. At the end of each month, the team leaders are required to

meet with unit managers to review the patient care load and team member performance. This is the

last week of the month, and Antonio has a meeting with the unit manager at the end of the week.

He is 2 weeks behind on staff evaluations and documentation of patients who exceeded length of

stay. He is becoming very stressed over his team leader responsibilities.

1. Why do you think Antonio is feeling stressed?

2. Make a to-do list for Antonio.

3. Develop a time log for Antonio to use to analyze his activities.

4. How can Antonio organize and streamline his work?

References American Bar Association Career Resource Center (n.d.).

Identifying & conquering time wasters. Retrieved December 20, 2005, from abanet.org/careercounsel

Baldwin, F.D. (2002). Making do with less. Healthcare Informatics, pp. 1–7. Online, March 2002.

Bos, C.S., & Vaughn, S. (1998). Strategies for Teaching Students With Learning and Behavioral Problems, 4th ed. Boston: Allyn & Bacon.

Brider, P. (1992). The move to patient-focused care. American Journal of Nursing, 92(9), 27–33.

Brumm, J. (2004). Time can be on your side. Nursing Spectrum. http://nursingspectrum.com/StudentsCorner/StudentFeatures/ TimeSide.htm.

Chappel, E.D. (1970). Culture and Biological Man: Exploration in Behavioral Anthropology. N.Y.: Holt, Rinehart, & Winston. (Reprinted as The Biological Foundations of Individuality and Culture. Huntingdon, N.Y.: Robert Krieger, 1979.)

Carroll, L. (1907). Alice’s Adventures in Wonderland. Reprint 2002. N.Y.: North-South Books.

Curry, P. (March 25, 2002). Pressure cooker: Hospital’s emphasis on productivity increases stress for nurses and patients. Nurseweek News, http://www.nurseweek. com

Drucker, P.E. (1967). The Effective Executive. N.Y.: Harper & Row. Ferrett, S.K. (1996). Connections: Study Skills for College and Career

Success. Chicago: Irwin Mirror Press. Gahar, A. (2000). Programming for College Students With Learning

Disabilities. (Grant No.: 84–078C) http://www.csbsju.edu Gonzalez, S.I. (1996). Time management. The Nursing Spectrum

in Florida, 6(17), 5. Hammerschmidt, R., & Meador, C.K. (1993). A Little Book of

Nurses’ Rules. Philadelphia: Hanley & Belfus.

Haynes, M.E. (1991). Practical Time Management. Los Altos, Calif.: Crisp Publications.

Hobbs, S. (1987). Getting to grips with business plans, audit, and applications. Nursing Standard.

Lundgren, S., & Segesten, K. (2001). Nurses’ use of time in a medical-surgical ward with all-RN staffing. Journal of Nursing Management, 9, 13–20.

MacKenzie, A. (1990). The Time Trap. N.Y.: American Management Association.

Matejka, J.K., & Dunsing, R.J. (1988). Time management: Changing some traditions. Management World, 17(2), 6–7.

Meyer, C. (1992). Equipment nurses like. American Journal of Nursing, 92(8), 32–38.

Moshovitz, R. (1993). How to Organize Your Work and Your Life. N.Y.: Doubleday.

Navuluri, R.B. (March 2001). Our time management in patient care. Research for Nursing Practice, 1–8.

Prescott, P.A. (1991). Changing how nurses spend their time. Image, 23(1), 23–28.

Robichaud, A.M. (1986). Time documentation of clinical nurse specialist activities. Journal of Nursing Administration, 16(1), 31–36.

Smith, H.W. (1994). The Ten Natural Laws of Successful Time and Life Management: Proven Strategies for Increased Productivity and Inner Peace. N.Y.: Warner Books.

Turkington, C.A. (1996). Reflections for Working Women: Common Sense, Sage Advice, and Unconventional Wisdom. N.Y.: McGraw-Hill.

Webber, R.A. (1980). Time Is Money! Tested Tactics That Conserve Time for Top Executives. N.Y.: Free Press.

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3 unit

Professional Issues

chapter 12 Promoting a Healthy Workplace

chapter 13 Work-Related Stress and Burnout

chapter 14 Your Nursing Career

chapter 15 Nursing Yesterday and Today

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2208_Ch12_169-196.qxd 11/6/09 6:01 PM Page 170

chapter 12 Promoting a Healthy Workplace

OBJECTIVES After reading this chapter, the student should be able to: ■ Recognize the components of nurse job satisfaction.

■ Describe quality indicators related to safety and quality.

■ Recognize threats to safety in the workplace.

■ Identify agencies responsible for overseeing workplace safety.

■ Describe methods of dealing with violence in the workplace.

■ Identify the role of the nurse in dealing with terrorism and other disasters.

■ Recognize situations that may reflect sexual harassment.

■ Make suggestions for improving the physical and social environment.

■ Understand the American Nurses Association (ANA) Future Vision for Nursing.


Workplace Safety

Threats to Safety

Reducing Risk


Centers for Disease Control and Prevention



Joint Commission on the Accreditation of Healthcare Organizations

Institute of Medicine



Sexual Harassment

Latex Allergy

Needlestick Injuries

Your Employer’s Responsibility

Your Responsibility

Ergonomic Injuries

Back Injuries

Repetitive Stress Injuries

Impaired Workers

Substance Abuse

Microbial Threats

Enhancing the Quality of Work Life

Rotating Shifts

Mandatory Overtime

Staffing Ratios

Using Unlicensed Assistive Personnel

Reporting Questionable Practices

Terrorism and Other Disasters

Enhancing the Quality of Work Life

Social Environment

Working Relationships

Support of One’s Peers and Supervisors

Involvement in Decision Making

Professional Growth and Innovation

Encourage Critical Thinking

Seek Out Educational Opportunities

Encourage New Ideas

Reward Professional Growth

Cultural Diversity

Physical Environment



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172 unit 3 | Professional Issues

Almost half our waking hours are spent in the

workplace. For this reason alone, the quality of the

workplace environment is a major concern. Yet, it is

neglected to a surprising extent in many health-care

organizations. It is neglected by administrators who

would never allow peeling paint or poorly main-

tained equipment but who leave their staff, their

most costly and valuable resource, unmaintained

and unrefreshed. The “do more with less” thinking

that has predominated many organizations places

considerable pressure on staff and management

alike (Chisholm, 1992). Improvement of the work-

place environment is more difficult to accomplish

under these circumstances, but it is more important

than ever.

Much of the responsibility for enhancing the

workplace rests with upper-level management,

people who have the authority and resources to

encourage organization-wide growth and change.

Nurses, however, have begun to take more respon-

sibility for identification of and problem solving for

workplace issues. This chapter focuses on these

issues, in addition to sexual harassment, impaired

workers, enhancement of work-life quality, diversity,

and disabled workers.

Workplace Safety

Safety is not a new concept in the workplace. The

modern movement began during the Industrial

Revolution. In 1913, the National Council for

Industrial Safety (now the National Safety

Council) was formed. The Occupational Safety and

Health Act of 1970 created both the National

Institute of Occupational Safety and Health

(NIOSH) and the Occupational Safety and Health

Administration (OSHA). The OSHA, part of the

U.S. Department of Labor, is responsible for devel-

oping and enforcing workplace safety and health

regulations. The NIOSH, part of the U.S.

Department of Health and Human Services, pro-

vides research, information, education, and training

in occupational safety and health. The National

Safety Council (NSC) partners with the OSHA to

provide training in a variety of safety initiatives.

The NSC maintains that safety in the workplace is

the responsibility of both the employer and the

employee. The employer must ensure a safe, health-

ful work environment, and employees are account-

able for knowing and following safety guidelines

and standards (National Safety Council, 1992).

Threats to Safety

Working in a health-care facility is reported to be

one of the most dangerous jobs in the United

States. The Department of Labor reports that a

health-care worker in a nursing facility is more likely

to be injured on the job than a coal miner. Health

and safety threats in the nursing workplace include

infectious diseases, physical violence, ergonomic

injuries related to the movement and repositioning

of patients, exposure to hazardous chemicals and

radiation, and sharps injuries (ANA, 2007).

Health care is the second-fastest-growing sector

of the U.S. economy, employing more than 12 million

workers. Women represent nearly 80% of the

health-care workforce. Health-care workers face a

wide range of hazards on the job, including needle-

stick injuries, back injuries, latex allergy, violence,

and stress. Although it is possible to prevent or

reduce health-care worker exposure to these haz-

ards, health-care workers are experiencing increas-

ing numbers of occupational injuries and illnesses;

rates of occupational injury have risen over the past

decade. By contrast, two of the most hazardous

industries, agriculture and construction, are safer

today than they were a decade ago. NIOSH-TIC-2

is a searchable bibliographical database of occupa-

tional safety and health publications, documents,

grant reports, and journal articles supported in

whole or in part by the NIOSH (cdc.gov/niosh/


In spring 2001, a Florida nurse with 20 years’

psychiatric nursing experience died of head and

face trauma. Her assailant, a former wrestler, had

been admitted involuntarily in the early morning to

the private mental health–care facility. An investi-

gation found that the facility did not have a policy

on workplace violence and no method of summon-

ing help in an emergency (Arbury, 2002).

Six hundred thousand to one million needlestick

injuries occur annually to U.S. health-care workers.

Percutaneous exposure is the principal route for

human immunodeficiency virus (HIV ) and hepatitis

B and C virus transmission. Additionally, infections

such as tuberculosis, syphilis, malaria, and herpes

can be transmitted through needlesticks.

Threats to safety in the workplace vary from one

setting to another and from one individual to

another. A pregnant staff member may be more

vulnerable to risks from radiation; staff members

working in the emergency room of a large urban

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chapter 12 | Promoting a Healthy Workplace 173

public hospital are at more risk for HIV and

tuberculosis than the staff members working in the

newborn nursery. All staff members have the right

to be made aware of potential risks. No worker

should feel intimidated or uncomfortable in the


Reducing Risk


The Occupational Safety and Health Act of 1970

and the Mine Safety and Health Act of 1977 were

the first federal guidelines and standards related to

safe and healthful working conditions. Through

these acts, the NIOSH and OSHA were formed.

OSHA regulations apply to most U.S. employers

that have one or more employees and that engage in

businesses affecting commerce. Under OSHA reg-

ulations, the employer must comply with standards

for providing a safe, healthful work environment.

Employers are also required to keep records of all

occupational (job-related) illnesses and accidents.

Examples of occupational accidents and injuries

include burns, chemical exposures, lacerations, hear-

ing loss, respiratory exposure, musculoskeletal

injuries, and exposure to infectious diseases.

OSHA regulations provide for workplace

inspections that may be conducted with or without

prior notification to the employer. However, cata-

strophic or fatal accidents and employee complaints

may also trigger an OSHA inspection. OSHA

encourages employers and employees to work

together to identify and remove any workplace haz-

ards before contacting the nearest OSHA area

office. If the employee has not been able to resolve

the safety or health issue, the employee may file a

formal complaint, and an inspection will be ordered

by the area OSHA director (U.S. Department of

Labor, 1995). Any violations found are posted

where all employees can view them. The employer

has the right to contest the OSHA decision. The

law also states that the employer cannot punish or

discriminate against employees for exercising their

rights related to job safety and health hazards

or participating in OSHA inspections (U.S.

Department of Labor, 1995).

OSHA inspections have focused especially on

blood-borne pathogens, lifting and ergonomic

(proper body alignment) guidelines, confined-space

regulations, respiratory guidelines, and workplace

violence. Since September 11, 2001, the OSHA has

added protecting the worksite against terrorism

(osha.gov). Table 12-1 lists the major categories of

potential hazards found in hospitals as identified by

the OSHA. The U.S. Department of Labor pub-

lishes fact sheets related to various OSHA guide-

lines and activities. They can be obtained from your

employer, at the local public library, or via the

Internet at osha.gov

table 12-1

Potential Hospital Hazards Hazard Definition Examples

Biological Infectious/biological agents such as bacteria, HIV, vancomycin-resistant enterococcus,

viruses, fungi, parasites methicillin-resistant Staphylococcus aureus, hepatitis

B virus, tuberculosis

Chemical Medications, solutions, and gases that are Ethylene oxide, formaldehyde, glutaraldehyde, waste

potentially toxic or irritating to the body anesthetic gases, cytotoxic agents, pentamidine

system ribavirin

Psychological Factors and situations encountered in or Stress, workplace violence, shiftwork, inadequate

associated with the work environment staffing, heavy workload, increased patient acuity

that create or potentiate stress, emotional

strain, and/or interpersonal problems

Physical Agents that cause tissue trauma Radiation, lasers, noise, electricity, extreme temperatures,

workplace violence

Environmental, Factors in work environment that cause Tripping hazards, unsafe or unguarded equipment, air

mechanical, or lead to accidents, injuries, strain, quality, slippery floors, confined spaces, obstructed

biomedical or discomfort work areas or passageways, awkward postures,

localized contact stresses, temperature extremes,

repetitive motions, lifting and moving patients

Adapted from osha.gov/SLTC/healthcarefacilities/hazards

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174 unit 3 | Professional Issues

Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention

(CDC) is the lead federal agency for protecting the

health and safety of citizens both at home and

abroad. The CDC partners with other agencies

throughout the nation to investigate health prob-

lems, conduct research, implement prevention

strategies, and promote safe and healthy environ-

ments. The CDC publishes continuous updates of

recommendations for prevention of HIV transmis-

sion in the workplace and universal precautions

related to blood-borne pathogens; it also publishes

the most recent information on other infectious

diseases in the workplace, such as tuberculosis and

hepatitis. Currently, the CDC is targeting public

health emergency preparedness and response relat-

ed to biological and chemical agents and threats

(cdc.gov/). Information can be obtained by con-

sulting the Mortality and Morbidity Weekly

Report (MMWR) in the library, via the Internet

(cdc.gov/health/diseases), or through the toll-free

phone number (800-311-3435). Interested health-

care workers can also be placed on the CDC’s

mailing list to receive any free publications.


The NIOSH is part of the CDC and is the feder-

al agency responsible for conducting research and

making recommendations for the prevention of

work-related disease and injury. Occupational

hazards for health-care workers continue to be

enormous health and economic problems.

According to statistics from the NIOSH, more

than 6.1 million illnesses and injuries occur in the

workplace yearly, with more than 2.9 million lost

workdays attributed to occupational illnesses and

injuries (cdc.gov/niosh/about).

Box 12-1 lists the most important federal laws

enacted to protect individuals in the workplace.


When looking at agencies that are instrumental in

dealing with workplace safety, the ANA must be

included. The ANA is discussed more completely

in Chapters 10 and 15. The ANA’s history embod-

ies advocacy for the nurse.

In 1999 the Commission on Workplace

Advocacy was established as part of the ANA. The

Commission consists of nine members, appointed

box 12-1

Federal Laws Enacted to Protect the Worker in the Workplace • Equal Pay Act of 1963: Employers must provide equal pay for equal work, regardless of sex.

• Title VII of Civil Rights Act of 1964: Employees may not be discriminated against on the basis of race, color, religion, sex,

or national origin.

• Age Discrimination in Employment Act of 1967: Private and public employers may not discriminate against persons

40 years of age or older except when a certain age group is a bona fide occupational qualification.

• Pregnancy Discrimination Act of 1968: Pregnant women cannot be discriminated against in employment benefits if they

are able to perform job responsibilities.

• Fair Credit Reporting Act of 1970: Job applicants and employees have the right to know of the existence and content of

any credit files maintained on them.

• Vocational Rehabilitation Act of 1973: An employer receiving financial assistance from the federal government may not

discriminate against individuals with disabilities and must develop affirmative action plans to hire and promote individuals

with disabilities.

• Family Education Rights and Privacy Act—Buckley Amendment of 1974: Educational institutions may not supply

information about students without their consent.

• Immigration Reform and Control Act of 1986: Employers must screen employees for the right to work in the United

States without discriminating on the basis of national origin.

• Americans With Disabilities Act of 1990: Persons with physical or mental disabilities or who are chronically ill cannot be

discriminated against in the workplace. Employers must make “reasonable accommodations” to meet the needs of the

disabled employee. These include such provisions as installing foot or hand controls; readjusting light switches, telephones,

desks, tables, and computer equipment; providing access ramps and elevators; offering flexible work hours; and providing

readers for blind employees.

• Family Medical Leave Act of 1993: Employers with 50 or more employees must provide up to 13 weeks of unpaid leave for

family medical emergencies, childbirth, or adoption.

• Needlestick Safety and Prevention Act of 2001: This act directed the OSHA to revise the blood-borne pathogens stan-

dard to establish in greater detail requirements that employers identify and make use of effective and safer medical devices.

Adapted from Strader, M., & Decker, P. (1995). Role Transition to Patient Care Management. Norwalk, Conn.: Appleton and

Lange; osha.gov/needlesticks/needlefact

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chapter 12 | Promoting a Healthy Workplace 175

by the ANA Board of Directors, and represent

constituent member associations. Additionally,

state member associations often offer their own

workplace advocacy information. Issues such as

collective bargaining, workplace violence, mandatory

overtime, staffing ratios, conflict management, del-

egation, ethical issues, compensation, needlestick

safety, latex allergies, pollution prevention, and

ergonomics are addressed.

The ANA Web site (www.nursingworld.org)

keeps up-to-date information related to workplace

advocacy and safety available to all nurses.

Joint Commission

The Joint Commission ( JC) is an independent,

nonprofit organization. Established more than

50 years ago, it is governed by a board that includes

physicians, nurses, and consumers. The JC evalu-

ates the quality and safety of care for more than

15,000 health-care organizations. To earn and

maintain accreditation, organizations must have an

extensive on-site review by a team of JC health-

care professionals at least once every 3 years. Many

of the national patient safety goals discussed in

Chapter 10 were influenced by the safety of the

health-care worker. For example, fatigue due to

mandatory overtime has been identified as causing

increased medication errors.

Institute of Medicine

The Institute of Medicine (IOM) is a private, non-

governmental organization that carries out studies

at the request of many government agencies. The

mission of the IOM is to improve the health of peo-

ple everywhere; thus, the topics it studies are very

broad (iom.edu). In 1996 the IOM began a quality

initiative to assess the nation’s health. Part of this ini-

tiative was the 2004 report: Keeping Patients Safe:

Transforming the Work Environment of Nurses.

The report identified concerns and issues related to

organizational management, workforce deployment

practices, work design, and organizational culture

(Beyea, 2004). Each of these issues will be discussed

in the section of this chapter on enhancing the

quality of work life.


