Management and Leadership in Nursing

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I dedicate this book to the two most important

partnerships in my life: my husband, Don Marquis,

and my colleague, Carol Huston. Bessie L. Marquis

I dedicate this book to my husband Tom.

We have built an incredible life together and

I thank you for always being at my side. Carol J. Huston

Reviewers

Patricia Bishop, PhD, MSN, RN Dean and Chief Nurse Administrator Dean of Nursing Brookline College of Nursing Phoenix, Arizona

Barbara B. Blozen, EdD, MA, RN-BC, CNL Associate Professor New Jersey City University Jersey City, New Jersey

Linda Cole, DNP, RN, CCNS, CPHQ, CNE Assistant Professor Department of Graduate Studies Cizik School of Nursing The University of Texas Houston, Texas

Susan Davis, MSN, RN Senior Instructor Nursing Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences University of Colorado Colorado Springs, Colorado

Elmer V. Esguerra, MAN, RN Faculty, Associate Degree Nursing Program South Texas College Nursing & Allied Health Weslaco, Texas

Cindy Farris, PhD, MSN, MPH, CNE Indiana University Fort Wayne Fort Wayne, Indiana

Teresa Faykus, DNP, MSN, BSN, RN, CNE Professor Nursing RN-BSN Coordinator West Liberty University West Liberty, West Virginia

Dawn Frambes, PhD, RN, MSA Assistant Professor Calvin University Grand Rapids, Michigan

Kristi Frisbee, DNP, RN Associate Professor and Master Advisor Pittsburg State University Pittsburg, Kansas

Rose A. Harding, MSN, RN Instructor JoAnne Gay Dishman School of Nursing Lamar University Beaumont, Texas

Janice Hausauer, DNP, APRN, FNP-BC Assistant Clinical Professor Montana State University College of Nursing

Bozeman, Montana

Renee Hoeksel, PhD, RN, MSN, ANEF Professor College of Nursing Washington State University Vancouver Vancouver, Washington

Janine Johnson, RN, MSN Associate Professor Clarkson College Omaha, Nebraska

Judy Kitchin, MS, RN, CNOR Clinical Lecturer Decker School of Nursing Binghamton University Binghamton, New York

Kathleen M. Lamaute, EdD, FNP-BC, NEA-BC, CNE, MA, MS, RN Professor of Nursing Barbara H. Hagan School of Nursing Molloy College Rockville Centre, New York

Diana Martinez Dolan, PhD, RN Assistant Professor St. David’s School of Nursing Texas State University Round Rock Campus Round Rock, Texas

Deborah Merriam, DNS, RN, CNE Assistant Professor of Nursing Daemen College

Amherst, New York

Missy Mohler, MS, RN Assistant Professor Mount Carmel College of Nursing Columbus, Ohio

Dona Molyneaux, PhD, RN, CNE Associate Professor Frances M. Maguire School of Nursing and Health Professions Gwynedd Mercy University Gwynedd Valley, Pennsylvania

Sue Powell, MS, RN, PhN, CNE Professor Nursing Department Century College White Bear Lake, Minnesota

Mark Reynolds, DNP, RN, COI Clinical Assistant Professor, RN-BSN/MSN Program Director The University of Alabama in Huntsville Huntsville, Alabama

Wendy Robb, PhD, RN, MSN, BSN, AND, CNE Dean School of Nursing Cedar Crest College Allentown, Pennsylvania

Joyce A. Shanty, PhD, RN Professor Coordinator, Allied Health Professions Indiana University of Pennsylvania

Indiana, Pennsylvania

Cynthia Shartle, MSN, RN ADN Program Instructor South Texas College McAllen, Texas

Ana Stoehr, PhD, RN, Post-MSN, MSN, BSN Coordinator of the Master’s in Nursing Administration Concentration George Mason University Fairfax, Virginia

Diana Tilton, MSN, RN Assistant Professor Saint Luke’s College of Health Sciences Kansas City, Kansas

Debra Wagner, DNP, RN Associate Professor Department of Nursing Saginaw Valley State University University Center, Michigan

Daryle Wane, PhD, ARNP, FNP-BC Professor, Nursing BSN Pasco-Hernando State College New Port Richey, Florida

Debra White-Jefferson, DNP, MSN, RN Assistant Professor University of Louisiana at Lafayette Lafayette, Louisiana

Mary B. Williams, MS, RN

Professor of Nursing School of Nursing and Health Sciences Gordon State College Barnesville, Georgia

Preface

Legacy of Leadership Roles and Management Functions in Nursing This book’s philosophy has evolved over 38 years of teaching leadership and management. We entered academe from the acute care sector of the health-care industry, where we held nursing management positions. In our first effort as authors, Management Decision Making for Nurses: 101 Case Studies, published in 1987, we used an experiential approach and emphasized management functions appropriate for first- and middle-level managers. The primary audience for this text was undergraduate nursing students.

Our second book, Retention and Productivity Strategies for Nurse Managers, focused on leadership skills necessary for managers to decrease attrition and increase productivity. This book was directed at the nurse-manager rather than the student. The experience of completing research for the second book, coupled with our clinical observations, compelled us to incorporate more leadership content in our teaching and to write this book.

Leadership Roles and Management Functions in Nursing was also influenced by national events in business and finance that led many to believe that a lack of leadership in management was widespread. It became apparent that if managers are to function effectively in the rapidly changing health-care industry, enhanced leadership and management skills are needed.

What we attempted to do, then, was to combine these two very necessary elements: leadership and management. We do not see leadership as merely one role of management or management as only one role of leadership. We view the two as equally important and necessarily integrated. We have attempted to show this interdependence by defining the leadership components and management functions inherent in all phases of the management process. Undoubtedly, a few readers will find fault with our divisions of management functions and leadership roles; however, we felt it was necessary first to artificially separate the two components for the reader and then to integrate the roles and functions. We do believe strongly that adoption of this integrated role is critical for success in management.

The second concept that shaped this book was our commitment to developing critical thinking skills with the use of experiential learning exercises. We propose that integrating leadership and management can be accomplished using learning exercises. Most academic instruction continues to be conducted in a teacher-lecturer–student- listener format, which is one of the least effective teaching strategies. Few individuals learn best using this style. Instead, most people learn best by methods that utilize concrete, experiential, self- initiated, and real-world learning experiences.

In nursing, theoretical teaching is almost always accompanied by concurrent clinical practice that allows concrete and real-world learning experience. However, the exploration of leadership and management theory may have only limited practicum experience, so learners often have little first-hand opportunity to observe middle- and top-level managers in nursing practice. As a result, novice managers frequently have little chance to practice their skills before assuming their first management position, and their decision making thus often reflects trial-and-error methodologies. For us, then, there is little question that vicarious learning, or learning through mock experience, provides students the opportunity to make significant

leadership and management decisions in a safe environment and to learn from the decisions they make.

Having moved away from the lecturer–listener format in our classes, we lecture for only a small portion of class time. A Socratic approach, case study debate, and small and large group problem solving are emphasized. Our students, once resistant to the experiential approach, are now enthusiastic supporters. We also find this enthusiasm for experiential learning apparent in the workshops and seminars we provide for registered nurses. Experiential learning enables management and leadership theory to be fun and exciting, but most important, it facilitates retention of didactic material. The research we have completed on this teaching approach supports these findings.