The primary objective of any workplace safety

program is to protect staff members from harm

and the organization from liability related to that


The first step in development of a workplace

safety program is to recognize a potential hazard and then take steps to control it. Based on OSHA reg-

ulations (U.S. Department of Labor, 1995), the

employer must inform staff members of any poten-

tial health hazards and provide as much protection

from these hazards as possible. In many cases, ini-

tial warnings come from the CDC, NIOSH, and

other federal, state, and local agencies. For example,

employers must provide tuberculosis testing and

hepatitis B vaccine; protective equipment such as

gloves, gowns, and masks; and immediate treat-

ment after exposure for all staff members who may

have contact with blood-borne pathogens.

Employers are expected to remove hazards, educate

employees, and establish institution-wide policies

and procedures to protect their employees

(Herring, 1994; Roche, 1993). Nurses who are not

provided with latex gloves may refuse to participate

in any activities involving blood or blood products.

The employee cannot be subjected to discrimina-

tion in the workplace, and reasonable accommoda-

tions for safety against blood-borne pathogens

must be provided. This may mean that the nurse

with latex allergies is placed in an area where expo-

sure to blood-borne pathogens is not an issue

(Strader & Decker, 1995; U.S. Department of

Labor, 1995). The OSHA also has information

available on exposure to chemical or biological

agents related to terrorism. Terrorism response

exercises are conducted through OSHA to train

health-care workers on responding to terrorism

threats (http://www.osha.gov/). The second step in

a workplace safety program is a thorough assessment of the amount of risk entailed. Staff members, for example, may become very fearful in situations that

do not warrant such fear. For example:

Nancy Wu is the nurse manager on a busy geriatric unit. Most patients require total care: bathing, feed- ing, and positioning. She observed that several of the staff members working on the unit use poor body mechanics when lifting and moving the patients. In the last month, several of the staff members were referred to Employee Health for back pain. This week, she noticed that the patients seemed to remain in the same position for long periods and were rarely out of bed or in a chair for the entire day. When she confronted the staff, the response was the same from all of them: “I have to work for a living. I can’t afford to risk a back injury for someone who may

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176 unit 3 | Professional Issues

not live past the end of the week.” Nancy was concerned about the care of the patients as well as the apparent lack of information her staff had about prevention of back injuries. She decided to seek assistance from the nurse practitioner in charge of Employee Health in order to develop a back injury prevention program.

Assessment of the workplace may require consider-

able data gathering to document the incidence of

the problem and consultation with experts before a

plan of action is drawn up. Health-care organiza-

tions often create formal committees, consisting of

experts from within the institution and representa-

tives from the affected departments, to assess these

risks. It is important that staff members from vari-

ous levels of the organization be allowed to offer

input into an assessment of safety needs and risks.

The third step is to create a plan to provide opti- mal protection for staff members. It is not always a

simple matter to protect staff members without

interfering with the provision of patient care. For

example, some devices that can be worn to prevent

transmission of tuberculosis interfere with commu-

nication with the patient Some attempts have been

made to limit visits or withdraw home health-care

nurses from high-crime areas, but this leaves

homebound patients without care (Nadwairski,

1992). A threat assessment team that evaluates

problems and suggests appropriate actions may

reduce the incidence and severity of problems due

to violent behavior, but it may also increase

employees’ fear of violence if not handled well.

Developing a safety plan includes the following:

■ Seeking evidence-based practices and recom-

mendations related to the problem

■ Consulting federal, state, and local regulations

■ Distinguishing real from imagined risks

■ Seeking administrative support and enforcement

for the plan

■ Calculating costs of a program

The fourth and final stage in developing a work-

place safety program is implementing the program. Educating the staff, providing the necessary safety

supplies and equipment, and modifying the envi-

ronment contribute to an effective program.

Protecting patient and staff confidentiality and

monitoring adherence to control and safety proce-

dures should not be overlooked in the implementa-

tion stage ( Jankowski, 1992).

An example of a safety program is the one for

health-care workers exposed to HIV, instituted at

the Department of Veterans Affairs Hospital,

San Francisco (Armstrong, Gordon, & Santorella,

1995). An HIV exposure can be stressful for health-

care workers and their loved ones. This employee

assistance program includes up to 10 hour-long indi-

vidual counseling sessions on the meaning and expe-

rience of this traumatic event. Additional counseling

sessions for couples are also provided. Information

about HIV and about dealing with acute stress reac-

tions is provided. Counseling helps workers identify

a plan to obtain assistance from their individual sup-

port systems, identify practice methods of dealing

with blood-borne pathogens, and return to work.

A systematic review related to needlestick injury pro-

vides evidence for the use of tissue adhesives.

In the past, the options for wound closure have

been limited largely to sutures (needle and thread),

staples, and adhesive tapes. Tissue adhesives (glues)

offer the advantages that there are no sutures to

remove later for the patient and no risk of needle-

stick injury to the health-care worker. The adhesive

is applied over the surgical wound and holds the

edges together until healing has occurred.

Adhesives have been compared with alternative

methods of surgical wound closure in eight ran-

domized clinical trials involving 630 patients.

There was no evidence of a difference in rates of

wound dehiscence or infection after surgical inci-

sion closure with tissue adhesive, sutures, or adhe-

sive tape. The recommendation from the evidence

was that health-care providers may consider the use

of tissue adhesives for the closure of incisions in the

operating room, and a protocol was published in

2004 (Coulthard et al., 2004).


Violence in the workplace is a contemporary social

issue. Newspapers and magazines have reported

numerous violent incidents; one of six violent crimes

occurs in the workplace, and homicide is the second

leading cause of workplace death (Edwards, 1999).

According to the Census of Fatal Occupational

Injuries, there were 551 workplace homicides and

5703 workplace injuries in 2004. The rate of assaults

on hospital workers is much higher than the rate of

assaults for all private-sector industries. The Bureau

of Labor Statistics measures the number of assaults

resulting in injury per 10,000 full-time workers.

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chapter 12 | Promoting a Healthy Workplace 177

The overall private sector injury incidence rate is 2;

the overall incidence rate for health service workers

9.3. Broken down further, the incidence rate for

social service workers is 15, and the rate for nurses

and personal care workers is 25 (bls.gov/news/


The aggressor can be a disgruntled employee or

employer, an unhappy significant other, or a person

committing a random act of violence. Nurses have

been identified as a group at risk for violence from

patients, family members, and other staff members.

Violence may also have negative organizational

outcomes. Box 12-2 identifies some of the causes.

Examples of violence include:

■ Threats. Expressions of intent to cause harm, including verbal threats, threatening body lan-

guage, and written threats

■ Physical assaults. Slapping, beating, rape, homi- cide, and the use of weapons such as firearms,

bombs, and knives

■ Muggings. Assaults conducted by surprise with intent to rob (cdc.gov/niosh/pdfs/2002-101.pdf )

The circumstances surrounding health-care work

contributes to workers’ susceptibility to homicide

and assault (Edwards, 1999; nursingworld.org/

dlwa/osh/wp5; cdc.gov/niosh/pdfs/2002-101.pdf;


■ Prevalence of handguns and other weapons

among patients, families, and friends

■ Increased use of hospitals for criminal holds and

violent individuals

■ Increased number of acute and chronic mentally

ill patients being released without follow-up care

■ Health-care personnel having routine contact

with the public in unrestricted areas

■ Health-care personnel working alone or in small


■ Health-care personnel working late or until very

early morning hours

■ Health-care personnel working in high-crime


■ Health-care personnel working in buildings

with poor security

■ Health-care personnel treating weapon-carrying

patients and families

■ Health-care personnel working with inexperi-

enced staff

■ Health-care personnel working in units needing

seclusion or restraint activities

■ Health-care personnel transporting patients

■ Patients waiting long times for service

■ Overcrowded, uncomfortable waiting areas

■ Health-care personnel lacking training and poli-

cies for managing crises

Nurses must know their workplace. For example


■ How does violence from the surrounding

community affect your workplace?

■ Do services like trauma or acute psychiatric care

increase the likelihood of violence?

■ Does the facility’s physical layout invite

violence—for example, do doors open to the

street? are waiting rooms cramped?

■ How frequently do assaultive incidents, threats,

and verbal abuse occur? where? who is involved?

are incidents reported?

■ Are current emergency response systems


■ Are post-assaultive treatment and support

available to staff?

■ Are staffing patterns sufficient? is the staff


Earlier in the chapter, the Florida nurse who was

attacked and killed by a patient in April 2001 was

mentioned. Although assaults that result in severe

injury or death usually receive media coverage,

most assaults on nurses by patients or coworkers are

not reported by the nurse.

Ms. Jones works on the evening shift in the emergency department (ED) at a large urban hospital. The ED frequently receives patients who are victims of gunshot wounds, stabbings, and other gang-related incidents. Many of the patients entering the ED are high on alcohol or drugs. Ms. Jones has just inter- viewed a 21-year-old male patient who is awaiting treatment as a result of a f ight after an evening of heavy drinking. Because his injuries have been deter- mined not to be life-threatening, he had to wait to see

box 12-2

Negative Organizational Outcomes Due to Workplace Violence

• Low worker morale

• Increased job stress

• Increased worker turnover

• Reduced trust of management

• Reduced trust of coworkers

• Hostile working environment

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178 unit 3 | Professional Issues

a physician. “I’m tired of waiting. Let’s get this show on the road,” he screamed loudly as Ms. Jones walked by. “I’m sorry you have to wait, Mr. P., but the doctor is busy with another patient and will get to you as soon as possible.” She handed him a cup of juice she had been bringing to another patient. He grabbed the cup, threw it in her face, and then grabbed her arm. Slamming her against the wall, he jumped off the stretcher and yelled obscenities at her. He continued to scream in her face until a security guard intervened.

Be aware of clues that may indicate a potential for

violence (Box 12-3). These behaviors may occur in

patients, family members, visitors, or even other

staff members. Even patients with no history of

violent behavior may react violently to medication

or pain (Carroll & Sheverbush, 1996; Lanza &

Carifio, 1991).

In the health-care industry, violence is underre-

ported, and there are persistent misperceptions that

assaults are part of the job and that the victim

somehow caused the assault. Causes of underre-

porting may be a lack of institutional reporting

policies and employee fear that the assault was a

result of negligence or poor job performance (U.S.

Department of Labor, 1995). Box 12-4 lists some

of the faulty reasoning that leads to placing blame

on the victim of the assault.

Actions to address violence in the workplace

include (1) identifying the factors that contribute to

violence and controlling as many as possible and

(2) assessing staff attitudes and knowledge regarding

violence in the workplace (Carroll & Sheverbush,

1996; Collins, 1994; Mahoney, 1991).

When you begin your new job, you may want

to find out the policies and procedures related to

violence in the workplace at your institution.

Preventing an incident is better than having to

intervene after violence has occurred. The following

are suggestions to nurses about how to participate in

workplace safety related to violence (nursingworld.


■ Participate in or initiate regular workplace assessments. Identify unsafe areas and the factors within the organization that contribute

to assaultive behavior, such as inadequate

staffing, high-activity times of day, invasion of

personal space, seclusion or restraint activities,

and lack of experienced staff. Work with

management to make and monitor changes.

■ Be alert for suspicious behavior such as verbal expressions of anger and frustration, threatening

body language, signs of drug or alcohol use, or

presence of a weapon. Assess patients or suspi-

cious workers, patients, and visitors for potential

violence. Evaluate each situation for potential

violence. Keep an open path for exiting.

■ Maintain behavior that helps to defuse anger. Present a calm, caring attitude. Do not match

threats, give orders, or present with behaviors

that may be interpreted as aggressive.

Acknowledge the person’s feelings.

■ If you cannot defuse the situation, then remove yourself from it quickly, call Security, and report

the situation to management.

■ Know your patients. Be aware of any history of violent behaviors, diagnoses of dementia,

alcohol, or drug intoxication.

Box 12-5 lists some additional actions that can be

taken to protect staff members and patients from

violence in the workplace.

box 12-3

Behaviors Indicating a Potential for Violence

• History of violent behavior

• Delusional, paranoid, or suspicious speech

• Aggressive, threatening statements

• Rapid speech, angry tone of voice

• Pacing, tense posture, clenched fists, tightening jaw

• Alcohol or drug use

• Male gender, youth

• Policies that set unrealistic limits

Adapted from Kinkle, S. (1993). Violence in the ED: How to stop it before it

starts. American Journal of Nursing, 93(7), 22–24; Carroll, C., & Sheverbush,

J. (September 1996). Violence assessment in hospitals provides basis for

action. American Nurse, 18.

box 12-4

When an Assault Occurs: Placing Blame on Victims

• Victim gender: Women receive more blame than men.

• Subject gender: Female victims receive more blame

from women than men.

• Severity: The more severe the assault, the more often

the victim is blamed.

• Beliefs: The world is a just place, and therefore the

person deserves the misfortune.

• Age of victim: The older the victim, the more he or she is

held to blame.

Adapted from Lanza, M.L., & Carifio, J. (1991). Blaming the victim: Complex

(nonlinear) patterns of causal attribution by nurses in response to

vignettes of a patient assaulting a nurse. Journal of Emergency Nursing,

17(5), 299–309.

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chapter 12 | Promoting a Healthy Workplace 179

What if, in spite of all precautions, violence occurs?

What should you do? You should:

■ Report to your supervisor. Report threats as well

as actual violence. Include a description of the

situation; names of victims, witnesses, and per-

petrators; and any other pertinent information.

■ Call the police. Although the assault is in the

workplace, nurses are entitled to the same rights

as workers assaulted in another setting.

■ Get medical attention. This includes medical

care, counseling, and evaluation.

■ Contact your collective bargaining unit or your

state nurses association. Inform them if the

problems persist.

■ Be proactive. Get involved in policy making


Violence in the workplace can also be the result of

horizontal violence or interactive workplace trauma.

These terms denote a workplace that is infested

with one or more “bullies.” These bullies project

domineering and aggressive behaviors toward oth-

ers, usually when the other person is preoccupied or

unaware. Individuals who desire to control others

may use a variety of approaches, including verbal

abuse, punishment, criticism, put-downs, and mali-

cious gossip. Unfortunately, these individuals are

often not identified during the employment inter-

view. Bullies in the workplace may be coworkers,

superiors, or subordinates. Regardless of their place

on the organizational chart, bullies can cause a great

deal of distress to others in the workplace. Barbara

Broome (2008) states that bullies are like sharks.

The shark tries to dominate the other fish and have

a superior presence. They attack aggressively, and

when the victim bleeds, the victim becomes a fatal-

ity. Broome has suggestions for dealing with bullies

in the workplace:

■ Assume all identified “fish” are “sharks.” Until

you get to know people, do not make assump-

tions one way or the other.

■ Do not “bleed.” Crying or arguing only makes

the bully more aggressive. Remove yourself from

the presence of the shark.

■ Admit it is difficult not to bleed, but know

you can. Control your anger, and deal with facts


■ Counter any aggression promptly. Recognize

that aggression is often a prelude to an attack.

■ Avoid ingratiating behaviors. You might believe

that these will ward off the attack, but they will

not, and you could still “lose your limb.”

■ Respond to all inappropriate behaviors appro-

priately. Bullies often believe that you will forget

what they did in the last attack. Always respond


■ Make it known that the behavior is unaccept-

able and will not be tolerated. If the behavior

continues, file a written complaint with Human


Sexual Harassment

A new supervisor on the unit needed to be hired. After months of interviewing, the candidate selected was a young male nurse whom the staff members jokingly described as “a blond Tom Cruise.” The new supervisor was an instant hit with the predomi- nantly female executives and staff members. However, he soon found himself on the receiving end of sexual jokes and innuendoes. He had been trying to prove himself a competent supervisor, with hopes of eventually moving up to a higher manage- ment position. He viewed the behavior of the female staff members and supervisors as undermining his credibility, in addition to being embarrassing and annoying. He attempted to have the unwelcome conduct stopped by discussing it with his boss, a female nurse manager. She told him jokingly that it was nothing more than “good-natured fun” and besides, “men can’t be harassed by women” (Outwater, 1994).

In spite of the requirement for workplace educa-

tion, sexual harassment remains one of the most

box 12-5

Steps Toward Increasing Protection From Workplace Violence

• Security personnel and escorts

• Panic buttons in medication rooms, stairwells, activity

rooms, and nursing stations

• Bulletproof glass in reception, triage, and admitting areas

• Locked or key-coded access doors

• Closed-circuit television

• Metal detectors

• Use of beepers and/or cellular car phones

• Handheld alarms or noise devices

• Lighted parking lots

• Escort or buddy system

• Enforced wearing of photo identification badges

Adapted from Simonowitz, J. (1994). Violence in the workplace: You’re

entitled to protection. RN, 57(11), 61–63; nursingworld.org/dlwa/osh/wp6.

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180 unit 3 | Professional Issues

persistent problems. The reasons are complex, but

sex-role stereotypes and the unequal balance of

power between men and women are major contrib-

utors. Unfortunately, underreporting of this prob-

lem is common, even though the emotional costs of

anger, humiliation, and fear are high (nursingworld.


The laws that prohibit discrimination in the

workplace are based on the Fifth and Fourteenth

Amendments to the Constitution, mandating due

process and equal protection under the law. The

Equal Employment Opportunity Commission

(EEOC) oversees the administration and enforce-

ment of issues related to workplace equality.

Although there may be exemptions from any law, it

is important that nurses recognize that there is sig-

nificant legislation that prohibits employers from

making workplace decisions based on race, color,

sex, age, disability, religion, or national origin. The

employer may ask questions related to these issues

but cannot make decisions about employment

based on them. Behaviors that could be defined as

sexual harassment are identified in Box 12-6. The

EEOC issued a statement in 1980 that sexual

harassment is a form of sex discrimination prohib-

ited by Title VII of the Civil Rights Act of 1964.

Two forms of sexual harassment are identified;

both are based on the premise that the action is

unwelcome sexual conduct:

1. Quid pro quo. Sexual favors are given in exchange for favorable job benefits or continua-

tion of employment. The employee must

demonstrate that he or she was required to

endure unwelcome sexual advances to keep the

job or job benefits and that rejection of these

behaviors would have resulted in deprivation of

a job or benefits. Example: The administrator

approaches a nurse for a date in exchange for

a salary increase 3 months before the scheduled


2. Hostile environment. This is the most com- mon sexual harassment claim and the most dif-

ficult to prove. The employee making the claim

must prove that the harassment is based on

gender and that it has affected conditions of

employment or created an environment so

offensive that the employee could not effective-

ly discharge the responsibilities of the job

(Outwater, 1994). In 1993, the Supreme Court

ruled that a plaintiff is not required to prove

any psychological injury to establish a harass-

ment claim. If the environment could be shown

to be hostile or abusive, then there was no fur-

ther need to establish that it was also psycho-

logically injurious. Although sexual harassment

against women is more common, men can be

victims as well.

Sexual harassment can cost an employer money,

unfavorable publicity, expensive lawsuits, and large

damage awards. Low morale caused by a hostile

work environment can cause significant decreases

in employee productivity, increased absenteeism,

increases in sick leave and medical payments, and

decreased job satisfaction.

In addition to Title VII, other legal protections

include Title IX of the Education Amendments

of 1972 and state fair employment statutes. Title IX

of the Education Amendments of 1972 prohibits sex

discrimination and sexual harassment in any educa-

tional program receiving financial assistance from

the federal government. Students and employees are

covered by this law. Most state fair employment

statutes apply to public and private employers,

employment agencies, and labor organizations.

Often, state workers’ compensation statutes provide

remedies for employees who have been injured,

either physically or psychologically, by sexual harass-

ment in the workplace. Prohibition against sexual

harassment in the workplace may also be included in

collective bargaining agreements (nursingworld.org/


Addressing the issue of sexual harassment in the

workplace is important. As an employee, be famil-

iar with the policies and procedures related to

reporting sexual harassment incidents. If you

box 12-6

Behaviors That Could Be Defined as Sexual Harassment

• Pressure to participate in sexual activities

• Asking about another person’s sexual activities, fantasies,


• Making sexual innuendoes, jokes, comments, or suggestive

facial expressions

• Continuing to ask for a date after the other person has

expressed disinterest

• Making sexual gestures with hands or body movements

or showing sexual graffiti or visuals

• Making remarks about a person’s gender or body

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chapter 12 | Promoting a Healthy Workplace 181

supervise other employees, regularly review your

agency’s policies and procedures. Seek appropriate

guidance from your Human Resources personnel.

If an employee approaches you with a complaint,

then a confidential investigation of the charges

should be initiated. Above all, do not dismiss any

incidents or charges of sexual harassment involving

yourself or others as “just having fun” or respond

that “there is nothing anyone can do.” Responses

such as this can have serious consequences in the

workplace (Outwater, 1994).

The ANA cites four tactics to fight sexual harass-

ment (nursingworld.org/dlwa/wpr/wp3/htm):

1. Confront. Indicate immediately and clearly to the harasser that the attention is unwanted.

If you are in a union facility, ask the nursing

representative to accompany you.

2. Report. Report the incident immediately to your supervisor. If the harasser is your supervi-

sor, report the incident to a higher authority.

File a formal complaint, and follow the chain

of command.

3. Document. Document the incident immedi- ately while it is fresh in your mind—what

happened, when and where it occurred, and

how you responded. Name any witnesses. Keep

thorough records, and keep them in a safe place

away from work.

4. Support. Seek support from friends, relatives, and organizations such as your state nurses

association. If you are a student, seek support

from a trusted faculty member or advisor.

Additionally, your employer has a responsibility

to maintain a harassment-free workplace. You

should expect your employer to demonstrate

commitment to creating a harassment-free

workplace, provide strong written policies

prohibiting sexual harassment and describing

how employees will be protected, and educate

all employees verbally and in writing.

Latex Allergy

A nurse developed hives in 1987, nasal congestion

in 1989, and asthma in 1992. She was diagnosed

with latex allergy. Eventually she developed severe

respiratory symptoms in the health-care environ-

ment even when she had no direct contact with

latex. The nurse was forced to leave her occupation

because of these health effects (Bauer et al., 1993).

A midwife initially suffered hives, nasal conges-

tion, and conjunctivitis. Within a year, she devel-

oped asthma, and 2 years later she went into shock

after a routine gynecological examination during

which latex gloves were used. The midwife also suf-

fered respiratory distress in latex-containing envi-

ronments when she had no direct contact with latex

products. She was unable to continue working

(Bauer et al., 1993).

A physician with a history of seasonal allergies,

runny nose, and eczema on his hands suffered

severe runny nose, shortness of breath, and collapse

minutes after putting on a pair of latex gloves. A

cardiac arrest team successfully resuscitated him

(Rosen et al., 1993).

Latex products are manufactured from the

milky fluid of the rubber tree. Latex allergy was

first identified in the late 1970s. It has become such

a major health problem in the workplace that both

the OSHA and the ANA have devoted Web sites

to the problem. It is estimated that currently

8%–12% of health-care workers are sensitive to

natural rubber latex products. Table 12-2 lists prod-

ucts commonly produced with latex.

Since the 1987 CDC recommendations for uni-

versal precautions, use of latex gloves has greatly

increased exposure of health-care workers to natu-

ral rubber latex (NRL). The two major routes of

exposure to NRL are skin and inhalation, particu-

larly when glove powder acts as a carrier for NRL

protein (OSHA latex alert: cdc.gov/niosh/latexalt).

Reactions range from contact dermatitis, with scal-

ing, drying, cracking, and blistering skin, to allergic

contact dermatitis in the form of generalized hives.

More serious reactions can progress to generalized

urticaria, rhinitis, wheezing, swelling, shortness of

breath, and anaphylaxis. According to the NIOSH,

the most common reaction to latex products is

irritant contact dermatitis, the development of

dry, itchy, irritated areas on the skin, usually the

hands. This reaction is caused by irritation from

wearing gloves and by exposure to the powders

added to them.

Allergic contact dermatitis (sometimes called

chemical sensitivity dermatitis) results from the chemicals added to latex during harvesting, pro-

cessing, or manufacturing. These chemicals can

cause a skin rash similar to that of poison ivy.

Neither irritant contact dermatitis nor chemical

sensitivity dermatitis is a true allergy (cdc.gov/


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182 unit 3 | Professional Issues

Latex allergy should be suspected if an employee

develops symptoms after latex exposures. A com-

plete medical history can reveal latex sensitivity,

and blood tests approved by the U.S. Food and Drug

Administration are available to detect latex antibod-

ies. Skin testing and glove-use tests are also available.

Compete latex avoidance is the most effective

approach. Medications may reduce allergic symp-

toms, and special precautions are needed to prevent

exposure during medical and dental care.

Encourage employees with a latex allergy to wear a

medical alert bracelet.

Decreasing the potential for development of latex

allergy consists of reducing unnecessary exposure to

NRL proteins for health-care workers. Many

employees in a health-care setting, such as food han-

dlers or gardeners, can use alternative gloves. If an

employee must use NRL gloves, gloves with a lower

protein content and those that are powder-free

should be considered. Good housekeeping practices

should be identified to remove latex-containing dust

from the workplace. Employee education programs

to ensure appropriate work practices and hand wash-

ing should be encouraged. Identification of employ-

ees with increased potential for latex allergies is not

possible. However, clinical evidence indicates that

certain workers may be at greater risk, including

those with histories of allergies to pollens, grasses,

and certain foods or plants (avocado, banana, kiwi,

chestnut) and histories of multiple surgeries.

Decrease the potential for latex allergy problems


■ Evaluate any cases of hand dermatitis or other

signs or symptoms of potential latex allergy.

■ Use latex-free procedure trays and crash carts.

■ Use nonlatex gloves for activities that do not

involve contact with infectious materials.

■ Avoid using oil-based creams or lotions, which

can cause glove deterioration.

■ Seek ongoing training and the latest informa-

tion related to latex allergy.

■ Wash, rinse, and dry hands thoroughly after

removing gloves or between glove changes.

■ Use powder-free gloves.

In spite of all precautions, what do you do if you

develop a latex allergy? At this point, never wear

latex gloves. Be aware of the following precautions


■ Avoid all types of latex exposure.

■ Wear a medical alert bracelet.

■ Carry an Epi-kit with auto-injectible epinephrine.

■ Alert employers and colleagues to your latex


■ Carry nonlatex gloves.

OSHA “right to know” laws require employers to

inform health-care workers of potentially danger-

ous substances in the workplace. For continuing

information on latex allergies, see the NIOSH

home page at cdc.gov/niosh

Patients as well as workers are at risk and should

be screened for allergies. Patients with a history of

hay fever, food allergies (especially to bananas, avo-

cados, potatoes, tomatoes), asthma, or eczema can

be at risk. Taking a thorough health history is vital.

Treat any indication of potential latex sensitivity

seriously (Society of Gastroenterology Nurses and

Associates, 2001). As of 2006, most health-care

table 12-2

Latex Equipment Emergency Equipment Personal Protective Equipment Office Supplies Hospital Supplies

Blood pressure cuffs Gloves Rubber bands Anesthesia masks

Stethoscopes Surgical masks Erasers Catheters

Disposable gloves Goggles Wound drains

Oral and nasal airways Respirators Injection ports

Endotracheal tubes Rubber aprons Rubber tops of multi-dose vials

Tourniquets Dental dams

IV tubing Hot water bottles

Syringes Baby bottle nipples

Electrode pads Pacifiers

Adapted from OSHA latex allergy: osha-slc.gov/SLTC/latexallergy/index; and OSHA latex alert: cdc.gov/niosh/latexalt?

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chapter 12 | Promoting a Healthy Workplace 183

personnel were well aware of issues related to latex

allergies. In recent years, the number of new cases of

latex allergy has decreased due to improved diag-

nostic methods, improved education, and more

accurate labeling of medical devices. Although cur-

rent research does not demonstrate whether the

amount of allergen released during shipping and

storage into medications from vials with rubber clo-

sures is sufficient to induce a systemic allergic reac-

tion, nurses should take special precautions when

patients are identified as high risk for latex allergies.

The nursing staff should work closely with the

pharmacy staff to follow universal one-stick-rule

precautions, which assume that every pharmaceuti-

cal vial may contain a natural rubber latex closure,

and the nurse should remain with any patient at the

start of medication and keep frequent observations

and vital signs for 2 hours (Hamilton et al., 2005).

Needlestick Injuries

In 1997 a 27-year-old nurse, Lisa Black, attended

an in-service session on postexposure prophylaxis

for needlesticks. A short time later, she was

attempting to aspirate blood from a patient’s intra-

venous line. The patient, in the advanced stages of

acquired immunodeficiency syndrome, moved, and

the needle went into Lisa’s hand. Nine months later

she tested positive for HIV and 3 months after that

for hepatitis C. She continues to share her story

with nurses everywhere in an effort to prevent this

unfortunate accident from happening to one more

nurse (Trossman, 1999a).

On April 18, 2001, the Needlestick Act, or

revised Bloodborne Pathogens Standard, went

into effect. The revised OSHA Bloodborne

Pathogens Standard obligates employers to con-

sider safer needle devices when they conduct their

annual review of their exposure control plan.

Frontline employees must be included in the

annual review and updating of standards process.

Stricter requirements are now in effect for annual

review and updating to reflect changes in technol-

ogy that eliminate or reduce exposure to blood-

borne pathogens. JC surveyors are now asking if

health-care organization leaders are familiar with

the Needlestick Safety and Prevention Act and

whether any action being taken to comply

includes staff that use sharps and needles and are

therefore at risk for injury. The law requires

that these health-care workers and other staff be

included in the review of safer devices as well as in

making recommendations for replacement devices.




Your Employer’s Responsibility

According to the current OSHA requirements,

your employer must provide you with the following

(ANA, 1993; nursingworld.org/dlwa/osh/wp2):

■ Free hepatitis B vaccine

■ Protective equipment that fits you (gloves,

gowns, goggles, masks)

■ Immediate, confidential medical evaluation,

treatment, and follow-up if you are exposed

■ Implementation of universal precautions


■ Adequate sharps disposal

■ Proper removal of hazards from the workplace

■ Annual employee training

Many states have enacted their own laws related to

blood-borne pathogen exposures. These laws may

include some of the following requirements:

■ Listing of safety devices as engineering controls

■ Development of a list of available safety devices

by the state for use by employers

■ Development of a written exposure plan by

employers and periodic review and updates

■ Development of protocols for safety device

identification and selection by employers

and involvement by f rontline workers in the


■ Development of a sharps injury log and report-

ing log information

■ Development of methods to increase use of vac-

cines and personal protective equipment

■ Waivers or exemptions from safety device use

under certain circumstances (including patient

and/or worker safety issues, use of alternative effec-

tive strategies, market unavailability, and so on)

■ Placement of sharps containers in accessible


■ Training for workers regarding safety device

use (http://www.cdc.gov/niosh/topics/bbp/


Your Responsibility

What are your responsibilities related to this revised

legislation? Each year your institution must review

and update its blood-borne pathogen standards. You

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184 unit 3 | Professional Issues

will need to take the time to learn new devices, and

make certain that the current safety requirements

are enforced with employees. Volunteer to partici-

pate in evaluation committees, or work on teams

testing new devices. Follow these guidelines in your

daily nursing practice (ANA, 1993; Brooke, 2001;

nursingworld.org/dlwa/osh/wp2; Perry, 2001):

■ Always use universal precautions.

■ Use and dispose of sharps properly.

■ Be immunized against hepatitis B.

■ Immediately wash all exposed skin with soap

and water.

■ Flush affected eyes or mucous membranes with

saline or water.

■ Report all exposures according to your facility’s


■ If possible, know the HIV/hepatitis B virus

status of your patient.

■ Comply with postexposure follow-up.

■ Support others who are exposed.

■ Become active in the safety committee—be a

change agent.

■ Educate others.

Although health-care providers are aware of the

need to use gloves as a protection against blood-

borne pathogens, only one evidence-based summary

has been reported regarding blood-borne pathogens

and glove safety. The summary explored double

gloving versus single gloving in reducing the number

of infections. This includes postoperative wound

infections or blood-borne infections in surgical

patients and blood-borne infections in the surgical

team and to determine if double gloving reduces the

incidence of glove perforations compared with single

gloving. A total of 18 randomized controlled trials

met the inclusion criteria and were included in the

review. There is clear evidence from this review that

double gloving reduces the number of perforations

to the innermost glove. There does not appear to be

an increase in the number of perforations to the out-

ermost glove when two pairs of gloves are worn.

Korniewicz et al. (2004) participated in the first

clinical trial to test the barrier integrity of nonlatex

sterile surgical gloves after use in the operating room.

During the 14-month study, more than 21,000

gloves were collected from more than 4000 surgical

procedures. Based on results, Korniewicz et al. con-

cluded that nonlatex or intact latex gloves provide

adequate barrier protection but that nonlatex gloves

may tear more frequently than latex during use.

Ergonomic Injuries

Occupational-related back injuries affect more

than 75% of nurses over the lifetime of their

career. Poor ergonomics is a safety factor for both

nurses and patients, whose safe nursing care is

already in jeopardy by the escalating nursing short-

age (Durr, 2004).

Back Injuries

Back injuries are the most critical of ergonomic

injuries. Annually, 12% of nurses leave the profes-

sion as a result of back injuries, and more than

52% complain of chronic back pain. Nursing aides,

orderlies, and attendants ranked second and regis-

tered nurses sixth in a list of at-risk occupations for

strains and sprains (DOL, 2002). The problem

with lifting a patient is not just one of overcoming

heavy weight. Size, shape, and deformities of the

patient as well as balance and coordination, com-

bativeness, uncooperativeness, and contractures

must be considered. Any unpredictable movement

or resistance from the patient can throw the nurse

off balance quickly and result in a back injury.

Environmental considerations such as space, equip-

ment interference, and unadjustable beds, chairs,

and commodes also contribute to back injury risk

(Edlich, Woodard, & Haines, 2001).

This issue of back injuries and other ergonomic-

related injuries has become so severe that in July

2001 the OSHA began to develop a comprehensive

approach to ergonomics. Public forums, meetings

with stakeholder groups and individuals, and writ-

ten comments were analyzed. Out of this work, a

four-pronged comprehensive approach to ergonom-

ics was developed to include (osha.gov/ergonomics/


1. Task- or industry-specific written guidelines

2. Enforcement

3. Outreach/assistance

4. Research

The OSHA issued an ergonomics guideline for the

nursing home industry on March 13, 2003. The

back injury guide for health-care workers

(dir.ca.gov/dosh/dosh_publications/backinj.pdf )

and the OSHA guidelines for nursing homes


dex) are comprehensive resources. Although guide-

lines are less than legislated standards, the OSHA

uses the General Duty Clause to cite employers for

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chapter 12 | Promoting a Healthy Workplace 185

ergonomic hazards. Under this clause, employers

must keep their workplaces free from recognized

serious hazards, including ergonomic hazards. This

requirement exists whether or not there are voluntary

guidelines (osha.gov/ergonomics/FAQs-external).

The ANA, supported by the Johnson &

Johnson Foundation, has begun a campaign enti-

tled “Handle with Care.” This initiative is aimed at

preventing potentially career-ending back and

other musculoskeletal injuries among nurses.

Health-care facilities that have invested in these

assistive patient handling programs report cost sav-

ings in thousands of dollars both for direct costs of

back injuries and lost workdays (nursingworld.org/

handlewithcare/factsheet). In addition, assistive

patient handling equipment improves the quality

care of patients. Dr. de Castro, senior staff special-

ist for occupational health and safety at the ANA,

observes that such equipment:

■ Improves the safety of the patient by decreasing

the potential for manual patient-handling mishaps

■ Increases patient comfort by taking away the

human element of potentially awkward or force-

ful handlings

■ Restores patient dignity, especially in situations

when difficult handling situations impede on a

person’s privacy or self-esteem (de Castro, 2004)

The investment in a safe patient-handling program

may seem daunting due to the cost of equipment

such as mechanical lifts, transfer aids, and ergonom-

ic beds and chairs. However, the cost savings in

time, reduction of injuries, and lost workdays—as

well as the improved quality of patient care—make

this a sound return on investment.

Repetitive Stress Injuries

Repetitive stress injuries (RSIs) have been called the

workplace epidemic of the modern age. RSIs usually affect people who spend long hours at computers,

switchboards, and other worksites where repetitive

motions are performed. The most common RSIs

are carpal tunnel syndrome and mouse elbow. As

technology expands in health-care facilities, the use

of computers increases for all health-care personnel.

Badly designed computer workstations present the

highest risk of RSIs. Preventive measures (Krucoff,

2001) include the following:

■ Keep the monitor screen straight ahead of you,

about an arm’s length away. Position the center

of the screen where your gaze naturally falls.

■ Align the keyboard so that your forearms,

wrists, and hands are aligned parallel to the

floor. Do not bend the hands back.

■ Position the mouse directly next to you and on

the same level as the keyboard.

■ Keep thighs parallel to the floor as you sit on

the chair. Feet should touch the floor, and the

chair back should be ergonomically sound.

■ Vary tasks. Avoid long sessions of sitting. Do

not use excessive force when typing or clicking

the mouse.