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

New to This Edition The first edition of Leadership Roles and Management Functions in Nursing presented the symbiotic elements of leadership and management, with an emphasis on problem solving and critical thinking. This tenth edition maintains this precedent with a balanced presentation of a strong theory component along with a variety of real-world scenarios in the experiential learning exercises. We have also maintained the dual focus of leadership development with a balance of management content.

Responding to reviewer recommendations, we have added and deleted content. Specifically, we continue to increase the focus on quality and safety, interprofessional collaboration/team building, technology in health care, mandates for increased quality and value, healthy workplaces and civility, change management, and health- care reform. In addition, there is new content on elastic thinking; rebel leadership; agile leadership; stakeholder engagement; interprofessional education; and patient, family, and subordinate empowerment. We also have increased the use of outpatient/community settings in our learning exercises.

We believe we have retained the strengths of earlier editions, reflecting content and application exercises appropriate to the issues faced by nurse leader-managers as they practice in an era increasingly characterized by limited resources and emerging technologies. The tenth edition also includes a continued focus to include current research and theory to ensure accuracy of the didactic material.

The Text Unit I provides a foundation for the decision-making, problem-

solving, and critical-thinking skills as well as management and leadership skills needed to address the management–leadership problems presented in the text.

Unit II covers ethics, legal concepts, and advocacy, which we see as core components of leadership and management decision making.

Units III to VII are organized using the management processes of planning, organizing, staffing, directing, and controlling.

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

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

• Learning Exercises interspersed throughout each chapter foster readers’ critical-thinking skills and promote interactive discussions. Additional learning exercises are also presented at the end of each chapter for further study and discussion.

• Breakout Comments are highlighted throughout each chapter, visually reinforcing key ideas.

• Tables, displays, figures, and illustrations are liberally supplied throughout the text to reinforce learning as well as to help clarify complex information.

• Key Concepts summarize important information within every chapter.

The Crosswalk A crosswalk is a table that shows elements from different databases or criteria that interface. New to the eighth edition was a chapter crosswalk of content based on the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice (2008), the AACN Essentials of Master’s Education in Nursing (2011), the American Organization for Nursing Leadership (AONL) (formerly American Organization of Nurse Executives [AONE]) Nurse Executive Competencies (updated September 2015), and the QSEN Institute Competencies (2019). For the ninth edition, the newly revised Standards for Professional Performance from the American Nurses Association (ANA) Nursing: Scope and Standards of Practice (2015) were included. This edition continues to show how content in each chapter draws from or contributes to content identified as essential for baccalaureate and graduate education, for practice as a nurse administrator, and for safety and quality in clinical practice.

In health care today, baccalaureate education for nurses is being emphasized as of increasing importance, and the number of RN- MSN and BSN-PhD programs is always increasing. Nurses are being called on to remain lifelong learners and move with more fluidity than ever before. For these reasons, this textbook includes mapping to Essentials, Competencies, and Standards not only at the baccalaureate level but also at the master’s and executive levels so that nurses may become familiar with the competencies expected as they continue to grow in their careers.

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

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

provider of care, designer/manager/coordinator of care, and member of a profession (AACN, 2008) (Table 1).

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

Essential I: Liberal education for baccalaureate generalist nursing practice ● A solid base in liberal education provides the cornerstone for the

practice and education of nurses. Essential II: Basic organizational and systems leadership for quality care and patient safety ● Knowledge and skills in leadership, quality improvement, and

patient safety are necessary to provide high-quality health care. Essential III: Scholarship for evidence-based practice ● Professional nursing practice is grounded in the translation of

current evidence into one’s practice. Essential IV: Information management and application of patient-care technology ● Knowledge and skills in information management and patient-

care technology are critical in the delivery of quality patient care. Essential V: Health-care policy, finance, and regulatory environments ● Health-care policies, including financial and regulatory, directly

and indirectly influence the nature and functioning of the health- care system and thereby are important considerations in professional nursing practice.

Essential VI: Interprofessional communication and collaboration for improving patient health outcomes ● Communication and collaboration among health-care

professionals are critical to delivering high-quality and safe patient care.

Essential VII: Clinical prevention and population health

● Health promotion and disease prevention at the individual and population level are necessary to improve population health and are important components of baccalaureate generalist nursing practice.

Essential VIII: Professionalism and professional values ● Professionalism and the inherent values of altruism, autonomy,

human dignity, integrity, and social justice are fundamental to the discipline of nursing.

Essential IX: Baccalaureate generalist nursing practice ● The baccalaureate graduate nurse is prepared to practice with

patients, including individuals, families, groups, communities, and populations across the life span and across the continuum of health-care environments.

● The baccalaureate graduate understands and respects the variations of care, the increased complexity, and the increased use of health-care resources inherent in caring for patients.

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

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

Essential I: Liberal education for baccalaureate generalist nursing practice ● A solid base in liberal education provides the cornerstone for the

practice and education of nurses. Essential I: Background for practice from sciences and humanities ● Recognizes that the master’s-prepared nurse integrates scientific

findings from nursing, biopsychosocial fields, genetics, public health, quality improvement, and organizational sciences for the continual improvement of nursing care across diverse settings.

Essential II: Organizational and systems leadership ● Recognizes that organizational and systems leadership are

critical to the promotion of high quality and safe patient care. Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a systems perspective.

Essential III: Quality improvement and safety ● Recognizes that a master’s-prepared nurse must be articulate in

the methods, tools, performance measures, and standards related to quality as well as prepared to apply quality principles within an organization.

Essential IV: Translating and integrating scholarship into practice ● Recognizes that the master’s-prepared nurse applies research

outcomes within the practice setting, resolves practice problems, works as a change agent, and disseminates results.

Essential V: Informatics and health-care technologies

● Recognizes that the master’s-prepared nurse uses patient-care technologies to deliver and enhance care and uses communication technologies to integrate and coordinate care.

Essential VI: Health policy and advocacy ● Recognizes that the master’s-prepared nurse is able to intervene

at the system level through the policy development process and to employ advocacy strategies to influence health and health care.

Essential VII: Interprofessional collaboration for improving patient and population health outcomes ● Recognizes that the master’s-prepared nurse, as a member and

leader of interprofessional teams, communicates, collaborates, and consults with other health professionals to manage and coordinate care.

Essential VIII: Clinical prevention and population health for improving health ● Recognizes that the master’s-prepared nurse applies and

integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregates/identified populations.

Essential IX: Master’s-level nursing practice ● Recognizes that nursing practice, at the master’s level, is broadly

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

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

TABLE 3 AMERICAN ORGANIZATION FOR NURSING LEADERSHIP NURSE EXECUTIVE COMPETENCIES

1. Communication and relationship building ● Communication and relationship building includes effective

communication, relationship management, influencing behaviors, diversity, community involvement, medical/staff relationships, and academic relationships.

2. Knowledge of the health-care environment ● Knowledge of the health-care environment includes clinical

practice knowledge, delivery models and work design, health- care economics and policy, governance, evidence-based practice/outcome measurement and research, patient safety, performance improvement/metrics, and risk management.

3. Leadership ● Leadership skills include foundational thinking skills, personal

journey disciplines, systems thinking, succession planning, and change management.

4. Professionalism ● Professionalism includes personal and professional

accountability, career planning, ethics, and advocacy. 5. Business skills

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

Nursing Executive Competencies, 2015, 2011 by the American Organization for Nursing Leadership (AONL). All rights reserved.