■ Keep fingernails short, and use fingertips when


Impaired Workers

Substance Abuse

Sue had been a nurse for 20 years. Current marital and family problems were affecting her at work. To ease the tension, she took a Xanax from a patient’s medication drawer. This seemed to ease her tension. She continued to take medications, working her way up to narcotic analgesics.

Bill had begun weekend binge-drinking in col- lege. Ten years later, he continues the habit several times during the month. He does not believe he is an alcoholic because he can “control ” his drinking. After he begins showing up at work hung over and mak- ing medication errors, he is f ired for the medication errors. At the exit interview, no mention is made of his drinking problem. The agency feared a lawsuit for defamation of character.

Mr. P., the unit manager, has noticed that Ms. J. has been late for work frequently. She arrives with a wrinkled uniform, dirty shoes, unkempt hair, and broken nails. Lately she has been overheard making terse remarks to patients such as, “Who do you think I am—your maid?,” and spends longer and longer periods off the unit. The floor has a large number of surgical patients who receive intramuscular and oral medications for pain. Lately, Ms. J.’s patients continue to complain of pain even after medication administration has been charted. Ms. J. frequently forgets to waste her intramuscular narcotics in front of another nurse. Mr. P. is concerned that Ms. J. may be an impaired nurse.

As nursing education moved from the untrained

nurse—embodied in the character of Sairey Gamp

in the Dickens novel Martin Chuzzlewit—to the educated Florence Nightingale model, nurses were

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186 unit 3 | Professional Issues

expected to be of good moral character. The problem

of addiction among nurses was not discussed until

the 1950s, with addicted nurses receiving little sym-

pathy or treatment from their peers. Research on

addicted medical professionals increased in the

1970s, followed by major help for nurses with addic-

tive disease in 1980. At this time, the National

Nurses’ Society on Addictions (NNSA) task force

and the ANA task force on addictions and psycho-

logical functions jointly passed a resolution calling

for acknowledgment of the problem and guidelines

for impaired nurse programs (Heise, 2003).

Alcohol and drug abuse continue to be major

health problems in the United States. Health-care

professionals are not immune to alcoholism or

chemical dependency. In addition, various kinds of

mental illnesses may also affect a nurse’s ability to

deliver safe, competent care. Impaired workers can

adversely affect patient care, staff retention, morale,

and management time as team members try to pick

up the slack for the impaired worker (Damrosch &

Scholler-Jaquish, 1993). The most common signs

of impairment are (Blair, 2005; Damrosch &

Scholler-Jaquish, 1993):

■ Witnessed consumption of alcohol or other sub-

stances on the job

■ Changes in dress, appearance, posture, gestures

■ Slurred speech; abusive/incoherent language

■ Reports of impairment or erratic behavior from

patients and/or coworkers

■ Witnessed unprofessional conduct

■ Significant lack of attention to detail

■ Witnessed theft of controlled substances

■ When assigned patients routinely request pain

medication within a short period of being


Most employers and state boards of nursing have

strict guidelines related to impaired nurses.

Impaired-nurse programs, which are conducted by

state boards of nursing, work with the employer to

assist the impaired nurse to remain licensed while

receiving help for the addiction problem. It is

important that you become aware of workplace

issues surrounding the impaired worker, signs and

symptoms of impairment, and the policies and

reporting procedures concerning an impaired

worker. Compassion from coworkers and supervi-

sors is of utmost importance in assisting the

impaired worker to seek help (Damrosch &

Scholler-Jaquish, 1993; Sloan & Vernarec, 2001).

The National Council of State Boards lists all

state boards of nursing. Information on support

programs for impaired nurses can be obtained

f rom each state board (ncsbn.org/regulation/


Upholding the standards of the nursing profes-

sion is everyone’s responsibility. Often coworkers,

noticing a change in another’s behavior, become

protective and take on more work to ease the bur-

den of their coworker. Although it is difficult to

report a colleague, covering up or ignoring the

problem can cause serious risks for the patient and

the nurse. Many state boards make it mandatory

for nurses to report suspected impaired coworkers;

most states accept anonymous reports. In many

states, state law requires hospitals and health-care

providers to report impaired practitioners, but the

law also grants immunity from civil liability if the

report was made in good faith (Blair, 2005; Sloan

& Vernarec, 2001).

Microbial Threats

Health-care workers are an at-risk group for several

microbial threats. Severe acute respiratory syn-

dromes (SARS) is a respiratory illness that has

been reported in Asia, Europe, and North America.

According to the World Health Organization,

8098 people worldwide became sick with SARS

during the 2003 outbreak.

SARS begins with a high fever and mild respi-

ratory symptoms. Other symptoms may include

headache, an overall feeling of discomfort, and

body aches. It is not uncommon for the person to

have diarrhea and develop a dry cough. Most

patients develop pneumonia. The virus that causes

SARS is thought to be transmitted most readily by

respiratory droplets. The virus can also spread

when a person touches a surface or object contam-

inated with infectious droplets and then touches

his or her mouth, nose, or eyes. In addition, it is

possible that the SARS virus might spread more

broadly through the air (airborne spread) or by

other ways that are not known. The CDC provides

current information on the handling of SARS in

the workplace (cdc.gov).

Unlike the newer microbial threat SARS, tuber-

culosis (TB) was a leading cause of death among

infectious diseases from the 19th into the mid-

20th centuries. Although TB rates declined in the

1990s, they are currently on the rise as resources

that were committed to fighting the disease were

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chapter 12 | Promoting a Healthy Workplace 187

withdrawn. A more serious form of TB, mutidrug-

resistant tuberculosis (MDR-TB) is on the rise.

Nurses often come in contact with persons with

active TB. At times, patients do not know they are

infected until coming to the hospital with another

complaint. As with SARS, the CDC provides cur-

rent information and guidelines for dealing with

TB in the workplace (cdc.gov/nchstp/tb/pubs/


Enhancing the Quality of Work Life

The continued nursing shortage enforces an aware-

ness to “treat with kindness” the nurses who remain

in the workforce.

Rotating Shifts

Safety in the workplace involves nurses working

rotating shifts. Nurses who work permanently at

night often readjust their sleep-wake cycle.

However, even permanent night-workers may be

subjected to continuous sleep deprivation. Nurses

who randomly rotate shifts throw off their circa-

dian rhythm. Fatigue, the primary complaint of

these nurses, is the result of the body never get-

ting the chance to adapt to changing sleep-wake

cycles. The literature links some of the world’s

worst disasters, such as the Chernobyl nuclear

reactor catastrophe and the Exxon Valdez oil

spill, to rotating shift work and the changes in

circadian rhythm. Other effects of shift work

include a higher risk of miscarriage and prema-

ture labor, menstrual and digestive problems, and

respiratory irritation. One of the most serious

results of rotating night shifts is the increasing

number of nurses affected by coronary heart dis-

ease (CHD). Studies indicate that nurses who

rotate to nights for 6 years have a 70% greater

risk of developing CHD than nurses who never

rotated shifts due to the circadian effect of lower-

ing of blood pressure and heart rate at night

(Trossman, 1999b). Suggestions for nurses who

rotate shifts:

■ Try to schedule working the same shifts for an

entire scheduling period instead of rotating

different shifts in one schedule.

■ Try to schedule to same days off within the


■ If you become sleepy during the shift, take a

walk or climb stairs.

■ Limit caffeine intake, especially toward the end

of the shift.

■ If you work evenings or nights, do not eat a big

meal at the end of the shift. This interferes with


■ Try to sleep a continuous block of time instead

of catching a few hours here and there.

■ Make the room you are sleeping in as dark and

noise-free as possible.

■ Maintain good nutrition and an exercise


■ Negotiate your schedule with your manager.

If you and your colleagues feel strongly about

eliminating rotating shifts, work together to

make changes (Trossman, 1999b).

Mandatory Overtime

When nurses are forced routinely to work beyond

their scheduled hours, they can suffer a range of

emotional and physical effects. As patient acuity

and workloads increase, nurses working overtime

put both patients and nurses at greater risk.

Mandatory overtime is seen by nurses as a control

issue. Working overtime should be a choice, not a

requirement. In some facilities, nurses are being

threatened with dismissal or charge of patient aban-

donment if they refuse to participate in mandatory

overtime (nursingworld.org/tan/98mayjun/ot).

The ANA presented the following message to

the 107th Congress in 2001: “ANA opposes the use

of mandatory overtime as a staffing tool. We urge

you to support legislation that would ban the use of

mandatory overtime through Medicare and

Medicaid law. Nurses must be given the opportuni-

ty to refuse overtime if we believe that we are too

fatigued to provide quality care” (nursingworld.org

/gova/federal/legis/107/ovrtme). Dembe, Erickson,

Delbros, and Banks (2005) analyzed the occurrence

of occupational injury and illness between 1987

and 2000. After a review of 10,793 participants

working at least 12 hours per day, working overtime

was associated with a 23% increased work hazard

and a 61% higher injury hazard rate compared with

jobs without overtime. More recently, Rogers et al.

(2004) found that nurses’ error rates increase signif-

icantly during overtime, after 12 hours and over

more than 60 hours per week. Currently, there are

no regulations governing nurses’ work hours. About

half of staff nurses are scheduled routinely to work

12-hour shifts, and 85% of staff nurses routinely

work longer than scheduled hours.

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188 unit 3 | Professional Issues

Staffing Ratios

Although some state nurses associations are calling

for mandated staffing ratios, the issue is not clear-

cut. What has become clear is that there is no “one

size fits all” solution. In 2004 a review was conduct-

ed of peer-reviewed studies published between

1980 and 2003 of the effects of nurse staffing on

patient, nurse employee, and hospital outcomes.

The literature offered no support for specific nurse-

patient ratios. However, findings from 12 key stud-

ies stood out, citing specific effects of nurse staffing

on patient outcomes: incidences of failure to rescue,

in-patient mortality, pnuemonia, urinary tract

infections, and pressure ulcers. Effects of nurse

staffing levels on nurse employee outcomes includ-

ed needlestick injuries, nursing burnout, and nurs-

ing documentation, whereas hospital length of stay,

financial outcomes, and direct nursing care were

experienced by the hospital. Table 12-3 provides a

matrix for staffing decision making.

Above all, the ANA recommends moving

staffing away from an industrial model of measuring

time and motion to a more professional model that

examines factors needed to provide quality care.

Changes in staffing levels should be based on analy-

sis of nursing-sensitive indicators (nursingworld.org/


Using Unlicensed Assistive Personnel

Educational preparation and clinical experiences in

practice for nurses differs for basic registered nurse

(RN) education. The nursing shortage will contin-

ue to force health-care facilities to explore creative

ways of providing safe and effective patient care.

This will most likely include RNs working with not

only licensed practical nurses (LPNs) but also with

unlicensed assistive personnel (UAP). The legal reg-

ulation of nursing practice is defined by each state

nursing practice act; however, the ANA believes that

“curricula for all RN programs should include con-

tent on supervision, delegation, assignment, and

legal aspects regarding nursing’s utilization of assis-

tive personnel” (nursingworld.org/readroom/


Hospital workforce issues will continue to be

influenced by economic changes, managed care and

insurance issues, media forces, and the nursing

shortage. Linda Aiken has been researching rela-

tionships between positive patient, nurse, and

agency outcomes and RN staffing, educational

preparation, and organizational culture (Aiken,

2002, 2004). Nurses voice disillusionment with

nursing practice and decreased loyalty to organiza-

tions. Nursing leaders in the 21st century must

demonstrate a respect and value for their nursing

staff, communicate effectively with all levels of the

organization, maintain visibility, and establish par-

ticipative decision making. As you move forward in

your career, be part of the solution, not the problem

(Ray, Turkel, & Marino, 2002).

Reporting Questionable Practices

Most employers have policies that encourage the

reporting of behavior that may affect the workplace

environment. Behaviors to report may include

(ANA, 1994):

1. Endangering a patient’s health or safety

2. Abusing authority

3. Violating laws, rules, regulations, or standards

of professional ethics

4. Grossly wasting funds

The Code for Nurses (ANA, 2001) is very specific

about nurses’ responsibility to report questionable

behavior that may affect the welfare of a patient:

When a nurse is aware of inappropriate or ques-

tionable practice in the provision of health care, con-

cern should be expressed to the person carrying out

the questionable practice and attention called to the

possible detrimental effect on the patient’s welfare.

When factors in the health-care delivery system

threaten the welfare of the patient, similar action

should be directed to the responsible administrative

person. If indicated, the practice should then be

reported to the appropriate authority within the

table 12-3

Matrix for Decision Making: Staffing Patients Characteristics and number of patients

requiring care

Intensity of Unit Intensity of individuals within and across

and Care the unit; variability of care; admissions,

discharges, transfers, volume

Context Architecture of unit; technology available

Expertise Staff consistency, continuity, and

cohesion; staff preparation and


Other Quality improvement activities; nursing

control of practice

Adapted from nursingworld.org/readroom/stffprnc

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chapter 12 | Promoting a Healthy Workplace 189

institution, agency, or larger system (ANA, 2001).

The sources of various federal and state guidelines

governing the workplace are listed in Box 12-7.

Protection by the agency should be afforded to

both the accused and the person doing the report-

ing. Whistleblower is the term used for an employee who reports employer violations to an outside

agency. Do not assume that doing the right thing

will protect you. Speaking up could get you fired

unless you are protected by a union contract or

other formal employment agreement. In May

1994, the U.S. Supreme Court ruled that nurses

who direct the work of other employees may be

considered supervisors and therefore may not be

covered by the protections guaranteed under the

National Labor Relations Act. This ruling may

cause nurses to have no protection from retaliation

if they report illegal practices in the workplace

(ANA, 1995b). The 1995 brochure from the ANA

(1995a), Protect Your Patients—Protect Your License, states, “Be aware that reporting quality and safety

issues may result in reprisals by an employer.” Does

this mean that you should never speak up? Case

law, federal and state statutes, and the federal False

Claims Act may afford a certain level of protection.

Some states have whistleblower laws. They usually

apply only to state employees or to certain types of

workers. Although these laws may offer some pro-

tection, the most important point is to work

through the employer’s chain of command and

internal procedures: (a) make sure that whistle-

blowing is addressed at your facility, either through

a collective bargaining contract or workplace advo-

cacy program; (b) contact your state nurses associ-

ation to find out if your state offers whistleblower

protection or has such legislation pending; (c) be

politically active by contacting your state legislators

and urge them to support a pending bill or by edu-

cating your elected state officials on the need

for such protection for all health-care workers; and

(d) contact your U.S. congressional representatives

and urge them to support the Patient Safety Act


It is the responsibility of professional nurses

to become acquainted with the state and federal

regulations, standards of practice and professional

performance, and agency protocols and practice

guidelines governing their practice. Lack of knowl-

edge will not protect you from ethical and legal

obligations. Your state nurses association can help

you seek information related to incompetent,

unethical, or illegal practices. When you join your

state association, you will gain access to an organi-

zation that has input into policies and procedures

designed to protect the public.

Although the rights of disabled nurses are not

usually considered “questionable practices,” the

ANA is concerned with those rights. The

Americans With Disabilities Act, enacted in 1990,

makes it unlawful to discriminate against a quali-

fied individual with a disability. The employer is

required to provide reasonable accommodations for

the disabled person. A reasonable accommodation

is a modification or adjustment to the job, work

environment, work schedule, or work procedures

that enable a qualified person with a disability to

perform the job. Both you and your employer may

see information from the Equal Employment

Opportunity Commission (EEOC) for informa-

tion (nursingworld.org/dlwa/wpr/wp6).

Terrorism and Other Disasters

Since the attacks on the World Trade Center and

the Pentagon as well as the anthrax outbreaks and

continued terrorist threats nationwide, concerns

related to biological and chemical agents have sur-

faced. The CDC Web site (bt.cdc.gov/) supports

ongoing information related to public health emer-

gency preparedness and response. The ANA has

published a position statement for employers on

work release during a disaster. In addition, the ANA

provides RNs with valuable information on how

they can better care for their patients, protect them-

selves, and prepare their hospitals and communities

to respond to acts of bioterrorism and natural disas-

ters (nursingworld.org/news/disaster/). For example,

box 12-7

Laws Governing Health-Care Practices • State nurse practice acts

• Federal and state health regulations

• State and federal pharmacy laws for controlled substances


• State medical records and communicable disease laws

• Environmental laws regulating hazardous waste and air

and water quality

• CDC guidelines

• Federal and state antidiscrimination laws

• State clinical laboratory regulations

• JCAHO regulations

Adapted from American Nurses Association. (1994). Guidelines on Reporting

Incompetent, Unethical, or Illegal Practices. Washington, DC: ANA.

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190 unit 3 | Professional Issues

many nurses worked with the ANA to provide sup-

port for the victims of Hurricane Katrina.

Your importance in emergency readiness and

bioterrorism is important. Following are some sug-

gestions for steps that can be implemented in the

workplace (awhonn.org/HealthPolicyLegislative/

B I O T E R R O R I S M P R E P A R E D N E S S /


■ Know the evacuation procedures and routes in

your facility.

■ Develop your knowledge of the most likely and

dangerous biochemical agents.

■ Monitor for unusual disease patterns, and notify

appropriate authorities as needed.

■ Know the backup systems available for commu-

nication and staffing in the event of emergencies.

■ Know the disaster policies and procedures in

your facility as well as state and federal laws that

pertain to licensed personnel.

Enhancing the Quality of Work Life

Both the social and physical aspects of a workplace

can affect the way in which people work and how

they feel about their jobs. The social aspects include

working relationships, a climate that allows growth

and creativity, and cultural diversity.

Social Environment

Working Relationships

Many aspects of the social environment received

attention in earlier chapters. Team building, com-

municating effectively, and developing leadership

skills are essential to the development of working

relationships. The day-to-day interactions with

one’s peers and supervisors have a major impact on

the quality of the workplace environment.

Support of One’s Peers and Supervisors

Most employees feel keenly the difference between

a supportive and a nonsupportive environment:

Ms. B. came to work already tired. Her baby was sick and had been awake most of the night. Her team expressed concern about the baby when she told them she had a diff icult night. Each team member voluntarily took an extra patient so that Ms. B. could have a lighter assignment that day. When Ms. B. expressed her appreciation, her team leader said, “We know you would do the same for us.” Ms. B. worked in a supportive environment.

Ms. G. came to work after a sleepless night. Her young son had been diagnosed with leukemia, and she was very worried about him. When she men- tioned her concerns, her team leader interrupted her, saying, “Please leave your personal problems at home. We have a lot of work to do, and we expect you to do your share.” Ms. G. worked in a nonsup- portive environment.

Support from peers and supervisors involves pro-

fessional concerns as well as personal ones. In a

supportive environment, people are willing to make

difficult decisions, take risks, and “go the extra

mile” for team members and the organization. In

contrast, in a nonsupportive environment, members

are afraid to take risks, avoid making decisions, and

usually limit their commitment.

Involvement in Decision Making

The importance of having a voice in the decisions

made about one’s work and patients cannot be

overstated. Empowerment is a related phenome-

non. It is a sense of having both the ability and the

opportunity to act effectively (Kramer &

Schmalenberg, 1993). Empowerment is the oppo-

site of apathy and powerlessness. Many actions can

be taken to empower nurses: remove barriers to

their autonomy and to their participation in deci-

sion making, publicly express confidence in their

capability and value, reward initiative and assertive-

ness, and provide role models who demonstrate

confidence and competence. The following illus-

trates the difference between empowerment and


Soon after completing orientation, Nurse A heard a new nurse aide scolding a patient for soiling the bed. Nurse A did not know how incidents of potential verbal abuse were handled in this institution, so she reported it to the nurse manager. The nurse manager asked Nurse A several questions and thanked her for the information. The new aide was counseled immediately after their meeting. Nurse A noticed a positive change in the aide’s manner with patients after this incident. Nurse A felt good about having contributed to a more effective patient care team. Nurse A felt empowered and will take action again when another occasion arises.

A colleague of Nurse B was an instructor at a community college. This colleague asked Nurse B if students would be welcome on her unit. “Of course,” replied Nurse B. “I’ll speak with my head nurse

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chapter 12 | Promoting a Healthy Workplace 191

about it.” When Nurse B did so, the response was that the unit was too busy to accommodate students. In addition, Nurse B received a verbal reprimand from the supervisor for overstepping her authority by discussing the placement of students. “All requests for student placement must be directed to the educa- tion department,” she said. The supervisor directed Nurse B to write a letter of apology for having made an unauthorized commitment to the community college. Nurse B was afraid to make any decisions or public statements after this incident. Nurse B felt alienated and powerless.

Professional Growth and Innovation

The difference between a climate that encourages

staff growth and creativity and one that does not

can be quite subtle. In fact, many people are only

partly aware, if at all, whether they work in an envi-

ronment that fosters professional growth and

learning. Yet the effect on the quality of the work

done is pervasive, and it is an important factor in

distinguishing the merely good health-care organi-

zation from the excellent health-care organization.

Much of the responsibility for staff development

and promotion of innovation lies with upper-level

management, people who can sponsor seminars,

conduct organization-wide workshops, establish

educational policies, promote career mobility,

develop clinical ladders, initiate innovative projects,

and reward suggestions.

Some of the ways in which first-line managers

can develop and support a climate of professional

growth are to encourage critical thinking, provide

opportunities to take advantage of educational pro-

grams, encourage new ideas and projects, and

reward professional growth.

Encourage Critical Thinking

If you ever find yourself or staff members saying,

“Don’t ask why. Just do it!” then you need to evalu-

ate the type of climate in which you are function-

ing. An inquisitive frame of mind is relatively easy

to suppress in a work environment. Patients and

staff members quickly perceive a nurse’s impatience

or defensiveness when too many questions are

raised. Their response will be to simply give up ask-

ing these questions.

On the other hand, if you support critical

thinkers and act as a role model who adopts a

questioning attitude, you can encourage others to

do the same.

Seek Out Educational Opportunities

In most organizations, first-line managers do not

have discretionary funds that can be allocated for

educational purposes. However, they can usually

support a staff member’s request for educational

leave or for financial support and often have a

small budget that can be used for seminars or


Team leaders and nurse managers can make it

either easier or more difficult for staff members to

further their education. They can make things dif-

ficult for the staff member who is trying to balance

work, home, and school responsibilities, or they

can help lighten the load of the staff member who

has to finish a paper or take an examination.

Unsupportive supervisors have even attacked staff

members who pursue further education, criticizing

every minor error and blocking their advancement.

Obviously, such behavior should be dealt with

quickly by upper-level management because it is a

serious inhibitor of staff development.

Encourage New Ideas

The increasingly rapid accumulation of knowledge

in health care mandates continuous learning for

safe practice. Intellectual curiosity is a hallmark of

the professional.

Every move up the professional ladder should

bring new challenges that enrich one’s work

(Roedel & Nystrom, 1987). As a professional, you

can be a role model for an environment in which

every staff member is both challenged and rewarded

for meeting these challenges. Participating in

brainstorming sessions, group conferences, and

discussions encourages the generation of new

ideas. Although new nurses may think they have

nothing to offer, it is important for them to partic-

ipate in activities that encourage them to look at

fresh, new ideas.

Reward Professional Growth

A primary source of discontent in the workplace is

lack of recognition. Positive feedback and recogni-

tion of contributions are important rewards.

Everyone enjoys praise and recognition. A smile, a

card or note, or a verbal “thank you” goes a long way

with coworkers in recognizing a job well done.

Staff recognition programs have also been identi-

fied as a means of increasing self-esteem, social

gratification, morale, and job satisfaction (Hurst,

Croker, & Bell, 1994).

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192 unit 3 | Professional Issues

Cultural Diversity

Ms. V. is beginning orientation as a new staff nurse. She has been told that part of her orientation will be a morning class on cultural diversity. She says to the Human Resources person in charge of orientation, “I don’t think I need to attend that class. I treat all people as equal. Besides, anyone living in the United States has an obligation to learn the language and ways of those of us who were born here, not the other way around.”

Mr. M. is a staff nurse on a medical-surgical unit. A young man with HIV infection has been admitted. He is scheduled for surgery in the morn- ing and has requested that his signif icant other be present for the preoperative teaching. Mr. M. reluc- tantly agrees but mumbles under his breath to a coworker, “It wouldn’t be so bad if they didn’t throw their homosexuality around and act like an old married couple. Why can’t he act like a man and get his own preop instructions?”

Diversity in health-care organizations includes

ethnicity, race, culture, gender, lifestyle, primary

language, age, physical capabilities, and career

stages of employees. The composition of nurses in

health care is changing to include more older

workers, minorities, and men. Working with people

who have different customs, traditions, communi-

cation styles, and beliefs can be exciting as well as

challenging. An organization that fosters diversity

encourages respect and understanding of human

characteristics and acceptance of the similarities

and differences that make us human.

Often, when stressful situations arise, gender, age,

and culture can contribute to misunderstandings.

Davidhizer, Dowd, and Giger (1999) identified six

important factors in their model for understanding

cultural diversity:

1. Communication. Communication and culture are closely bound. Culture is transmitted

through communication, and culture influences

how verbal and nonverbal communication is

expressed. Vocabulary, voice qualities, intona-

tion, rhythm, speed, silence, touch, body pos-

tures, eye movements, and pronunciation differ

among cultural groups and vary among persons

from similar cultures. Using respect as a central

core to a relationship, everyone needs to assess

personal beliefs and communication variables of

others in the workplace.

2. Space. Personal space is the area that surrounds a person’s body. The amount of personal space

individuals prefer varies from person to person

and from situation to situation. Cultural beliefs

also influence a person’s personal space comfort

zone. In the workplace, an understanding of

coworkers’ comfort related to personal space is

important. Often, this comfort is relayed in

nonverbal rather than verbal communication.

3. Social organization. In most cultures, the family is the most important social organiza-

tion. For some people, the importance of family

supersedes that of other personal, work, or

national causes; for example, caring for a sick

child overrides the importance of being on time

or even coming to work, regardless of staffing

needs or policies. Because the health-care

industry employs a large number of women, the

value of the family becomes an important issue

in the workplace.

4. Time. Time orientation is often related to cul- ture, environment, and family experiences.

Some cultures are more past-oriented and focus

on maintaining traditions, with little interest in

goals. People from cultures with more of a pres-

ent and future orientation may be more likely

to engage in activities, such as returning to

school or receiving certifications that will

enhance the future. Working with people who

have different time orientations may cause

difficulty in planning schedules and setting

deadlines for the group.

5. Environment control. Environmental control consists of those activities that an individual

plans for controlling nature. Environmental

control is best understood through the psycho-

logical terms internal and external locus of control. Individuals with an external locus of control believe in fate or chance. People with an

internal locus of control believe in developing

plans and directing their environment. In the

workplace, nurses are expected to operate from

an internal locus of control. This approach may

be different from what a person has grown up

with or how a patient deals with illness.

6. Biological variations. More and more infor- mation is available to health-care workers about

the variations among races in aspects such as

body structure, skin color, genetic variations,

susceptibility to disease, and psychological

differences. The Joint Commission states that

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chapter 12 | Promoting a Healthy Workplace 193

cultural factors must be assessed in developing

materials for patient education.

As you begin your career, be alert to the signs of cul-

tural diversity or insensitivity where you work. Signs

that increased sensitivity and responsiveness to the

needs of a culturally diverse workforce are needed on

your team or in your organization may include a

greater proportion of minorities or women in lower-

level jobs, lower career mobility and higher turnover

rates in these groups, and acceptance or even

approval of insensitivity and unfairness (Malone,

1993). Observe interaction patterns, such as where

people sit in the cafeteria or how they cluster during

coffee breaks. Are they mixing freely, or are there

divisions by gender, race, language, or status in the

organization (Moch & Diemert, 1987; Ward, 1992)?

Other indications of an organization’s diversity

“fitness” include the following (Mitchell, 1995):

■ The personnel mix reflects the current and

potential population being served.

■ Individual cultural preferences pertaining to

issues of social distance, touching, voice volume

and inflection, silence, and gestures are respected.

■ There is awareness of special family and holiday

celebrations important to people of different


■ The organization communicates through action

that people are individuals first and members of

a particular culture second.

Effective management of cultural diversity requires

considerable time and energy. Although organized

cultural diversity programs are usually the respon-

sibility of middle- and upper-level managers, you

can play a part in raising awareness. You can be a

culturally competent practitioner and a role model

for others by becoming:

■ Aware of and sensitive to your own culture-

based preferences

■ Willing to explore your own biases and values

■ Knowledgeable about other cultures

■ Respectful of and sensitive to diversity among


■ Skilled using and selecting culturally sensitive

intervention strategies

Physical Environment

Attention to the physical environment of the work-

place is not as well developed as to the social aspect,

especially in nursing. The increasing focus on

workplace ergonomics—such as modifications to

various elements of the physical environment,

including floors, chairs, desks, beds, and worksta-

tions, to decrease the incidence of back and upper

extremity injuries—has already been discussed. The

use of lighting, colors, and music to improve the

workplace environment is increasing. Computer

workstations designed to promote efficiency in the

patient care unit are becoming commonplace.

Relocation of supplies and substations closer to

patient rooms to reduce the number of steps,

improved visual and auditory scanning of patients

from the nurses’ station, better light and ventila-

tion, a unified information system, and reduced

need for patient transport are all possible with

changes in the physical environment.

Health-care pollution is a more recently identi-

fied problem. Dioxin emissions, mercury, and bat-

tery waste are often not disposed properly in the

hospital environment. Disinfectants, chemicals,

waste anesthesia gases, and laser plumes that float

in the air are other sources of pollution exposure for

nurses. Nurses have a responsibility to be aware of

these potential problems and identify areas in the

hospital at risk. Rethinking product choices, such

as avoiding the use of polyvinyl chloride or mercu-

ry products, providing convenient collection sites

for battery and mercury waste, and making waste

management education for employees mandatory

are starts toward a more pollution-free environ-

ment (Slattery, 1998). The purchase of recycled

paper and products, waste treatment choices that

minimize toxic disinfectants, and waste disposal

choices that reduce incineration to a maximum are

needed. Nurses as professionals need to be aware of

the consequences of the medical waste produced by

the health sector, supporting continued education

for both nurses and patients.


Workplace safety is an area of increasing concern.

Staff members have a right to be informed of any

potential risks in the workplace. Employers have a

responsibility to provide adequate equipment and

supplies to protect employees and to create pro-

grams and policies to inform employees about

minimizing risks to the extent possible. Issues of

workplace violence, sexual harassment, impaired

workers, ergonomics and workplace injuries, and

terrorism should be addressed to protect both

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194 unit 3 | Professional Issues

employees and patients. The IOM and JCAHO

patient safety initiatives will continue to affect the

way nurses do business. Workplace issues related to

nursing and positive patient outcomes will contin-

ue to be discussed.

A social environment that promotes professional

growth and creativity and a physical environment

that offers comfort and maximum work efficiency

should be considered in improving the quality of

work life. Cultural awareness, respect for the diver-

sity of others, and increased contact between

groups should be the goals of the workforce for the

next century.

Many waking hours are spent in the workplace.

It can offer a climate of companionship, profession-

al growth, and excitement. Everyone is responsible

for promoting a safe, healthy work environment for

each other.

Study Questions

1. Why is it important for nurses to understand the major federal laws and agencies responsible to

protect the individual in the workplace?

2. What actions can nurses take if they believe that OSHA guidelines are not being followed in the


3. What are nurses’ responsibilities in dealing with the following workplace issues: transmission of

blood-borne pathogens, violence, sexual harassment, and impaired coworkers?

4. What information do you need to obtain from your employer related to terrorism and other disasters?

5. What will you look for in the work environment that will support positive patient outcomes?

6. Discuss experiences you have had in your clinical rotations. Were the environments supportive or

nonsupportive social environments? What recommendations would you make for improvement?

7. Review the ten areas of concern for Nursing’s Agenda for the Future. Identify what contributions you will make now and in the future to support this agenda.

Case Study to Promote Critical Reasoning

You have been hired as a new RN on a busy pediatric unit in a large metropolitan hospital. The

hospital provides services for a culturally diverse population, including African-American, Asian,

and Hispanic people. Family members often attempt alternative healing practices specific to their

culture and bring special foods from home to entice a sick child to eat. One of the more

experienced nurses said to you, “We need to discourage these people from fooling with all this

hocus pocus. We are trying to get their sick kid well in the time allowed under their managed care

plans, and all this medicine-man stuff is only keeping the kid sick longer. Besides, all this stuff

stinks up the rooms and brings in bugs.” You have observed how important these healing rituals

and foods are to the patients and families and believe that both the families and the children have

benefited from this nontraditional approach to healing.

1. What are your feelings about nontraditional healing methods?

2. How should you respond to the experienced nurse?

3. How can you be a patient advocate without alienating your coworkers?

4. What could you do to assist your coworkers in becoming more culturally sensitive to their patients

and families?

5. How can health-care facilities incorporate both Western and nontraditional medicine? Should they

do this? Why or why not?

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chapter 12 | Promoting a Healthy Workplace 195

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chapter 13 Work-Related Stress

and Burnout

OBJECTIVES After reading this chapter, the student should be able to: ■ Identify signs and symptoms of stress, reality shock, and


■ Describe the impact of stress, reality shock, and burnout on the individual and the health-care team.

■ Evaluate his or her own and colleagues’ stress levels.

■ Develop strategies to manage personal and professional stresses.


Consider the Statistics


Effects of Stress

Responses to Stress

The Real World

Initial Concerns

Differences in Expectations

Additional Pressures on the New Graduate

Resolving the Problem




Stressors Leading to Burnout

Personal Factors

Job-Related Conditions

Human Service Occupations

Conflicting Demands


Lack of Balance in Life


A Buffer Against Burnout

Stress Management

ABCs of Stress Management




Physical Health Management

Deep Breathing

Good Posture


Relaxation and Time Out

Proper Nutrition


Mental Health Management

Realistic Expectations



Social Support

Organizational Approaches to Job Stress



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198 unit 3 | Professional Issues

Consider the Statistics

Fifty years ago, the term personal anxiety was never used to describe stress. In the decades since, stress

has become the most common psychological com-

plaint and a widespread health problem. In the last

decade alone, approximately 28,000 studies have

been published on the subject of stress and over

1000 studies on the subject of burnout (Pines,

2004, p. 66).

In the workplace, stress is usually defined from a

“demand-perception-response” perspective—that

stress is related to the perception of the demands

being made on the individual as well as that individ-

ual’s perception of the ability to meet those demands.

When there is a mismatch between the two, the

stress response is triggered. The stress threshold, or

hardiness, depends on the individual’s characteristics,

experiences, coping mechanisms, and the circum-

stances of the event (McVicar, 2003).

The phrase “this is so stressful” is frequently

used to describe negative work and personal situa-

tions. However, in reality, some stress responses are

positive (eustress). The stress response is not a sin-

gle event but a continuum, ranging from feeling of

eustress to mild/moderate distress to severe dis-

tress. It is the severe and prolonged distress that

causes people to “burn out” emotionally and expe-

rience serious physiological and psychological dis-

turbances. Table 13-1 describes the continuum of

the stress response.


Effects of Stress

Hans Selye first explored the concept of stress in

the 1930s. Selye (1956) defined stress as the non- specific response of the body to any demands made

on it. His description of the general adaptation

syndrome (GAS) has had an enormous influence

on our present-day notions about stress and its

effect on people. The GAS consists of three stages:

1. Alarm. The body awakens to the stressor, and there is a slight change below the normal level

of resistance.

2. Resistance. The body adjusts to the stressor and tries to restore balance.

3. Exhaustion. As the stressor continues, the body energy falls below the normal level of

resistance, and illness may occur.

Most people think of stress as work pressure, rush-

hour traffic, or sick children. These are triggers to

the stress response, the actual body reaction to the

daily factors mentioned. As identified by Selye, stress is the fight-or-flight response in the body, caused by

adrenaline and other stress hormones, causing phys-

iological changes such as increased heart rate and

blood pressure, faster breathing, dilated pupils,

increased blood sugar, and dry mouth.

Currently, stress is assessed on four levels: envi-

ronmental, social, physiological, and psychological.

Environmental stressors include weather, pollens, noise, traffic, and pollution. Social stressors include deadlines, finances, work responsibilities and

interactions, and multiple demands on time and

attention. Physiological stressors include illness, aging, injuries, lack of exercise, poor nutrition, and

inadequate sleep. Psychological stressors are thoughts: how the brain interprets changes in the

environment and the body and determines when

the body turns on the fight-or-flight response

(Davis, Eshelman, & McCay, 2000).

Epidemiological research has shown that long-

term stress contributes to cardiovascular disease,

hypertension, ulcers, substance abuse, immune system

disorders, emotional disturbances, and job-related

injuries (Crawford, 1993; Lusk, 1993).

Responses to Stress

“Whether the stress you experience is the result of major life changes or the cumulative effect of minor everyday hassles, it is how you respond to these expe- riences that determines the impact stress will have on your life” (Davis, Eshelman, & McCay, 2000).