The American Nurses Association Standards of Professional Performance

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

TABLE 4 AMERICAN NURSES ASSOCIATION NURSING ADMINISTRATION STANDARDS OF PROFESSIONAL PERFORMANCE

Standard 7. Ethics ● The registered nurse practices ethically. Standard 8. Culturally congruent practice ● The registered nurse practices in a manner that is congruent with

cultural diversity and inclusion principles. Standard 9. Communication ● The registered nurse communicates effectively in all areas of

practice. Standard 10. Collaboration ● The registered nurse collaborates with health-care consumers

and other key stakeholders in the conduct of nursing practice. Standard 11. Leadership ● The registered nurse leads within the professional practice

setting and the profession. Standard 12. Education ● The registered nurse seeks knowledge and competence that

reflects current nursing practice and promotes futuristic thinking. Standard 13. Evidence-based practice and research ● The registered nurse integrates evidence and research findings

into practice. Standard 14. Quality of practice ● The registered nurse contributes to quality nursing practice. Standard 15. Professional practice evaluation ● The registered nurse evaluates one’s own and others’ nursing

practice. Standard 16. Resource utilization

● The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible.

Standard 17. Environmental health ● The registered nurse practices in an environmentally safe and

healthy manner.

The Quality and Safety Education for Nurses Competencies Using the Institute of Medicine (2003) competencies for nursing, the QSEN Institute (2019) defined six prelicensure and graduate quality and safety competencies for nursing (Table 5) and proposed targets for the knowledge, skills, and attitudes to be developed in nursing programs for each of these competencies. Led by a national advisory board and distinguished faculty, the QSEN Institute pursues strategies to develop effective teaching approaches to assure that future graduates develop competencies in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

TABLE 5 QUALITY AND SAFETY EDUCATION FOR NURSES COMPETENCIES

Patient-centered care ● Definition: Recognize the patient or designee as the source of

control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Teamwork and collaboration ● Definition: Function effectively within nursing and

interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

Evidence-based practice ● Definition: Integrate best current evidence with clinical expertise

and patient/family preferences and values for delivery of optimal health care.

Quality improvement ● Definition: Use data to monitor the outcomes of care processes

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

Safety ● Definition: Minimizes the risk of harm to patients and providers

through both system effectiveness and individual performance. Informatics ● Definition: Use information and technology to communicate,

manage knowledge, mitigate error, and support decision making.

Student and Faculty Resources Available

Leadership Roles and Management Functions in Nursing, tenth edition, has ancillary resources designed with both students and instructors in mind.

Student Resources Available • Glossary—Fully updated for the tenth edition, the glossary

contains definitions of important terms in the text. • Journal Articles—25 full articles from Wolters Kluwer journals are

provided for additional learning opportunities. • Learning Objectives from the textbook are available in Microsoft

Word for your convenience. • Nursing Professional Roles and Responsibilities

Instructor’s Resources Available • Competency Maps pull together the mapping provided in the

crosswalk feature for each chapter, showing how the book content integrates key competencies for practice.

• An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in your course.

• An Instructor’s Guide includes information on experiential learning and guidelines on how to use the text for various types of learners and in different settings as well as information on how to use the various types of Learning Exercises included in the text.

• All new PowerPoint Presentations provide an easy way for you to integrate the textbook with your students’ classroom experience, either via slide shows or handouts. Audience response questions are integrated into the presentations to promote class participation and allow you to use i-clicker technology.

• Sample Syllabi provide guidance for structuring your leadership and management course and are provided for two different course lengths: 8 and 15 weeks.

• Strategies for Effective Teaching offer creative approaches for engaging students.

• A Test Generator lets you put together exclusive new tests from a bank containing more than 750 questions to help you in assessing your students’ understanding of the material. Test questions link to chapter learning objectives.

• Access to all student resources.

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

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

skills and asks them to make decisions related to simple-to-complex scenarios.

Lippincott CoursePoint for Leadership and Management features the following:

• Leading content in context: Digital content from Leadership Roles and Management Functions in Nursing is embedded in our Powerful Tools, engaging students and encouraging interaction and learning on a deeper level. • The complete interactive eBook features annual content updates

with the latest evidence-based practices and provides students with anytime, anywhere access on multiple devices.

• Full online access to Stedman’s Medical Dictionary for the Health Professions and Nursing ensures students work with the best medical dictionary available.

• Powerful tools to maximize class performance: Additional course-specific tools provide case-based learning for every student: • Video Cases help students anticipate what to expect as a

nurse, with detailed scenarios that capture their attention and integrate clinical knowledge with leadership and management concepts that are critical to real-world nursing practice. By watching the videos and completing related activities, students will flex their problem-solving, prioritizing, analyzing, and application skills to aid both in NCLEX preparation and in preparation for practice.

• Interactive Modules help students quickly identify what they do and do not understand, so they can study smartly. With exceptional instructional design that prompts students to discover, reflect, synthesize, and apply, students actively learn. Remediation links to the digital textbook are integrated throughout.

• Curated collections of journal articles are provided via Lippincott NursingCenter, Wolters Kluwer’s premier destination for peer-reviewed nursing journals. Through integration of CoursePoint and NursingCenter, students will engage in how nursing research influences practice.

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

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

Lippincott RN to BSN Online: Leadership and Management is a postlicensure solution for online and hybrid courses, marrying experiential learning with the trusted content in Leadership Roles and Management Functions in Nursing, tenth edition.

Built around learning objectives that are aligned to the BSN Essentials and QSEN nursing curriculum standards, every aspect of Lippincott RN to BSN Online is designed to engage, challenge, and cultivate postlicensure students.

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

• Pre- and post-module assessments activate students’ existing knowledge prior to engaging with the module and then assess their competency after completing the module.

• Discussion board questions create an ongoing dialogue to foster social learning.

• Writing and group work assignments hone students’ competence in writing and communication, instilling the skills needed to advance their nursing careers.

• Collated journal articles acquaint students to the body of nursing research ongoing in recent literature.

• Case study assignments, including unfolding cases that evolve from cases in the interactive modules, aid students in applying theory to real-life situations.

• Best Practices in Scholarly Writing Guide covers American Psychological Association formatting and style guidelines.

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

To learn more about Lippincott RN to BSN Online, please visit http://www.nursingeducationsuccess.com/nursing-education- solutions/lippincott-rn-bsn-online/

Closing Note It is our hope and expectation that the content, style, and organization of this tenth edition of Leadership Roles and Management Functions in Nursing will be helpful to those students who want to become skillful, thoughtful leaders and managers.

Bessie L. Marquis, RN, MSN Carol J. Huston, RN, MSN, DPA, FAAN

R E F E R E N C E S

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved September 6, 2018, from http://www.aacnnursing.org/Portals/42/Publications/BaccEssentia ls08.pdf

American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Retrieved September 6, 2018, from http://www.aacnnursing.org/Portals/42/Publications/MastersEsse ntials11.pdf

American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

American Organization for Nursing Leadership. (AONL, AONE, 2015). AONL nurse executive competencies. Retrieved September 26, 2019, from https://www.aonl.org/sites/default/files/aone/nec.pdf

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press.