Some people manage potentially stressful events

more effectively than others (Crawford, 1993;

Teague, 1992). Perceptions of events and the sub-

sequent stress responses vary considerably from

one person to another. A patient crisis that one

nurse considers stressful, for example, may not

seem stressful to a coworker. The following is an


A new graduate was employed on a busy teleme- try floor. Often, when patients were admitted, they were in acute distress, with shortness of breath, diaphoresis, and chest pain. Family mem- bers were distraught and anxious. Each time the new graduate had to admit a patient, she experi- enced a “sick-to-the-stomach” feeling, tightness in the chest and throat, and diff iculty concentrating.

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chapter 13 | Work-Related Stress and Burnout 199

She was afraid that she would miss something important and that the patient would die during the admission. The more experienced nurses seemed to handle each admission with ease, even when the patient’s physical condition was severely compromised.

Selye also differentiated between “good” stress and

“bad” stress. In 1974, Selye stated: “Stress is the

spice of life. Since stress is associated with all

types of activity, we could not avoid most of it

only by never doing anything” (Lenson, 2001,

p. 5). Good stress can push people to perform bet-

ter and accomplish more. What makes an event

“good stress” or “bad stress”? Lenson identified

seven factors:

1. People can exert a high level of control over the

outcomes of good stresses. With bad stresses,

there is little or no control.

2. Positive feelings are experienced in processing

good stress. With bad stress, negative or

ambivalent feelings occur.

3. Good stress helps achieve positive goals. No

desirable outcomes occur with bad stress.

4. There is a feeling of eagerness when anticipat-

ing the work that needs to be done to process

the good stressors.

table 13-1

Stress Continuum Eustress Distress Severe Distress



Individual response

Adapted from Martin, K. (May 1993). To cope with stress. Nursing 93, 39–41, with permission; Goliszek, A. (1992). Sixty-Six Second Stress Management: The

Quickest Way to Relax and Ease Anxiety. Far Hills, N.J.: New Horizon; and McVicar, A. (2003). Workplace stress in nursing: A literature review. Journal of

Advanced Nursing, 44(6), 633–642.


Autonomic nervous system

response: increased blood

pressure/heart rate;

increased metabolic rate;

release of cortisol; quicker

reaction times


Increased alertness

Focus totally on the situation

Able to respond to changes



Energized for fight or flight


Feelings of uneasiness, appre-

hension, sadness, depression,

pessimism, listlessness

Lack of self-esteem

Increased level of arousal/

mental acuity

Negative attitude

Increased use of alcohol/


Decreased interest in sexual


Procrastination/unable to

complete tasks

Prolonged elevated blood



Bowel disturbances

Weight gain or loss

Reduced immunity

Fatigue/low energy

Poor sleep habits


Trembling hands, fingers, body

Dry mouth and throat

Varies among individuals but

usually maladaptive






Emotional exhaustion/

depersonalization and



Clinical hypertension

Coronary artery disease

Gastric disorders

Menstrual problems

Varies among individuals but

usually severely maladaptive,

possible life-threatening

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200 unit 3 | Professional Issues

5. Bad stress leaves feelings of exhaustion and


6. Good stress helps growth; bad stress is limiting.

Good stress improves interpersonal relation-

ships; bad stress makes these relationships


7. Processing all stress requires human action.

The Real World

Today’s health-care system has adopted the cor-

porate mindset. Both the new graduate and the

seasoned professional continue to experience

redesigning, changing staffing models, complex

documentation requirements, continued nursing

shortages, and the expectation that work does not

end when the employee goes home (Trossman,

1999). Most agencies expect new graduates to

come to the work setting able to organize their

work, set priorities, and provide leadership to

ancillary personnel. New graduates often say, “I

had no idea that nursing would be this demand-

ing.” Even though nursing programs of study are

designed to help students prepare for the

demands of the work setting, new nurses still need

to continue to learn on the job. In fact, experi-

enced nurses say that what they learned in school

is only the beginning; school provided them with

the fundamental knowledge and skills needed to

continue to grow and develop as they practice

nursing in various capacities and work settings.

Graduation signals not the end of learning but the

beginning of a journey toward becoming an expert

nurse (Benner, 1984).

Right now you are probably thinking,

“Nothing can be more stressful than going to

school. I can’t wait to go to work and not have to

study for tests, go to the clinical agency for my

assignment, do patient care plans,” and so forth.

In most associate degree programs, students are

assigned to care for one to three patients a day,

working up to six or seven patients under a

preceptor’s supervision by the end of their pro-

gram. Compare this with your “next clinical rota-

tion,” your first real job as a nurse. You may work

7–10 days in a row on 8- to 12-hour shifts, car-

ing for 10 or more patients. You may also have to

supervise several technicians or licensed practical

nurses. These drastic changes from school to

employment cause many to experience reality shock (Kraeger & Walker, 1993; Kramer, 1981).

Initial Concerns

The first few weeks on a new job are the “honey-

moon” phase. The new employee is excited and

enthusiastic about the new position. Coworkers

usually go out of their way to make the new person

feel welcome and overlook any problems that arise.

But honeymoons do not last forever. The new

graduate is soon expected to behave like everyone

else and discovers that expectations for a profes-

sional employed in an organization are quite differ-

ent from expectations for a student in school.

Those behaviors that brought rewards in school are

not necessarily valued by the organization. In fact,

some of them are criticized. The new graduate who

is not prepared for this change feels confused,

shocked, angry, and disillusioned. The tension of

the situation can become almost unbearable if it is

not resolved. Table 13-2 provides a list of ongoing

and newer workplace stresses

Graduate nurses in the first 3 months of employ-

ment identified concerns related to skills, personal

and professional roles, patient care management, the

table 13-2

Stress in the Workplace Ongoing Sources Newer Sources

Conflict with physicians Terrorism

Work overload/ Changes in technology

work devalued

Role conflict Downsizing

Ineffective, hostile, Constant changes in nursing

incompetent supervisors care delivery

and/or peers Work/home conflicts

Lack of personal job fit; Elder and child care issues

inadequate preparation, Workplace violence

recognition, or clear job


Poor work control, fear Lawsuits related to job stress

and uncertainty related

to career progress

Age, gender, racial, Demands of accreditation/

religious discrimination compliance issues

Dealing with death Pressure for immediate results

and dying patients/


Salary Colleagues’ inexperience

Adapted from DeFrank, R., & Ivancevich, J. (1998). Stress on the job: An

executive update. Academy of Management Executives, 12(3), 55;

McVicar, A. (2003). Workplace stress in nursing: A literature review.

Journal of Advanced Nursing, 44(6), 633–642; and Hall, D. (2004).

Work-related stress of registered nurses in a hospital setting. Journal

for Nurses in Staff Development, 20(1), 6–14.

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chapter 13 | Work-Related Stress and Burnout 201

shocks of bad experiences, the affirmations of good

experiences, constructive evaluation, knowledge of

the unit routine, and priorities of school versus work

(Godinez, Schweiger, Gruver, & Ryan, 1999;

Heslop, 2001).

Well-supervised orientation programs are very

helpful for newly licensed nurses. In this era of the

nursing shortage, the orientation program may be

cut short and the new nurse required to function on

his or her own very quickly. One way to minimize

initial work stress is to ask questions about the ori-

entation program: How long will it be? Whom will

I be working with? When will I be on my own?

What happens if at the end of the orientation I still

need more assistance?

Differences in Expectations

The enthusiasm and eagerness of the first new job

quickly disappear as reality sets in. Regardless of

the career one chooses, there is no perfect job. The

problem begins when reality and expectations col-

lide. After 2 or 3 months, the new nurse begins to

experience a formal separation from being a stu-

dent and embraces the professional reality of the

nursing role. To cope with reality, several facts of

work life need to be recognized (Goliszek, 1992,

pp. 36, 46):

1. Expectations are usually distortions of reality.

Unless you accept this and react positively, you

will go through life experiencing disappoint-

ment. As a student, you had only two or three patients to care for, and you are very surprised to hear on your f irst full day of orientation that you have f ive patients. Although you did hear the nurses talking about their caseload while you were a stu- dent, you expected to continue to have two or three patients for at least the next 4 months.

2. To some extent, you need to fit yourself into

your work, not fit the work to suit your needs

or demands. Having a positive attitude helps to

maintain flexibility and a sense of humor. Your f irst position is at a physician’s off ice. The physi- cian is ready to retire, and his patient load is dwindling. You wanted to apply for a position in acute care, but you have a very active social life and did not want to work weekends. The current position is not very challenging, and you are con- cerned that you might be unemployed soon. You are starting to miss the acute care environment. Go back to your SWOT analysis. Evaluate your

current strengths, weaknesses, opportunities, and threats. Where do you see yourself in 1 year? 5 years? How will you f it yourself into your work to meet your goals?

3. The way you perceive events on the job will

influence how you feel about your work. Your

attitude will affect whether work is a pleasant or

unpleasant experience. Health care is not easy.

Sick people can be cranky and demanding. Health- care agencies continue to want to do more with less. How you perceive your contribution to the health- care system will def initely influence your reality.

4. Feelings of helplessness and powerlessness at

work cause frustration and unrelieved job

stress. If you go to work every day feeling that

you do not make a difference, it is time to

reevaluate your position and your goals.

What are these differences in expectations?

Kramer (1981), who studied reality shock for

many years, found a number of them, which are

listed in Table 13-3.

Ideally, health care should be comprehensive. It

should meet not only all of a patient’s needs but

also be delivered in a way that considers the patient

as a whole person, a member of a particular family

that has certain unique characteristics and needs,

and a member of a particular community. Most

health-care professionals, however, are not

employed to provide comprehensive, holistic care.

Instead, they are asked to give medications, provide

counseling, make home visits, or prepare someone

for surgery, but rarely to do all these things. These

tasks are divided among different people, each a

specialist, for the sake of efficiency rather than con-

tinuity or effectiveness.

table 13-3

Professional Ideals and Work Realities Professional Ideals Work Realities

Comprehensive, holistic Mechanistic, fragmented care


Emphasis on quality of Emphasis on efficiency


Explicit expectations Implicit (unstated) expectations

Balanced, frequent Intermittent, often negative

feedback feedback

Assignments that

“make sense”

Adapted from Kramer, M. (January 27–28, 1981). Coping with reality

shock. Workshop presented at Jackson Memorial Hospital, Miami, Fla.

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202 unit 3 | Professional Issues

When efficiency is the goal, the speed and

amount of work done are rewarded rather than the

quality of the work. This creates a conflict for the

new graduate, who while in school was allowed to

take as much time as needed to provide good care.

Expectations are also communicated in different

ways. In school, an effort is made to provide explicit

directions so that students know what they are

expected to accomplish. In many work settings, how-

ever, instructions on the job are brief, and many

expectations are left unspoken. New graduates who

are not aware of these expectations may find that they

have unknowingly left tasks undone or are considered

inept by coworkers. The following is an example:

Brenda, a new graduate, was assigned to give med- ications to all her team’s patients. Because this was a fairly light assignment, she spent some time looking up the medications and explaining their actions to the patients receiving them. Brenda also straightened up the medicine room and f illed out the order forms, which she thought would please the task-oriented team leader. At the end of the day, Brenda reported these activities with some satisfaction to the team leader. She expected the team leader to be pleased with the way she used the time. Instead, the team leader looked annoyed and told her that whoever passes out medications always does the blood pressures as well and that the other nurse on the team, who had a heavier assignment, had to do them. Also, because supplies were always ordered on Fridays for the weekend, it would have to be done again tomorrow, so Brenda had in fact wasted her time.

Additional Pressures on the New Graduate

The first job a person takes after finishing school is

often considered a proving ground where newly

gained knowledge and skills are tested. Many peo-

ple set up mental tests for themselves that they feel

must be passed before they can be confident of

their ability to function. Passing these self-tests also

confirms achievement of identity as a practitioner

rather than a student.

At the same time, new graduates are undergoing

testing by their coworkers, who are also interested

in finding out whether the new graduate can han-

dle the job. The new graduate is entering a new

group, and the group will decide whether to accept

this new member. The group is usually reasonable,

but sometimes new graduates are given tasks they

are not ready to handle. If this happens, Kramer

(1981) recommended that new graduates refuse to

take the test rather than fail it. Another opportuni-

ty for proving themselves will soon come along.

Additional problems, such as dealing with

resistant staff members, cultural differences, and

age differences, may also occur. Above all, the expe-

rience of loss is frequently described by new grad-

uates. Losses are described as the following

(Boychuk, 2001):

■ The ideal world of caring and curing they had

come to know through their education

■ Their innocence

■ The familiarity of academia

■ The protection of clinical supervision by nursing


■ Externally set boundaries of care and safety

■ A sense of collegiality and trusted relationships

with peers

■ Grounded feedback

Resolving the Problem

Before considering ways to resolve these problems,

some less successful ways of coping with these

problems are listed.

■ Abandon professional goals. When faced with reality shock, some new graduates abandon their

professional goals and adopt the organization’s

operative goals as their own. This eliminates

their conflict but leaves them less effective care-

givers. It also puts the needs of the organization

before their needs or the needs of the patient

and reinforces operative goals that might better

be challenged and changed.

■ Give up professional ideals. Others give up their professional ideals but do not adopt the

organization’s goals or any others to replace

them. This has a deadening effect; they become

automatons, believing in nothing related to their

work except doing what is necessary to earn a

day’s pay.

■ Leave the profession. Those who do not give up their professional ideals try to find an organi-

zation that will support them. Unfortunately, a

significant proportion of those who do not want

to give up their professional ideals escape these

conflicts by leaving their jobs and abandoning

their profession. Kramer and Schmalenberg

(1993) stated that there would be fewer short-

ages of nurses if more health-care organizations

met these ideals.

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chapter 13 | Work-Related Stress and Burnout 203

Instead of focusing on the bad stress, new nurses

can meet the transition to professional nursing by

adapting to good stress:

■ Develop a professional identity. Opportunities to challenge one’s competence and develop an

identity as a professional can begin in school.

Success in meeting these challenges can immu-

nize the new graduate against the loss of confi-

dence that accompanies reality shock.

■ Learn about the organization. The new gradu- ate who understands how organizations operate

will not be as shocked as the naïve individual.

When you begin a new job, it is important to

learn as much as you can about the organization

and how it really operates. This not only saves

you some surprises but also gives you some ideas

about how to work within the system and how

to make the system work for you.

■ Use your energy wisely. Keep in mind that much energy goes into learning a new job. You

may see many things that you think need to be

changed, but you need to recognize that to

implement change requires your time and energy.

It is a good idea to make a list of these things so

that you do not forget them later when you have

become socialized into the system and have

some time and energy to invest in change.

■ Communicate effectively. Deal with the prob- lems that can arise with coworkers. The same

interpersonal skills you use in communicating

with patients can be effective in dealing with

your coworkers.

■ Seek feedback often and persistently. Seeking feedback not only provides you with needed

information but also pushes the people you work

with to be more specific about their expectations

of you.

■ Develop a support network. Identify colleagues who have held onto their professional ideals

with whom you can share your problems and the

work of improving the organization. Their

recognition of your work can keep you going

when rewards from the organization are meager.

A support network is a source of strength when

resisting pressure to give up professional ideals

and a source of power when attempting to bring

about change. Developing your skills can help to

prevent the problems of reality shock.

■ Find a mentor. A mentor is someone more experienced within or outside the organization

who provides career development support, such

as coaching, sponsoring advancement, providing

challenging assignments, protecting protégés

from adversity, and promoting positive visibility.

Mentors provide guidance to new graduates

as they change from student to professional

nurse. Mentors can also assume psychosocial

functions, such as personal support, friendship,

acceptance, role modeling, and counseling. Many

organizations have preceptors for the new

employee. In many instances, the preceptor will

become your mentor. However, the mentor role

is much more encompassing than the preceptor

role. The mentor relationship is a voluntary

one and is built on mutual respect and

development of the mentee. Table 13-4 identi-

fies responsibilities of the mentor and mentee

in this relationship (Scheetz, 2000; Simonetti &

Ariss, 1999).

You have made it through the first 6 months of

employment, and you are finally starting to feel like

a “real” nurse. You are beginning to realize that a

stress-free work environment is probably impossi-

ble to achieve. Shift work, overtime, distraught

families, staff shortages, and pressure to do more

with less continue to contribute to the stresses

placed on nurses. An inability to deal with this con-

tinued stress will eventually lead to burnout.

table 13-4

Mentor and Mentee Responsibilities Mentor Responsibilities Mentee Responsibilities

Has excellent Demonstrates eagerness to

communication and learn

listening skills

Shows sensitivity to needs Participates actively in the

of nurses, patients, relationship by keeping

and workplace all appointments and


Able to encourage Seeks feedback and uses it

excellence in others to modify behaviors

Able to share and provide Demonstrates flexibility and

counsel an ability to change

Exhibits good Is open in the relationship

decision-making skills with mentor

Shows an understanding Demonstrates an ability to

of power and politics move toward


Demonstrates Able to evaluate choices

trustworthiness and outcomes

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204 unit 3 | Professional Issues



The ultimate result of unmediated job stress is

burnout. The term burnout became a favorite buzz- word of the 1980s and continues to be part of

today’s vocabulary. Herbert Freudenberger formal-

ly identified it as a leadership concern in 1974. The

literature on job stress and burnout continues to

grow as new books, articles, workshops, and videos

appear regularly. A useful definition of burnout is

the “progressive deterioration in work and other

performance resulting from increasing difficulties

in coping with high and continuing levels of job-

related stress and professional frustration” (Paine,

1984, p. 1).

More than 20 years of research on nursing work

environments point to personal, job, and organiza-

tional factors that contribute to dissatisfaction and

ultimately burnout (McLennan, 2005). Ultimately,

nurse burnout affects patients’ satisfaction with

their nursing care. A survey of 820 nurses and

621 patients in 20 hospitals across the United

States (Vahey et al., 2004) showed that units char-

acterized by nurses as having adequate staff, good

administrative support for nursing care, and good

relations between physicians and nurses were twice

as likely as other units to report high satisfaction

with nursing care. The level of nurse burnout on

these units also affected patient satisfaction.

Much of the burnout experienced by nurses has

been attributed to the frustration that arises because

care cannot be delivered in the ideal manner nurses

learned in school. For those whose greatest satisfac-

tion comes from caring for patients, anything that

interferes with providing the highest quality care

causes work stress and feelings of failure.

People who expect to derive a sense of signifi-

cance from their work enter their professions with

high hopes and motivation and relate to their

work as a calling. When they feel that they have

failed, that their work is meaningless, that they

make no difference in the world, they start feeling

helpless and hopeless and eventually burn out

(Pines, 2004, p. 67).