QSEN Institute. (2019). Competencies. Retrieved September 6, 2018, from http://qsen.org/competencies/

Contents

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

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

Introduction Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning Vicarious Learning to Increase Problem-Solving and Decision- Making Skills

Case Studies, Simulation, and Problem-Based Learning The Marquis-Huston Critical Thinking Teaching Model

Theoretical Approaches to Problem Solving and Decision Making Traditional Problem-Solving Process Managerial Decision-Making Models The Nursing Process Integrated Ethical Problem-Solving Model Intuitive Decision-Making Models

Critical Elements in Problem Solving and Decision Making Define Objectives Clearly Gather Data Carefully

Take the Time Necessary Use an Evidence-Based Approach Generate Numerous Alternatives Think Logically Choose and Act Decisively

Individual Variations in Decision Making Gender Values Life Experience Individual Preference Brain Hemisphere Dominance and Thinking Styles

Overcoming Individual Vulnerability in Decision Making Values Life Experience Individual Preference Individual Ways of Thinking

Decision Making in Organizations Effect of Organizational Power Rational and Administrative Decision Making

Decision-Making Tools Decision Grids Payoff Tables Decision Trees Consequence Tables Logic Models Program Evaluation and Review Technique Pitfalls in Using Decision-Making Tools

Integrating Leadership Roles and Management Functions in Decision Making Key Concepts Additional Learning Exercises and Applications

2 Classical Views of Leadership and Management

Introduction Managers Leaders Historical Development of Management Theory

Scientific Management (1900 to 1930) Management Functions Identified Human Relations Management (1930 to 1970)

Historical Development of Leadership Theory (1900 to Present) The Great Man Theory/Trait Theories (1900 to 1940) Behavioral Theories (1940 to 1980) Situational and Contingency Leadership Theories (1950 to 1980) Interactional Leadership Theories (1970 to Present) Transactional and Transformational Leadership Full-Range Leadership Model/Theory Leadership Competencies

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

3 Twenty-First-Century Thinking About Leadership and Management

Introduction New Thinking About Leadership and Management

Strengths-Based Leadership and the Positive Psychology Movement Level 5 Leadership Servant Leadership Principal Agent Theory Human and Social Capital Theory

Emotional Intelligence Authentic Leadership Thought Leadership and Rebel Leadership Agile Leadership Reflective Thinking and Practice Quantum Leadership

Transition From Industrial Age Leadership to Relationship Age Leadership Integrating Leadership Roles and Management Functions in the 21st Century Key Concepts Additional Learning Exercises and Applications

UNIT II

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

4 Ethical Issues Introduction Moral Issues Faced by Nurses Ethical Frameworks for Decision Making Principles of Ethical Reasoning

Autonomy (Self-Determination) Beneficence (Doing Good) Paternalism Utility Justice (Treating People Fairly) Veracity (Truth Telling) Fidelity (Keeping Promises) Confidentiality (Respecting Privileged Information)

Codes of Ethics and Professional Standards

Ethical Problem Solving and Decision Making The Traditional Problem-Solving Process The Nursing Process The Moral Decision-Making Model

Working Toward Ethical Behavior as the Norm Separate Legal and Ethical Issues Collaborate Through Interprofessional Ethics Committees Use Institutional Review Boards Appropriately Foster an Ethical Work Environment

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

5 Legal and Legislative Issues Introduction Sources of Law Types of Laws and Courts Legal Doctrines and the Practice of Nursing Professional Negligence (Malpractice)

Elements of Malpractice Being Sued for Malpractice Avoiding Malpractice Claims

Extending the Liability Incident Reports and Adverse Event Forms Intentional Torts Other Legal Responsibilities of the Manager

Informed Consent Informed Consent for Clinical Research

Medical Records The Patient Self-Determination Act Good Samaritan Laws

Health Insurance Portability and Accountability Act of 1996 Legal Considerations of Managing a Diverse Workforce Professional Versus Institutional Licensure Integrating Leadership Roles and Management Functions in Legal and Legislative Issues Key Concepts Additional Learning Exercises and Applications

6 Patient, Subordinate, Workplace, and Professional Advocacy

Introduction Becoming an Advocate Patient Advocacy

Patient and Family Engagement Person- and Family-Centered Care

Patient Rights The Right to Die Movement and Physician-Assisted Suicide

Subordinate and Workplace Advocacy Whistleblowing as Advocacy Professional Advocacy

Nursing’s Advocacy Role in Legislation and Public Policy Nursing and the Media

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

UNIT II I Roles and Functions in Planning

7 Organizational Planning

Introduction Visioning: Looking to the Future Proactive Planning

Forecasting Strategic Planning at the Organizational Level

SWOT Analysis Balanced Scorecard Strategic Planning as a Management Process Who Should Be Involved in Strategic Planning?

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

8 Planned Change Introduction Lewin’s Change Theory of Unfreezing, Movement, and Refreezing

Unfreezing Movement Refreezing

Lewin’s Change Theory of Driving and Restraining Forces A Contemporary Adaptation of Lewin’s Model

Classic Change Strategies Resistance: The Expected Response to Change Planned Change as a Collaborative Process The Leader-Manager as a Role Model During Planned Change Organizational Change Associated With Nonlinear Dynamics

Complexity and Complex Adaptive Systems Change Theory Chaos Theory

Organizational Aging: Change as a Means of Renewal Integrating Leadership Roles and Management Functions in Planned Change Key Concepts Additional Learning Exercises and Applications

9 Time Management Introduction Three Basic Steps to Time Management

Taking Time to Plan and Establishing Priorities The Time-Efficient Work Environment Priority Setting and Procrastination Making Lists Reprioritizing Dealing With Interruptions Time Wasters

Personal Time Management Using a Time Inventory

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

10 Fiscal Planning and Health-Care Reimbursement

Introduction Balancing Cost and Quality Responsibility Accounting Budget Basics

Steps in the Budgetary Process Types of Budgets

The Personnel Budget The Operating Budget The Capital Budget

Budgeting Methods Incremental Budgeting Zero-Based Budgeting Flexible Budgeting Performance Budgeting

Critical Pathways and Variance Analysis Health-Care Reimbursement Medicare and Medicaid The Prospective Payment System Managed Care

Types of Managed Care Organizations Medicare and Medicaid Managed Care Proponents and Critics of Managed Care Speak Up The Future of Managed Care

Health-Care Reform Efforts: The Patient Protection and Affordable Care Act. What Comes Next?

Bundled Payments Accountable Care Organizations Hospital Value-Based Purchasing The Patient-Centered Medical Home Health Insurance Marketplaces Outcomes of the Affordable Care Act

Integrating Leadership Roles and Management Functions in Fiscal Planning

Key Concepts Additional Learning Exercises and Applications

11 Career Planning and Development in Nursing Introduction Career Stages Justifications for Career Development Individual Responsibility for Career Development The Organization’s Role in Employee Career Development Career Coaching Management Development Promotion: A Career Management Tool Continued Competency as Part of Career Development

Mandatory Continuing Education to Promote Continued Competence

Professional Specialty Certification Reflective Practice and the Professional Portfolio Career Planning and the New Graduate Nurse

Transition-to-Practice Programs/Residencies for New Graduate Nurses

Resumé Preparation Resumé Format

Integrating Leadership Roles and Management Functions in Career Planning and Development Key Concepts Additional Learning Exercises and Applications

UNIT IV Roles and Functions in Organizing

12 Organizational Structure

Introduction Formal and Informal Organizational Structure Organizational Theory and Bureaucracy Components of Organizational Structure

Relationships and Chain of Command Span of Control Managerial Levels Centrality

Limitations of Organization Charts Types of Organizational Structures

Line Structures Ad Hoc Design Matrix Structure Service Line Organization Flat Designs

Decision Making Within the Organizational Hierarchy Stakeholders Organizational Culture Shared Governance: Organizational Design for the 21st Century Magnet Designation and Pathway to Excellence Committee Structure in an Organization

Responsibilities and Opportunities of Committee Work Integrating Leadership Roles and Management Functions Associated With Organizational Structure Key Concepts Additional Learning Exercises and Applications