The often unrealistic and sometimes sexist

image of nurses in the media adds to this frustra-

tion. Neither the school ideal nor the media image

is realistic, but either may make nurses feel dissat-

isfied with themselves and their jobs, keeping stress

levels high (Corley et al., 1994; Fielding & Weaver,

1994; Grant, 1993; Hendrickson, Knickman, &

Finkler, 1994; Kovner-Malkin, 1993; Nakata &

Saylor, 1994; Pines, 2004; Skubak, Earls, & Botos,


Sharon had wanted to be a nurse for as long as she could remember. She married early, had three chil- dren, and put her dreams of being a nurse on hold. Now her children are grown, and she f inally real- ized her dream by graduating last year from the local community college with a nursing degree. However, she has been overwhelmed at work, criti- cal of coworkers and patients, and argumentative with supervisors. She is having diff iculty adapting to the restructuring changes at her hospital and goes home angry and frustrated every day. She cannot stop working for f inancial reasons but is seriously thinking of quitting nursing and taking some computer classes. “I’m tired of dealing with people. Maybe machines will be more f riendly and predictable.” Sharon is experiencing burnout.


Goliszek (1992) identified four stages of the

burnout syndrome:

1. High expectations and idealism. At the first stage, the individual is enthusiastic, dedicated,

and committed to the job and exhibits a high

energy level and a positive attitude.

2. Pessimism and early job dissatisfaction. In the second stage, frustration, disillusionment, or

boredom with the job develops, and the indi-

vidual begins to exhibit the physical and psy-

chological symptoms of stress.

3. Withdrawal and isolation. As the individual moves into the third stage, anger, hostility, and

negativism are exhibited. The physical and psy-

chological stress symptoms worsen. Through

stage three, simple changes in job goals, attitudes,

and behaviors may reverse the burnout process.

4. Irreversible detachment and loss of interest. As the physical and emotional stress symptoms

become severe, the individual exhibits low self-

esteem, chronic absenteeism, cynicism, and

total negativism. Once the individual has

moved into this stage and remains there for any

length of time, burnout is inevitable.

Regardless of the cause, experiencing burnout

leaves an individual emotionally and physically


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chapter 13 | Work-Related Stress and Burnout 205

Stressors Leading to Burnout

Personal Factors

Some of the personal factors influencing job stress

and burnout are age, gender, number of children,

education, experience, and favored coping style. For

example, the fact that many nurses are single par-

ents raising families alone adds to the demands of

already difficult days at work. Married nurses may

have the additional stress of dual-career homes,

causing even more stress in coordinating work and

vacation schedules as well as day-care problems.

Baby boomers are finding they need to care for el-

derly parents along with their children (DeFrank &

Ivancevich, 1998). Competitive, impatient, and

hostile personality traits have also been associated

with emotional exhaustion and subsequent burnout

(Borman, 1993). Most experienced nurses state

that they separate their home from work when

dealing with work-related stressors and that they

try but usually fail to leave their work-related stres-

sors in the workplace (Hall, 2004).

Job-Related Conditions

Job-related stress is broadly defined by the

National Institute for Occupational Safety and

Health as the “harmful physical and emotional

responses that occur when the requirements of the

job do not match the capabilities, resources, or

needs of the worker” (http://www.cdc.gov/niosh/

homepage.html). Since the prior edition of this

text, the threat of terrorism has been added to the

list of job-related conditions that contribute to job-

related stress. Box 13-1 lists some of these condi-

tions, which were discussed in Chapter 12.

Human Service Occupations

People who work in human service organizations

consistently report lower levels of job satisfaction

than do people working in other types of organiza-

tions. Much of the stress experienced by nurses is

related to the nature of their work: continued

intensive, intimate contact with people who often

have serious and sometimes fatal physical, mental,

emotional, and/or social problems. Efforts to save

patients or help them achieve a peaceful ending to

their lives are not always successful. Despite nurses’

best efforts, many patients get worse, not better.

Some return to their destructive behaviors; others

do not recover and die. The continued loss of

patients alone can lead to burnout. Even exposure

to medicinal and antiseptic substances, unpleasant

sights, and high noise levels can cause stress for

some people. Health-care providers experiencing

burnout may become cynical and even hostile

toward their coworkers and colleagues (Carr &

Kazanowski, 1994; Dionne-Proulx & Pepin, 1993;

Goodell & Van Ess Coeling, 1994; Stechmiller &

Yarandi, 1993; Tumulty, Jernigan, & Kohut, 1994).

In some instances, human service professionals

also experience lower pay, longer hours, and more

extensive regulation than do professionals in other

fields. Inadequate advancement opportunities for

women and minorities in lower-status, lower-paid

positions are apparent in many health-care areas.

Conflicting Demands

Meeting work-related responsibilities and main-

taining a family and personal life can increase stress

when there is insufficient time or energy for all of

these. As mentioned in the section on personal fac-

tors, both the single and the married parent are at

risk because of the conflicting demands of their

personal and work lives. The perception of balance

in one’s life is a personal one.

There appear to be some differences in the way

that men and women find a comfortable balance.

box 13-1

Five Sources of Job Stress That Can Lead to Burnout

1. Intrinsic factors. Characteristics of the job itself, such as

the multiple aspects of complex patient care that many

nurses provide; lack of autonomy

2. Organizational variables. Characteristics of the

organization, such as limited financial resources, staffing,

workload, models of care delivery

3. Reward system. The way in which employees are

rewarded or punished, particularly if these are obviously


4. Human resources system. In particular, the number

and availability of opportunities for staff development,

salary and benefits, organizational policies

5. Leadership. The way in which managers relate to their

staff, particularly if they are unrealistic, uncaring, or

unfair; communication patterns with supervisors and


Adapted from Carr, K., & Kazanowski, M. (1994). Factors affecting job satisfac-

tion of nurses who work in long-term care. Journal of Advanced Nursing, 19,

878–883; Crawford, S. (1993). Job stress and occupational health nursing.

American Association of Occupational Health Nurses Journal, 41, 522–529;

Duquette, A., Sandhu, B., & Beaudet, L. (1994). Factors related to nursing

burnout: A review of empirical knowledge. Issues in Mental Health Nursing,

15, 337–358; and Best, M., & Thurston, N. (2004). Measuring nurse job

satisfaction, Journal of Nursing Administration, 34(6), 283–290.

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206 unit 3 | Professional Issues

Men often define themselves in terms of their sep-

arateness and their career progress; women are more

likely to define themselves through attachment and

connections with other people. Women who try to

focus on occupational achievement and pursue per-

sonal attachments at the same time are likely to

experience conflict in both their work and personal

lives. In addition, society evaluates the behaviors of

working adult men and women differently. “When

a man disrupts work for his family, he is considered

a good family man, while a woman disrupting work

for family risks having her professional commit-

ment questioned” (Borman, 1993, p. 1).

Closely tied to conflicting demands is the deci-

sion to come to work when ill. Nurses who come to

work when ill describe tension associated with

making this decision: tension between the nurse

and the supervisor, tension between the nurse and

the team members, and tension within the nurse

due to responsibilities to self and others. As you

move forward in your career, be proactive in work-

ing with team members and your supervisors in

helping yourself and others find balance in the

workplace (Crout, Change, & Cioffi, 2005).


Decisions related to changes in technology are

often made without input from employees. These

same employees are then required to adapt and

cope with the changes. How many of the following

changes have you had to adapt to: e-mail, voice

mail, fax machines, computerized charting, desktop

computers, cellular phones? Often, employees feel

that their role has become secondary to technology

(DeFrank & Ivancevich, 1998).

Lack of Balance in Life

When personal interests and satisfactions are lim-

ited to work, a person is more susceptible to

burnout; trouble at work becomes trouble with that

individual’s whole life. A job can become the center

of someone’s world, and that world can become

very small. Two ways out of this are to set limits on

the commitment to work and to expand the num-

ber of satisfying activities and relationships outside

of work.

Many people in the helping professions have dif-

ficulty setting limits on their commitment. This is

fine if they enjoy working extra hours and taking

calls at night and on weekends, but if it exhausts

them, then they need to stop doing it or risk serious

burnout. For example, when you are asked to work

another double shift or the third weekend in a row,

you can say no. At the same time as you are setting

limits at work, you can expand your outside activi-

ties so that you live in a large world in which a blow

to one part can be cushioned by support from other

parts. If you are the team leader or nurse manager,

you also need to recognize and accept staff mem-

bers’ need to do this as well. Ask yourself the follow-

ing questions:

■ Do I exercise at least three times weekly?

■ Do I have several close friends I see regularly?

■ Do I have a plan for my life and career that I

have told someone about?

■ Do I have strong spiritual values that I carry out

in practice regularly?

■ Do I have some strong personal interests that I

regularly enjoy?

Studies have shown that the two best indicators of

customer satisfaction are related to employee satis-

faction and employee work-life balance. Well-

rounded employees have a different perspective on

life and are perceived by employers as more trust-

worthy and more grounded in reality. You do not

have to give up your personal life to excel in your

professional life (Farren, 1999).


Certain combinations of personal and organizational

factors can increase the likelihood of burnout.

Finding the right fit between your preferences and

the characteristics of the organization for which you

work can be keys to preventing burnout. Health

care demands adaptable, innovative, competent

employees who care about their patients, desire to

continue learning, and try to remain productive

despite constant challenges. Unfortunately, these are

the same individuals who are prone to burnout if

preventive action is not taken (Lickman, Simms, &

Greene, 1993; McGee-Cooper, 1993).

Burnout has financial, physical, emotional, and

social implications for the professional, the patients,

and the organization. Burnout can happen to any-

one, not just to people with a history of emotional

problems. In fact, it is not considered an emotional

disturbance in the sense that depression is; instead,

it is considered a reaction to sustained organization-

al stressors (Duquette, Sandhu, & Beaudet, 1994).

The shortage of professional nurses is predicted

to continue for at least another 10 years. Two of the

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chapter 13 | Work-Related Stress and Burnout 207

main causes of the shortage are individuals not

entering the profession and nurses leaving. As dis-

cussed, one reason for leaving is burnout. A recent

study of 106 nurses demonstrated that the three

dimensions of burnout (emotional exhaustion,

depersonalization, and personal accomplishment)

were correlated with work excitement. Work

excitement is defined as “personal enthusiasm

and commitment for work evidenced by creativi-

ty, receptivity to learning, and ability to see

opportunity in everyday situations (Sadovich,

2005, p. 91). Work excitement factors include:

work arrangements, variable work experiences,

the work environment, and growth and develop-

ment opportunities. As you pursue your nursing

career, consider looking for positions that support

a favorable work environment.

A Buffer Against Burnout

The idea that personal hardiness provides a buffer

against burnout has been explored in recent years.

Hardiness includes the following:

■ A sense of personal control rather than power-


■ Commitment to work and life’s activities rather

than alienation

■ Seeing life’s demands and changes as challenges

rather than as threats

The hardiness that comes from having this perspec-

tive leads to the use of adaptive coping responses,

such as optimism, effective use of support systems,

and healthy lifestyle habits (Duquette, Sandhu, &

Beaudet, 1994; Nowak & Pentkowski, 1994). In

addition, letting go of guilt, fear of change, and

the self-blaming, “wallowing-in-the-problem” syn-

drome will help you buffer yourself against burnout

(Lenson, 2001).

Ask yourself, “What can I possibly do as a new

graduate? I don’t even have a job yet, let alone

understand the politics of health-care organiza-

tions.” It is never too early to understand yourself—

what triggers stressful situations for you, how you

respond to stress, and how you manage it.

Stress Management

Although you cannot always control the demands

placed on you, you can learn to manage your reac-

tions to them and to make healthy lifestyle choices

that better prepare you to meet those demands.

ABCs of Stress Management

Frances Johnston (1994) suggested using the

ABCs of stress management (awareness, belief, and

commitment) in order to have as constructive a

response to stress as possible (Box 13-2).


How do you know that you are under stress and

may be beginning to burn out? The key is being

honest with yourself. Asking yourself the questions

in Box 13-3 and answering them honestly is one

way to assess your personal risk. To analyze your

responses to stress further, you may also want to

answer the questions in Box 13-4. The answers to

these questions require some thought. You do not

have to share your answers with others unless you

want to, but you do need to be completely honest

with yourself when you answer them or the exercise

will not be worth the time spent on it. Try to deter-

mine the sources of your stress (Goliszek, 1992):

■ Is it the time of day you do the activity? ■ Is it the reason you do the activity? ■ Is it the way you do the activity? ■ Is it the amount of time you need to do the activity?

Another suggestion is to keep a stress diary. People

often have “flash points” that send stress levels sky-

rocketing. Keeping a stress diary often helps in

identifying these triggers. Identify the date, time,

situation, scale (on a scale from 1 to 10), symptoms,

reaction, and efficiency (on a scale from 1 to 10,

how well did you cope with this stressor?). What

was your reaction? Did you solve the problem, qui-

etly seethe, or become reactionary? After 2 weeks,

analyze the diary, and reflect on where and when

your highest stress levels occured. Keep your stress

diary for as long as you think necessary in order to

identify personal stress triggers and patterns of

behavior (Bruce, 2007).

box 13-2

ABCs of Stress Management Become Aware of your own responses to stress and the

consequences of too much stress.

Believe that you can change your perspective and your


Commit yourself to take action to prevent conflicts that

cause stress, to learn techniques that help you cope in

situations over which you have no control, and to understand

that you can choose how to react in stressful situations.

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208 unit 3 | Professional Issues


Now that you have done the A part of stress man- agement, you are ready to move on to B, which is belief in yourself. Your relationship with your

inner self may be the most important relationship

of all. Building your self-image and self-esteem

will enable you to block out negativism

(Davidhizar, 1994). You must also believe that

your destiny is not inevitable but that change is

possible. Be honest with yourself. Truly value

your life. Ask yourself, “If I could live 1 more

month, what would I do?”—and start doing it

( Johnston, 1994).


As you move forward to C, you will need to make a commitment to continuing to work on stress recog-

nition and reduction. Once you have recognized the

warning signs of stress and impending burnout and

have gained some insight into your personal needs

and reactions to stress, it is time to find the stress

management techniques that are right for you.

The stress management techniques in the next

section are divided into physical and mental health

management for ease in reading and remembering

them. However, bear in mind that this is really an

artificial division and that mind and body interact

continuously. Stress affects both mind and body, and

you need to care for both if you are going to be suc-

cessful in managing stress and preventing burnout.

Physical Health Management

Nurses spend much of their time teaching their

patients the basics of keeping themselves healthy.

However, many fail to apply these principles in their

own lives. Some of the most important aspects of

health promotion and stress reduction are reviewed

in this section: deep breathing, good posture, rest,

relaxation, proper nutrition, and exercise (Davidhizar,

1994; Posen, 2000; Wolinski, 1993).

Deep Breathing

Most of the time, people use only 45% of their lung

capacity when they breathe. Remember all the

times you instructed your patients to “take a few

Adapted from Golin, M., Buchlin, M., & Diamond, D. (1991). Secrets of

Executive Success. Emmaus, Pa.: Rodale Press; and Goliszek, A. (1992).

Sixty-Six Second Stress Management: The Quickest Way to Relax and Ease

Anxiety. Far Hills, N.J.: New Horizon.

box 13-3

Assessing Your Risk for Burnout Do you feel more fatigued than energetic?

Do you work harder but accomplish less?

Do you feel cynical or disenchanted most of the time?

Do you often feel sad or cry for no apparent reason?

Do you feel hostile, negative, or angry at work?

Are you short-tempered? Do you withdraw from friends or


Do you forget appointments or deadlines? Do you

frequently misplace personal items?

Are you becoming insensitive, irritable, and short-tempered?

Do you experience physical symptoms such as headaches

or stomachaches?

Do you feel like avoiding people?

Do you laugh less? Feel joy less often?

Are you interested in sex?

Do you crave junk food more often?

Do you skip meals?

Have your sleep patterns changed?

Do you take more medication than usual? Do you use alco-

hol or other substances to alter your mood?

Do you feel guilty when your work is not perfect?

Are you questioning whether the job is right for you?

Do you feel as though no one cares what kind of work you


Do you constantly push yourself to do better, yet feel frus-

trated that there is no time to do what you want to do?

Do you feel as if you are on a treadmill all day?

Do you use holidays, weekends, or vacation time to catch


Do you feel as if you are “burning the candle at both ends”?

box 13-4

Questions for Self-Assessment What does the term health mean to me?

What prevents me from living this definition of health?

Is health important to me?

Where do I find support?

Which coping methods work best for me?

What tasks cause me to feel pressured?

Can I reorganize, reduce, or eliminate these tasks?

Can I delegate or rearrange any of my family responsibilities?

Can I say no to less important demands?

What are my hopes for the future in terms of (1) career

(2) finances (3) spiritual life and physical needs (4) family

relationships (5) social relationships?

What do I think others expect of me?

How do I feel about these expectations?

What is really important to me?

Can I prioritize in order to have balance in my life?

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chapter 13 | Work-Related Stress and Burnout 209

deep breaths”? Practice taking a few slow, deep,

“belly” breaths. When faced with a stressful situa-

tion, people often hold their breath for a few sec-

onds. This reduces the amount of oxygen delivered

to the brain and causes them to feel more anxious.

Anxiety can lead to faulty reasoning and a feeling

of losing control. Often you can calm yourself by

taking a few deep breaths. Try it right now. Don’t

you feel better already?

Good Posture

A common response to pressure is to slump down

into your chair, tensing your upper torso and abdom-

inal muscles. Again, this restricts blood flow and the

amount of oxygen reaching your brain. Instead of

slumping, imagine a hook on top of your head

pulling up your spine; relax your abdomen, and look

up. Now, shrug your shoulders a few times to loosen

the muscles, and picture a sunny day at the beach or

a walk in the woods. Do you feel more relaxed?


Sleep needs vary with the individual. Find out how

much sleep you need, and work on arranging your

activities so that you get enough sleep. Fatigue in

the human body is no different than fatigue in

anything else. Starting out small, a fatigue fracture

may remain unnoticed until a catastrophic failure

occurs. Several studies indicate the consequences

of fatigue:

■ Subjects who had gone 17–19 hours without

sleep ranked on testing as equal or worse than

someone with a blood alcohol level of 0.05%.

■ 24% of 2259 adults surveyed cited fatigue as the

primary reason for a recent visit to a physician.

■ 16%–60% of all traffic accidents are related to


Fatigue is a multidimensional symptom. Origins of

fatigue may be biological, psychological, and/or

behavioral in nature. What can you do to ward off

workplace fatigue?

1. Spot the pattern. Be aware of a weakened state

or decrease in strength, an interruption in the

ability to perform activities of daily living, or an

overabundance in conditions or behaviors that

contribute to fatigue such as physical or mental

stress, sleep loss, or drug use.

2. Identify precursors. Are you pushing yourself

continuously beyond the healthy limits of your

physical and/or mental capabilities? You are

bound to encounter fatigue.

3. Recognize the signs. Emotional outbursts,

clumsiness, loss of sensory motor control,

weariness, and exhaustion may indicate fatigue.

4. Discern the results. Physical and mental disor-

ders, physical injuries, collapse, and even death

may be the catastrophic consequences of

fatigue. Be aware of the symptoms of fatigue in

yourself and others. Plan how to care for your-

self. Be supportive of your coworkers to safe-

guard against fatigue in others (Smith, 2004).

Relaxation and Time Out

Many people have found that relaxation with

guided imagery or other forms of meditation

decreases the physiological and psychological

impact of chronic stress. Guided imagery has been

used in competitions for many years, in golf, ice

skating, baseball, and other sports. Research stud-

ies have shown that creation of a mental image of

the desired results enhances one’s ability to reach

the goal. Positive behavior or goal attainment is

enhanced even more if you imagine the details of

the process of achieving your desired outcome

(Vines, 1994). Box 13-5 lists useful relaxation


Imagine taking the National Council License Examination. You sit down at the computer, take a few deep breaths, and begin. Visualize yourself reading the questions, smiling as you identify the correct answer, and hitting the Enter key after recording your answer. You complete the examina- tion, feeling conf ident that you were successful. A week later, you go to your mailbox and f ind a letter waiting for you: “Congratulations, you have passed the test and are now a licensed registered nurse.” You imagine telling your family and friends. What an exciting moment!

box 13-5

Useful Relaxation Techniques Guided imagery


Transcendental meditation

Relaxation tapes or music

Favorite sports or hobbies

Quiet corners or favorite places

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Taking breaks and time out during the day for a

short walk or a refreshment (not caffeine) break or

just to daydream can help de-stress you. Just as

people have circadian rhythms during the night,

circadian rhythms function during the day. These

cycles are peaks of energy, with troughs of low

energy. Watching for these low-energy cycles and

taking breaks at that time will help keep stress from

building up.

Proper Nutrition

New research results endorsing the benefits of

healthful eating habits seem to appear almost daily.

Although the various authorities may prescribe

somewhat different regimens, ultimately it appears

that too little or too much of any nutrient can be

harmful. Many people do not realize that simply

decreasing or discontinuing caffeine can help

decrease a stress reaction in the body. Some gener-

al guidelines for good nutrition are in Box 13-6.


Regular aerobic exercise for 20 minutes three times

a week is recommended for most people. The exer-

cise may be walking, swimming, jogging, bicycling,

stair-stepping, or low-impact aerobics. Whichever

you choose, work at a pace that is comfortable for

you and increase it gradually as you become condi-

tioned. Do not overdo it. The experience should

leave you feeling invigorated, not exhausted.

The physiological benefits of exercise are well

known. Exercise may not eliminate the stressors in

life, but it is an important element in a healthy

lifestyle. Exercise has been shown to improve

people’s mood and to induce a state of relaxation

through the reduction of physiological tension.

Regular exercise decreases the energy from the

fight-or-flight response discussed at the beginning

of this chapter.

Exercise can also be a useful distraction, allow-

ing time to regroup before entering a stressful situ-

ation again (Long & Flood, 1993). It is important

to choose an exercise that you enjoy doing and that

fits into your lifestyle. Perhaps you could walk to

work every day or pedal an exercise bicycle during

your favorite television program. It is not necessary

to join an expensive club or to buy elaborate equip-

ment or clothing to begin an exercise program. It is

necessary to get up and get moving, however.

Some people recommend an organized exercise

program to obtain the most benefit. For some,

however, the cost or time required may actually

contribute to their stress. For others, the organized

program is an excellent motivator. Find out what

works for you.

Keep your exercise plan reasonable. Plan for the

long term, not just until you get past your next per-

formance evaluation or lose that extra five pounds.

Mental Health Management

Mental health management begins with taking responsibility for your own thoughts and attitudes. Do not allow self-defeating thoughts to dominate

your thinking. You may have to remind yourself to

stop thinking that you have to be perfect all the

time. You may also have to adjust your expecta-

tions and become more realistic. Do you always

have to be in control? Does everything have to be

perfect? Do you have a difficult time delegating?

Are you constantly frustrated because of the way

you perceive situations? If you answer yes to many

of these questions, you may be setting yourself up

for failure, resentment, low self-esteem, and

burnout. Give yourself positive strokes, even if no

one else does (Davidhizar, 1994; Posen, 2000;

Wolinski, 1993).

Realistic Expectations

One of the most common stressors in life is having

unrealistic expectations. Expecting family mem-

bers, coworkers, and your employer to be perfect

and meet your every demand on your time sched-

ule is setting yourself up for undue stress.

box 13-6

Guidelines for Good Nutrition Eat smaller, more frequent, meals for energy. Six small

meals are more beneficial than three large ones.

Eat foods that are high in complex carbohydrates, contain

adequate protein, and are low in fat content. Beware of fad


Eat at least five servings of fruits and vegetables daily.

Avoid highly processed foods.

Avoid caffeine.

Use salt and sugar sparingly.

Drink plenty of water.

Make sure you take enough vitamins, including C, B, E, beta

carotene, and calcium; and minerals, including copper,

manganese, zinc, magnesium, and potassium.

Adapted from Bowers, R. (1993). Stress and your health. National Women’s

Health Report, 15(3), 6.

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chapter 13 | Work-Related Stress and Burnout 211


Reframing is looking at a situation in many differ-

ent ways. When you can reframe stressful situa-

tions, they often become less stressful or at least

more understandable. If you have an extremely

heavy workday and believe it is due to the fact that

your nurse manager created it for personal reasons,

the day becomes much more stressful than if

you realize that, unfortunately, all institutions are



Laughter relieves tension. Humor is a good way to

reduce stress both for yourself and your patients.

Remember, however, that humor is very individual,

and what may be funny to you may be hurtful to

your patient or coworker.

Social Support

Much research has been done to show that the

presence of social support and the quality of rela-

tionships can significantly influence how quickly

people become ill and how quickly they recover. A

sense of belonging and community, an environment

where people believe they can share their feelings

without fear of condemnation or ridicule, helps to

maintain a sense of well-being. Having friends

with whom to share hopes, dreams, fears, and con-

cerns and with whom to laugh and cry is para-

mount to mental health and stress management. In

the work environment, coworkers who are trusted

and respected become part of social support sys-

tems (Wolinski, 1993). Box 13-7 lists some addi-

tional tips for coping with work stress.

Nurses are professional caregivers. Many years

ago, Carl Rogers (1977) said that you cannot care

for others until you have taken care of yourself. The

word self ish may bring to mind someone who is greedy, self-centered, and egotistical; however, to

take care of yourself you have to become creatively self ish. Learn to nurture yourself so that you will be better able to nurture others.

Stress reduction, relaxation techniques, exercise,

and good nutrition are all helpful in keeping ener-

gy levels high. Although they can prepare people to

cope with the stresses of a job, they are not solu-

tions to the conflicts that lead to reality shock and

burnout. It is more effective to resolve the problem

than to treat the symptoms (Lee & Ashforth,

1993). Box 13-8 lists the keys already discussed to

physical and mental health management.

Organizational Approaches to Job Stress

The nursing shortage phenomenon has cause many

organizations to address issues of stress on the

job as a method of recruitment and retention.

Organizational change and stress management are

useful approaches for preventing stress at work.

The National Institute for Occupational Safety and

Health has identified factors that lead to a healthy,

low-stress workplace ( Judkins, Reid, & Furlow,

2006; Sauter et al., 1999):

■ Employee recognition for performance

■ Opportunities for career development

■ An organizational culture that values the


■ Management decisions that are aligned with

organizational values

box 13-7

Coping With Daily Work Stress Spend time on outside interests, and take time for yourself.

Increase professional knowledge.

Identify problem-solving resources.

Identify realistic expectations for your position. Make sure

you understand what is expected of you; ask questions if

anything is unclear.

Assess the rewards your work can realistically deliver.

Develop good communication skills, and treat coworkers

with respect.

Join rap sessions with coworkers. Be part of the solution,

not part of the problem.

Do not exceed your limits—you do not always have to say


Deal with other people’s anger by asking yourself, “Whose

problem is this?”

Recognize that you can teach other people how to treat you.

box 13-8

Keys to Physical and Mental Health Management

Deep breathing






Realistic expectations



Social support

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212 unit 3 | Professional Issues

■ Collaborative practice and shared governance


In 2002, Dr. Linda Aiken and her colleagues iden-

tified a relationship between staffing, mortality,

nurse burnout, and job dissatisfaction (Aiken et al.,

2002). With each additional patient assigned to a

nurse, the following occurred:

■ A 30-day mortality increase of 7%

■ Failure-to-rescue rate increase of 7%

■ Nursing job dissatisfaction increase of 15%

■ Burnout rate increase of 23%

■ 43% of nurses surveyed were suffering from



You already know that the work of nursing is not

easy and may sometimes be very stressful. Yet nurs-

ing is also a profession filled with a great deal of

personal and professional satisfaction. Periodically

ask yourself the questions designed to help you

assess your stress level and risk for burnout, and

review the stress management techniques described

in this chapter.

There is no one right way to manage stress and

avoid burnout. Rather, by managing small segments

of each day, you will learn to identify and manage

your stress. This chapter contains many reminders

to help you de-stress during the day (Box 13-9). You

can also help your colleagues do the same. If you

find yourself in danger of job burnout during your

career, you will have learned how to bring yourself

back to a healthy, balanced position.

Ultimately, you are in control. Every day you are

faced with choices. By gaining power over your

choices and the stress they cause, you empower

yourself. Instead of being preoccupied with the past

or the future, acknowledge the present moment,

and say to yourself (Davidson, 1999):

■ I choose to relish my days.

■ I choose to enjoy this moment.

■ I choose to be fully present to others.

■ I choose to fully engage in the activity at hand.

■ I choose to proceed at a measured, effective


■ I choose to acknowledge all I have achieved

so far.

■ I choose to focus on where I am and what I am


■ I choose to acknowledge that this is the only

moment in which I can take action.

People cannot live in a problem-free world, but they

can learn how to handle stress. Using the suggestions

in this chapter, you will be able to adopt a healthier

personal and professional lifestyle. The self-

assessment worksheet on DavisPlus, entitled

“Coping with Stress,” can help you manage stress and

help you understand your responses better.The work-

sheet on DavisPlus, entitled “Values Clarification,” will

help you identify how to begin to change taking into

account what is most important to you.

Adapted from Bowers, R. (1993). Stress and your health. National Women’s

Health Report, 15(3), 6.

box 13-9

Ten Daily De-Stress Reminders Express yourself! Communicate your feelings and emotions

to friends and colleagues to avoid isolation and share

perspectives. Sometimes, another opinion helps you see

the situation in a different light.

Take time off. Taking breaks, or doing something unrelated

to work, will help you feel refreshed as you begin work


Understand your individual energy patterns. Are you a

morning or an afternoon person? Schedule stressful duties

during times when you are most energetic.

Do one stressful activity at a time. Although this may take

advanced planning, avoiding more than one stressful situa-

tion at a time will make you feel more in control and satis-

fied with your accomplishments.

Exercise! Physical exercise builds physical and emotional

resilience. Do not put physical activities “on the back

burner” as you become busy.

Tackle big projects one piece at a time. Having control of

one part of a project at a time will help you to avoid feeling

overwhelmed and out of control.

Delegate if possible. If you can delegate and share in

problem solving, do so. Not only will your load be lighter,

but others will be able to participate in decision making.

It’s okay to say no. Do not take on every extra assignment

or special project.

Be work-smart. Improve your work skills with new

technologies and ideas. Take advantage of additional

job training.

Relax. Find time each day to consciously relax and reflect

on the positive energies you need to cope with stressful

situations more readily.

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chapter 13 | Work-Related Stress and Burnout 213

Evidence-Based Practice Faragher, E., Cass, M., & Cooper, C. (2003). The relationship between job satisfaction and health: A meta-analysis. Journal of

Occupational and Environmental Medicine, 62, 105–112.

This systematic review and meta-analysis, completed in 2003, consisted of 500 studies of job satisfaction with 267,995

employees in a large variety of organizations, It demonstrated a strong correlation between job satisfaction and mental and

physical health. Aspects of mental health, i.e., burnout, lowered self-esteem, anxiety, and depression, were identified.

Cardiovascular disease was the main physical illness showing a correlation between job satisfaction and physical health.

These relationships demonstrated that job satisfaction level is an important factor influencing health of workers.

Additional studies can be found in:

Ekstedt, M. (2005). Lived experiences of the time preceding burnout. Journal of Advanced Nursing, 49(1), 59–67.

Ruggeriero, J. (2005). Health, work variables, and job satisfaction among nurses. Journal of Nursing Administration, 35(5),


Study Questions

1. Discuss the characteristics of health-care organizations that may lead to burnout among nurses.

Which of these have you observed in your clinical rotations? How could they be changed or


2. How can a new graduate adequately prepare for reality shock? Based on your responses to the

questions in Boxes 13-3 and 13-4, what plans will you make to prepare yourself for your new role?

3. What qualities would you look for in a mentor? What qualities would you demonstrate as a

mentee? Can you identify someone you know who might become a mentor to you?

4. How are the signs of stress, reality shock, and burnout related?

5. How can you help colleagues deal with their stress? What if a colleague does not recognize that

he/she is under stress? What might you do to guide your colleague?

6. Identify the physical and psychological signs and symptoms you exhibit during stress. What sources

of stress are most likely to affect you? How do you deal with these signs and symptoms?

7. Develop a plan to manage stress on a long-term basis.

Case Study to Promote Critical Reasoning

Shawna, a new staff member, has been working from 7 a.m. to 3 p.m. on an infectious disease floor

since obtaining her RN license 4 months ago. Most of the staff members with whom she works

with have been there since the unit opened 5 years ago. On a typical day, the staffing consists of a

nurse manager, two RNs, an LPN, and one technician for approximately 40 patients. Most patients

are HIV-positive with multisystem failure. Many are severely debilitated and need help with their

activities of daily living. Although the staff members encourage family members and loved ones to

help, most of them are unavailable because they work during the day. Several days a week, the

nursing students from Shawna’s community college program are assigned to the floor.

Tina, the nurse manager, does not participate in any direct patient care, saying that she is “too busy

at the desk.” Laverne, the other RN, says the unit depresses her and that she has requested a transfer

to pediatrics. Lynn, the LPN, wants to “give meds” because she is “sick of the patients’ constant

whining,” and Sheila, the technician, is “just plain exhausted.” Lately, Shawna has noticed that the

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214 unit 3 | Professional Issues

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2. Identify the major problems and the factors that contributed to these problems.

3. What factors might have contributed to the behaviors exhibited by Tina, Lynn, and Sheila?

4. How would you feel if you were Shawna?

5. Is there anything Shawna can do for herself, for the patients, and for the staff members?

6. What do you think Tina, the nurse manager, should do?

7. How is the nurse manager reacting to the changes in her staff members?

8. What is the responsibility of administration?

9. How are the patients affected by the behaviors exhibited by all staff members?

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chapter 14 Your Nursing Career

OBJECTIVES After reading this chapter, the student should be able to: ■ Evaluate personal strengths, weaknesses,

opportunities, and threats using a SWOT analysis.

■ Develop a résumé including objectives, qualifications, skills experience, work history, education, and training.

■ Compose job search letters including cover letter, thank-you letter, and acceptance and rejection letters.

■ Discuss components of the interview process.

■ Discuss the factors involved in select- ing the right position.

■ Explain why the first year is critical to planning a career.


Getting Started

SWOT Analysis





Beginning the Search

Oral and Written Communication Skills

Researching Your Potential Employer

Writing a Résumé

Essentials of a Résumé

How to Begin


Your Objective

Skills and Experience


Job Search Letters

Cover Letter

Thank-You Letter

Acceptance Letter

Rejection Letter

Using the Internet

The Interview Process

Initial Interview

Answering Questions

Background Questions

Professional Questions

Personal Questions

Additional Points About the Interview



Eye Contact

Posture and Listening Skills

Asking Questions

After the Interview

The Second Interview

Making the Right Choice

Job Content



Work Climate


I Can Not Find a Job (or I Moved)

The Critical First Year

Attitude and Expectations

Impressions and Relationships

Organizational Savvy

Skills and Knowledge

Advancing Your Career



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218 unit 3 | Professional Issues

The National Center for Health Workforce Analysis

at Health Resources and Services Administration

has projected a growing shortage of registered nurs-

es (RNs) over the next 15 years, with a 12% shortage

by 2010 and a 20% shortage by 2015 (http:// bhpr.hrsa.gov/healthworkforce/nursingshortage/tec

h_report/default.htm). This continued shortage of RNs will allow you to have many choices and oppor-

tunities as a professional nurse. By now you have

invested considerable time, expense, and emotion

into preparing for your new career. Your educational

preparation, technical and clinical expertise, inter-

personal and management skills, personal interests

and needs, and commitment to the nursing profes-

sion will contribute to meeting your career goals.

Successful nurses view nursing as a lifetime pursuit,

not as an occupational stepping stone.

This chapter deals with the most important

endeavor: finding and keeping your first nursing

position. The chapter begins with planning your

initial search; developing a strengths, weaknesses,

opportunities, and threats (SWOT) analysis;

searching for available positions; and researching

organizations. Also included is a section on writing

a résumé and employment-related information

about the interview process and selecting the first


Getting Started

By now at least one person has said to you, “Nurses

will never be out of a job.” This statement is only

one of several career myths. These myths include

the following:

1. “Good workers do not get fired.” They may not

get fired, but many good workers have lost their

positions during restructuring and downsizing.

2. “Well-paying jobs are available without a

college degree.” Even if entrance into a career

path does not require a college education, the

potential for career advancement is minimal

without that degree. In many health-care

agencies, a baccalaureate degree in nursing is

required for an initial management position.

3. “Go to work for a good company, and move up

the career ladder.” This statement assumes that

people move up the career ladder due to

longevity in the organization. In reality, the

responsibility for career advancement rests on

the employee, not the employer.

4. “Find the ‘hot’ industry, and you will always be

in demand.” Nursing is projected to continue to

be one of the “hottest industries” well into the

next decade. A nurse who performs poorly will

never be successful, no matter what the demand.

Many students attending college today are adults

with family, work, and personal responsibilities. On

graduating with an associate degree in nursing, you

may still have student loans and continued respon-

sibilities for supporting a family. If this is so, you

may be so focused on job security and a steady

source of income that the idea of career planning

has not even entered your mind. You might even

assume that your goal is just