13 Organizational, Political, and Personal Power Introduction Understanding Power

Gender and Power Power and Powerlessness

Types of Power The Authority–Power Gap

Bridging the Authority–Power Gap Empowering Subordinates Mobilizing the Power of the Nursing Profession An Action Plan for Increasing Professional Power in Nursing Strategies for Building a Personal Power Base

Maintain Personal Energy Present a Powerful Picture to Others Work Hard and Be a Team Player Determine the Powerful in the Organization Learn the Language and Symbols of the Organization Learn How to Use the Organization’s Priorities Increase Professional Skills and Knowledge Maintain a Broad Vision Use Experts and Seek Counsel Be Flexible Develop Visibility and a Voice in the Organization Learn to Accept Compliments Maintain a Sense of Humor Empower Others

The Politics of Power Integrating Leadership Roles and Management Functions When Using Authority and Power in Organizations Key Concepts Additional Learning Exercises and Applications

14 Organizing Patient Care Introduction Traditional Models of Patient Care Organization

Total Patient Care Nursing or Case Method Nursing Functional Method

Team Nursing Modular Nursing Primary Nursing

Primary Nursing in the Inpatient Setting Interprofessional/Multidisciplinary Health-Care Teams

Registered Nurse Primary Care Coordinators in Patient- Centered Medical Homes

Case Management Case Management of Disease Management Programs

Selecting the Optimum Mode of Organizing Patient Care New Roles in the Changing Health-Care Arena: Nurse Navigators and Clinical Nurse-Leaders

Nurse Navigators The Clinical Nurse-Leader

Integrating Leadership Roles and Management Functions in Organizing Patient Care Key Concepts Additional Learning Exercises and Applications

UNIT V Roles and Functions in Staffing

15 Employee Recruitment, Selection, Placement, and Indoctrination

Introduction Predicting Staffing Needs Is a Nursing Shortage Looming? Supply and Demand Factors Leading to a Potential Nursing Shortage

Demand Supply

Recruitment

The Nurse-Recruiter The Relationship Between Recruitment and Retention

Interviewing as a Selection Tool Limitations of Interviews Overcoming Interview Limitations

Use a Team Approach Develop a Structured Interview Format for Each Job Classification Use Scenarios to Determine Decision-Making Ability Conduct Multiple Interviews Provide Training in Effective Interviewing Techniques

Planning, Conducting, and Controlling the Interview Evaluation of the Interview Legal Aspects of Interviewing

Tips for the Interviewee Selection

Educational and Credential Requirements Reference Checks and Background Screening Preemployment Testing Physical Examination as a Selection Tool Making the Selection Finalizing the Selection

Placement Indoctrination

Induction Orientation

Integrating Leadership Roles and Management Functions in Employee Recruitment, Selection, Placement, and Indoctrination Key Concepts Additional Learning Exercises and Applications

16 Educating and Socializing Staff in a Learning Organization

Introduction The Learning Organization Staff Development

Training Versus Education Responsibilities of the Education Department

Learning Theories Adult Learning Theory Social Learning Theory Other Learning Concepts

Assessing Staff Development Needs Evaluation of Staff Development Activities Shared Responsibility for Implementing Evidence-Based Practice Socialization and Resocialization

Socialization of the New Nurse: Overcoming Reality Shock Resocialization of the Experienced Nurse The Socialization and Orientation of New Managers Socializing International Nurses Clarifying Role Expectations Through Role Models, Preceptors, and Mentors

Role Models Preceptors Mentors

Overcoming Motivational Deficiencies Positive Sanctions Negative Sanctions

Coaching as a Teaching Strategy Meeting the Educational Needs of a Culturally Diverse Staff Integrating Leadership and Management in Team Building Through Socializing and Educating Staff in a Learning Organization

Key Concepts Additional Learning Exercises and Applications

17 Staffing Needs and Scheduling Policies Introduction Management’s Responsibilities in Meeting Staffing Needs Centralized and Decentralized Staffing Staffing and Scheduling Options Workload Measurement Tools The Relationship Between Nursing Care Hours, Staffing Mix, and Quality of Care Should Minimum Registered Nurse to Patient Staffing Ratios Be Mandated? Establishing and Maintaining Effective Staffing Policies Generational Considerations for Staffing The Impact of Nursing Staff Shortages on Staffing Fiscal and Ethical Accountability for Staffing Developing Staffing and Scheduling Policies Integrating Leadership Roles and Management Functions in Staffing and Scheduling Key Concepts Additional Learning Exercises and Applications

UNIT VI Roles and Functions in Directing

18 Creating a Motivating Climate Introduction Intrinsic Versus Extrinsic Motivation Motivational Theory

Maslow

Skinner Herzberg Vroom McClelland Gellerman McGregor

Strategies for Creating a Motivating Climate Worker Engagement Worker Empowerment Positive Reinforcement Incentives and Rewards The Relationship Between the Employee and His or Her Supervisor Self-Care

Integrating Leadership Roles and Management Functions in Creating a Motivating Climate at Work Key Concepts Additional Learning Exercises and Applications

19 Organizational, Interpersonal, and Group Communication in Team Building

Introduction The Communication Process Variables Affecting Organizational Communication Organizational Communication Strategies

Channels of Communication Communication Modes Elements of Nonverbal Communication

Silence Space Environment Appearance

Eye Contact Posture Gestures Facial Expression and Timing Vocal Expression

Verbal Communication Skills SBAR, ISBAR, ANTICipate, and I-PASS as Verbal Communication Tools

Listening Skills Written Communication Within the Organization Technology as a Tool in Contemporary Organizational Communication

The Internet Hospital Information Systems and Intranets Wireless Local Area Networking Social Media and Organizational Communication Balancing Technology and the Human Element

Communication, Confidentiality, and Health Insurance Portability and Accountability Act Electronic Health Records Group Communication Group Dynamics

Group Task Roles Group Building and Maintenance Roles Individual Roles of Group Members

Communication and Team Building Integrating Leadership and Management in Organizational, Interpersonal, and Group Communication in Team Building Key Concepts Additional Learning Exercises and Applications

20 Delegation

Introduction Delegating Effectively

Identify Necessary Skills and Education Levels Plan Ahead Select and Empower Capable Personnel Communicate Goals Clearly Set Deadlines and Monitor Progress Be a Role Model and Provide Guidance Evaluate Performance Reward Accomplishment

Common Delegation Errors Underdelegating Overdelegating Improper Delegating

Delegation as a Function of Professional Nursing Delegating to Unlicensed Assistive Personnel Unlicensed Assistive Personnel Scope of Practice

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

21 Conflict, Workplace Violence, and Negotiation Introduction The History of Conflict Management Intergroup, Intrapersonal, and Interpersonal Conflict The Conflict Process Conflict Management

Compromising Competing

Cooperating/Accommodating Smoothing Avoiding Collaborating

Managing Unit Conflict Bullying, Incivility, Mobbing, and Workplace Violence

Definitions Workplace Violence: Scope of the Problem Typology of Workplace Violence Consequences of Workplace Violence Whose Problem Is It? Strategies to Address the Problem

Negotiation Before the Negotiation During the Negotiation Destructive Negotiation Tactics Closure and Follow-Up to Negotiation

Alternative Dispute Resolution Seeking Consensus Integrating Leadership Skills and Management Functions in Managing Conflict Key Concepts Additional Learning Exercises and Applications

22 Collective Bargaining, Unionization, and Employment Laws

Introduction Unions and Collective Bargaining Historical Perspective of Unionization in America

Effective Labor–Management Relations Union Representation of Nurses American Nurses Association and Collective Bargaining

Employee Motivation to Join or Reject Unions Common Reasons Nurses Join Unions Common Reasons Nurses Do Not Join Unions

Averting the Union Union-Organizing Strategies Steps to Establish a Union The Managers’ Role During Union Organizing The Nurse as Supervisor: Eligibility for Protection Under the National Labor Relations Act Employment Legislation

Labor Standards Minimum Wages and Maximum Hours The Equal Pay Act of 1963 Equal Employment Opportunity Laws Civil Rights Act of 1964 Age Discrimination and Employment Act Sexual Harassment Legislation Affecting Americans With Disabilities Veterans Readjustment Assistance Act The Occupational Safety and Health Act

State Health Facilities Licensing Boards Integrating Leadership Skills and Management Functions When Working With Collective Bargaining, Unionization, and Employment Laws Key Concepts Additional Learning Exercises and Applications

UNIT VII Roles and Functions in Controlling

23 Quality Control in Creating a Culture of Patient Safety

Introduction Defining Quality Health Care Quality Control as a Systematic Process/FOCUS PDCA The Development of Standards Audits as a Quality Control Tool

Outcome Audit Process Audit Structure Audit

Standardized Nursing Languages Quality Improvement Models

Total Quality Management Who Should Be Involved in Quality Control? Quality Measurement as an Organizational Mandate Professional Standards Review Organizations The Prospective Payment System The Joint Commission

Sentinel Event Reporting Oryx Core Measures National Patient Safety Goals Medication Reconciliation

Centers for Medicare & Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems Survey Multistate Nursing Home Case Mix and Quality Demonstration

National Committee for Quality Assurance National Database of Nursing Quality Indicators Report Cards Medical Errors: An Ongoing Threat to Quality of Care

Reporting and Analyzing Errors in a Just Culture The Leapfrog Group Six Sigma Approach and Lean Manufacturing Reforming the Medical Liability System

Are We Making Progress? Integrating Leadership Roles and Management Functions With Quality Control Key Concepts Additional Learning Exercises and Applications

24 Performance Appraisal Introduction Using the Performance Appraisal to Motivate Employees Strategies to Ensure Accuracy and Fairness in the Performance Appraisal Performance Appraisal Tools

Trait Rating Scales Job Dimension Scales Behaviorally Anchored Rating Scales Checklists Essays Self-Appraisals Management by Objectives Peer Review The 360-Degree Evaluation

Planning the Performance Appraisal Interview Overcoming Appraisal Interview Difficulties

Before the Interview During the Interview After the Interview

Performance Management Coaching: A Mechanism for Informal Performance Appraisal

Becoming an Effective Coach When Employees Appraise Their Manager’s Performance Leadership Skills and Management Functions in Conducting Performance Appraisals

Key Concepts Additional Learning Exercises and Applications

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

Introduction Constructive Versus Destructive Discipline Self-Discipline and Group Norms Fair and Effective Rules Discipline as a Progressive Process Disciplinary Strategies for the Manager

Performance Deficiency Coaching Disciplining the Unionized Employee The Disciplinary Conference

Reason for Disciplinary Action Employee’s Response to Disciplinary Action Rationale for Disciplinary Action Clarification of Expectations for Change Agreement and Acceptance of Action Plan The Environment for Discipline Timing and Conference Length Closure

The Termination Conference Grievance Procedures

Formal Process Arbitration Rights and Responsibilities in Grievance Resolution

Transferring Employees The Marginal Employee The Chemically Impaired Employee

Prevalence of Chemical Dependency in Nursing

Commonly Misused or Abused Drugs Recognizing the Chemically Impaired Employee

Confronting the Chemically Impaired Employee The Manager’s Role in Assisting the Chemically Impaired Employee The Recovery Process State Board of Nursing Treatment Programs The Chemically Impaired Employee’s Reentry to the Workplace

Integrating Leadership Roles and Management Functions When Dealing With Problem Employees Key Concepts Additional Learning Exercises and Applications

Appendix Solutions to Selected Learning Exercises Index

U N I T I

The Critical Triad: Decision Making, Management, and Leadership

1

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

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

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

. . . If we start with the attitude that different viewpoints are additive rather than competitive, we become more effective because our ideas or decisions are honed and tempered by that discourse.—Edwin Catmull, President of Pixar and Walt Disney Animation Studios

CROSSWALK

This chapter addresses:

BSN Essential I: Liberal education for baccalaureate generalist nursing practice

BSN Essential III: Scholarship for evidence-based practice BSN Essential IV: Information management and application of patient-care technology

BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

MSN Essential I: Background for practice from sciences and humanities

MSN Essential IV: Translating and integrating scholarship into practice

AONL Nurse Executive Competency I: Communication and relationship building

AONL Nurse Executive Competency III: Leadership ANA Standard of Professional Performance 13: Evidence- based practice and research

ANA Standard of Professional Performance 16: Resource utilization

QSEN Competency: Informatics QSEN Competency: Evidence-based practice

LEARNING OBJECTIVES

The learner will:

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

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

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

identify characteristics of successful decision makers

use a PICO (patient or population, intervention, comparison, and outcome) format to search for current best evidence or practices to address a problem

identify strategies the new nurse might use to promote evidence-based practice

select appropriate models for decision making in specific situations

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

identify critical elements of decision making identify strategies that help decrease individual subjectivity and increase objectivity in decision making

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

discuss the effect of organizational power and values on individual decision making

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

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

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

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

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

Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning Decision making is a complex, cognitive process often defined as choosing a particular course of action. BusinessDictionary.com (2018) defines decision making as “the thought process of selecting a logical choice from the available options” (para. 1). This implies that doubt exists about several courses of action and that a choice is made to eliminate uncertainty.

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

Decision making, on the other hand, is usually triggered by a problem but is often handled in a way that does not focus on eliminating the underlying problem. For example, if a person decided to handle a conflict when it occurred but did not attempt to identify the real problem causing the conflict, only decision-making skills would be used. The decision maker might later choose to address the real cause of the conflict or might decide to do nothing at all about the problem. The decision has been made not to problem solve.

This alternative may be selected because of a lack of energy, time, or resources to solve the real problem. In some situations, this is an appropriate decision. For example, assume that a nursing supervisor has a staff nurse who has been absent a great deal over the last 3 months. Normally, the supervisor would feel compelled to intervene. However, the supervisor has reliable information that the nurse will be resigning soon to return to school in another state. Because the problem will soon no longer exist, the supervisor decides that the time and energy needed to correct the problem are not warranted.

Critical thinking, sometimes referred to as reflective thinking, is related to evaluation and has a broader scope than decision making and problem solving. Dictionary.com (2018) defines critical thinking as “disciplined thinking that is clear, rational, open-minded, and informed by evidence” (para. 1). Critical thinking also involves reflecting on the meaning of statements, examining the offered evidence and reasoning, and forming judgments about facts.

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

Whatever definition of critical thinking is used, most agree that it is more complex than problem solving or decision making, involves higher order reasoning and evaluation, and has both cognitive and

affective components. The authors believe that insight, intuition, empathy, and the willingness to take action are additional components of critical thinking. These same skills are necessary to some degree in decision making and problem solving. See Display 1.1 for additional characteristics of a critical thinker.

DISPLAY 1.1 CHARACTERISTICS OF A CRITICAL THINKER

Open to new ideas Intuitive Energetic Analytical Persistent Assertive Communicative

Flexible Empathetic Caring Observant Risk taker Resourceful “Outside-the-box”

thinker

Creative Insightful Willing to take

action Outcome directed Willing to change Knowledgeable Circular thinker

Nurses today must have higher order thinking skills to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. When nurses integrate and apply different types of knowledge to weigh evidence, critically think about arguments, and reflect on the process used to arrive at a diagnosis, this is known as clinical reasoning. Thus, clinical reasoning uses both knowledge and experience to make decisions at the point of care.

Finally, Mlodinow (2018) argues there is elastic thinking. Elastic thinking arises from what scientists call “bottom-up” processes. In this mode, individual neurons fire in complex fashion, with valuable input from the brain’s emotional centers rather than the brain’s high- level executive structures. This kind of processing is nonlinear and can produce creative ideas that would not have arisen in the step-by- step progression of analytical thinking. This allows decision makers

to solve novel problems and overcome the neural and psychological barriers that can impede us from looking beyond the existing order.

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

Moreover, information and new learning may not be presented within the context of real-life situations, although this is changing. For example, in teaching clinical reasoning, nurse educators strive to see that the elements of clinical reasoning, such as noticing crucial changes in patient status, analyzing these changes to decide on a course of action, and evaluating responses to modify care, are embedded at every opportunity throughout the nursing curricula (Rischer, 2017). In addition, time is included for meaningful reflection on the decisions that are made and the outcomes that result. Such learning can occur in both real-world settings and through vicarious learning, where students’ problem solve and make decisions based on simulated situations that are made real to the learner.

Case Studies, Simulation, and Problem-Based Learning

Case studies, simulation, and problem-based learning (PBL) are some of the strategies that have been developed to vicariously improve problem solving and decision making. Case studies may be thought of as stories that impart learning. They may be fictional or include real persons and events, be relatively short and self- contained for use in a limited amount of time, or be longer with significant detail and complexity for use over extended periods of time. Case studies, particularly those that unfold or progress over time, are becoming much more common in nursing education because they provide a more interactive learning experience for students than the traditional didactic approach.

Similarly, simulation provides learners opportunities for problem solving that have little or no risk to patients or to organizational performance. For example, some organizations are now using computer simulation (known as discrete event simulation) to imitate the operation of a real-life system such as a hospital. The learner’s actions in the simulation provide insight to the quality of the learner’s decision making based on priority setting, timeliness of action, and patient outcomes.

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

The Marquis-Huston Critical Thinking Teaching Model The desired outcome for teaching and learning decision making and critical thinking in management is an interaction between learners and others that results in the ability to critically examine

management and leadership issues. This is a learning of appropriate social/professional behaviors rather than a mere acquisition of knowledge. This type of learning occurs best in groups, using a PBL approach.

In addition, learners retain didactic material more readily when it is personalized or when they can relate to the material being presented. The use of case studies that learners can identify with assists in retention of didactic materials.

Also, although formal instruction in critical thinking is important, using a formal decision-making process improves both the quality and consistency of decision making. Many new leaders and managers struggle to make quality decisions because their opportunity to practice making management and leadership decisions is very limited until they are appointed to a management position. These limitations can be overcome by creating opportunities for vicariously experiencing the problems that individuals would encounter in the real world of leadership and management.

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

FIGURE 1.1 The Marquis-Huston Critical Thinking Teaching Model.

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

learning exercises, however, require some degree of critical thinking, problem solving, decision making, or clinical reasoning.

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

Some of the case studies have been solved (solutions are found at the back of the book) so that readers can observe how a systematic problem-solving or decision-making model can be applied in solving problems common to nurse-managers. The authors feel strongly, however, that the problem solving suggested in the solved cases should not be considered the only plausible solution or “the right solution” to that learning exercise. Most of the learning exercises in the book have multiple solutions that could be implemented successfully to solve the problem.

Theoretical Approaches to Problem Solving and Decision Making Parrish (2018) notes that most people don’t actually stop to think. They just take their first thought and run with it. That’s because most individuals rely on discrete, often unconscious, processes known as heuristics to make decisions. Heuristics use trial-and-error methods or a rule-of-thumb approach to problem solving rather than set rules. As such, they are practical mental shortcuts and are not expected to provide perfect or optimal problem solving. They do, however, provide a more immediate solution to the decision at hand. This is particularly true for uncertain or emergent situations where knowledge, time, and resources are limited.

Monteiro, Norman, and Sherbino (2018) agree, noting that heuristics are often used in medicine and clinical practice given the

ambiguity surrounding clinical decision making. Clinicians then turn to heuristics to look for general guiding principles to alleviate this ambiguity.

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

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

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

DISPLAY 1.2 TRADITIONAL PROBLEM-SOLVING PROCESS

1. Identify the problem. 2. Gather data to analyze the causes and consequences of the

problem. 3. Explore alternative solutions. 4. Evaluate the alternatives. 5. Select the appropriate solution. 6. Implement the solution. 7. Evaluate the results.

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

Managerial Decision-Making Models To address the weaknesses of the traditional problem-solving process, many contemporary models for management decision making have added an objective-setting step. These models are known as managerial decision-making models or rational decision- making models. One such model suggested by Decision-making- confidence.com (2006–2019) includes the six steps shown in Display 1.3.

DISPLAY 1.3 MANAGERIAL DECISION-MAKING MODEL

1. Determine the decision and the desired outcome (set objectives).

2. Research and identify options. 3. Compare and contrast these options and their consequences. 4. Make a decision. 5. Implement an action plan. 6. Evaluate results.

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

In step 2, problem solvers must attempt to identify as many alternatives as possible. Alternatives are then analyzed in step 3, often using some type of SWOT (strengths, weaknesses, opportunities, and threats) analysis. Decision makers may choose to apply quantitative decision-making tools, such as decision-making grids and payoff tables (discussed further later in this chapter), to objectively review the desirability of alternatives.

In step 4, alternatives are rank ordered on the basis of the analysis done in step 3 so that problem solvers can make a choice. In step 5, a plan is created to implement desirable alternatives or combinations of alternatives. In the final step, challenges to successful implementation of chosen alternatives are identified and strategies are developed to manage those risks. An evaluation is then conducted of both process and outcome criteria, with outcome criteria typically reflecting the objectives that were set in step 1.

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

DISPLAY 1.4 NURSING PROCESS

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

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

FIGURE 1.2 Feedback mechanism of the nursing process.

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

TABLE 1.1 COMPARING THE DECISION-MAKING PROCESS WITH THE NURSING PROCESS

Decision-Making Process Simplified Nursing Process

Identify the decision. Assess Collect data. Identify criteria for decision. Plan Identify alternatives. Choose alternative. Implement Implement alternative. Evaluate steps in decision. Evaluate

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

Integrated Ethical Problem-Solving Model Another model for effective thinking and problem solving was developed by the National Association of Social Workers (2017; Display 1.5). Although developed primarily for use in solving ethical problems, the model also works well as a general problem-solving model. Like the three models already discussed, this model provides a structured approach to problem solving that includes an assessment of the problem, problem identification, the analysis and selection of the best alternative, and reflection as a means for evaluation.

DISPLAY 1.5 INTEGRATED ETHICAL PROBLEM-SOLVING MODEL

1. DETERMINE whether there is an ethical issue or/and dilemma. 2. IDENTIFY the key values and principles involved. 3. RANK the values or ethical principles which—in your

professional judgment—are most relevant to the issue or dilemma.

4. DEVELOP an action plan that is consistent with the ethical priorities that have been determined as central to the dilemma.

5. IMPLEMENT your plan, utilizing the most appropriate practice skills and competencies.

6. REFLECT on the outcome of this ethical decision-making process.

Source: Adapted from National Association of Social Workers. (2017). Essential steps for ethical problem-solving. Retrieved September 12, 2018, from https://www.naswma.org/page/100/Essential-Steps-for-Ethical-Problem- Solving.htm

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

Intuitive Decision-Making Models There are theorists who suggest that intuition should always be used as an adjunct to empirical or rational decision-making models. Experienced (expert) nurses often report that gut-level feelings (intuition) encourage them to take appropriate strategic action that

impacts patient outcomes, although intuition generally serves as an adjunct to decision making founded on a nurse’s scientific knowledge base. Intuition then can and should be used in conjunction with evidence-based practice.

Krishnan (2018) agrees, noting that as nurses work in ever- changing health-care environments, neither logical thinking nor intuition are adequate to describe the dynamic processes nurses use in clinical decision making. Thus, the cognitive processes used in decision making are neither completely analytical nor completely intuitive (see Examining the Evidence 1.1).

EXAMINING THE EVIDENCE 1.1 Source: Krishnan, P. (2018). A philosophical analysis of clinical decision making in nursing. Journal of Nursing Education, 57(2), 73–78. doi:10.3928/01484834-20180123-03

Clinical Decision Making: A Combination of Systematic and Intuitive Decision Making The purpose of this study was to compare the use of systematic decision making and intuition in clinical decision making. The origin, aim, value, ontology and epistemology, assumptions, communicability, and context specificity of both models were examined.

The researcher found little evidence to suggest that either systematic decision-making models or intuitive models should be used solely to account for the breadth of processes used in clinical decision making in nursing. The pattern of knowing links information processing and intuition together in clinical decision making. The researchers concluded that the combination of scientific evidence-based knowledge in conjunction with intuition and contextual factors is what enables nurses to achieve excellent clinical decision making.

This recognition of familiar problems and the use of intuition to identify solutions is a focus of contemporary research on intuitive decision-making research. Klein (2008) developed the recognition- primed decision (RPD) model for intuitive decision making in the mid-1980s to explain how people can make effective decisions under

time pressure and uncertainty. Considered a part of naturalistic decision making, the RPD model attempts to understand how humans make relatively quick decisions in complex, real-world settings such as firefighting and critical care nursing without having to compare options.

Klein’s (2008) work suggests that instead of using classical rational or systematic decision-making processes, many individuals act on their first impulse if the “imagined future” looks acceptable. If this turns out not to be the case, another idea or concept can emerge from their subconscious and is examined for probable successful implementation. Thus, the RPD model blends intuition and analysis, but pattern recognition and experience guide decision makers when time is limited or systematic rational decision making is not possible.

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

DISPLAY 1.6 CRITICAL ELEMENTS IN DECISION MAKING

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

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

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

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

LEARNING EXERCISE 1.1

Applying Scientific Models to Decision Making

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

Last week, however, the director of human resources told you that the full-time director of health-care services for the plant is leaving and that the organization wants to appoint you to the position. You were initially thrilled and excited; however, you found out several days later that you and your spouse are expecting a baby.

Last night, you spoke with your spouse about your career future. Your spouse is an attorney whose practice has suddenly gained momentum. Although the two of you have shared child rearing equally until this point, your spouse is not sure how much longer this can be done if the law practice continues to expand. If you take the position, which you would like to do, it would mean full- time work and more management responsibilities. You want the decision you and your spouse reach to be well-

thought-out, as it has far-reaching consequences and concerns many people.

ASSIGNMENT:

Determine what you should do. Examine both the individual aspects of decision making and the critical elements in making decisions. Make a plan including a goal, a list of information, and data that you need to gather and areas where you may be vulnerable to poor decision making. Examine the consequences of each alternative available to you.

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

Gather Data Carefully Because decisions are based on knowledge and information available to the problem solver at the time the decision must be made, one must learn how to process and obtain accurate information. The acquisition of information begins with identifying the problem or the occasion for the decision and continues throughout the problem-solving process. Often, the information is unsolicited, but most information is sought actively.

Clear (2018) warns, however, that many people experience confirmation bias in their data gathering. Confirmation bias refers to our tendency to search for and favor information that confirms our

beliefs while simultaneously ignoring or devaluing information that contradicts our beliefs (Clear, 2018). The more someone believes he or she knows something, the more he or she filters and ignores information to the contrary. Thus, people negate new information if it does not validate their perceptions or ideas.

In addition, acquiring information always involves people, and no tool or mechanism is infallible to human error. Questions that should be asked in data gathering are shown in Display 1.7.

DISPLAY 1.7 QUESTIONS TO EXAMINE IN DATA GATHERING

1. What is the setting? 2. What is the problem? 3. Where is it a problem? 4. When is it a problem? 5. Who is affected by the problem? 6. What is happening? 7. Why is it happening? What are the causes of the problem?

Can the causes be prioritized? 8. What are the basic underlying issues? What are the areas of

conflict? 9. What are the consequences of the problem? Which is the most

serious?

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

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

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

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

In fact, Parrish (2018) argues that most people need to actually schedule time to think. Although some people might think more than a few minutes is a waste of time, this viewpoint is shortsighted and flawed. Parrish suggests that although it might take 30 minutes to come to the same conclusion that you might come to in 5 minutes, you’ll have a better idea of the nuances of the situation, including which variables matter the most, and you’ll make less mistakes if you take the time to really think about it.

Use an Evidence-Based Approach To gain knowledge and insight into managerial and leadership decision making, individuals must reach outside their current sphere

of knowledge in solving the problems presented in this text. Some data-gathering sources include textbooks, periodicals, experts in the field, colleagues, and current research. Indeed, most experts agree that the best practices in nursing care and decision making are also evidence-based practices (Prevost & Ford, 2020).

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

Given that human lives are often at risk, nurses, then, should feel compelled to use an evidence-based approach in gathering data to make decisions regarding their nursing practice. Yet, Prevost and Ford (2020) suggest that many practicing nurses feel they do not have the time, access, or expertise needed to search and analyze the research literature to answer clinical questions. In addition, many staff nurses practicing in clinical settings have less than a baccalaureate degree and therefore may not have been exposed to a formal research course. Findings from research studies may also be technical, difficult to understand, and even more difficult to translate into practice. Strategies the new nurse might use to promote evidence-based practice are shown in Display 1.8.

DISPLAY 1.8 STRATEGIES FOR THE NEW NURSE TO PROMOTE EVIDENCE-BASED BEST PRACTICE

1. Keep abreast of the evidence—subscribe to professional journals and read widely.

2. Use and encourage use of multiple sources of evidence. 3. Use evidence not only to support clinical interventions but also

to support teaching strategies. 4. Find established sources of evidence in your specialty—do not

reinvent the wheel. 5. Implement and evaluate nationally sanctioned clinical practice

guidelines. 6. Question and challenge nursing traditions and promote a spirit

of risk taking. 7. Dispel myths and traditions not supported by evidence. 8. Collaborate with other nurses locally and globally. 9. Interact with other disciplines to bring nursing evidence to the

table.

Source: Reprinted from Prevost, S., & Ford, C. D. (2019). Evidence-based practice. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 69–80). Philadelphia, PA: Wolters Kluwer.

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

It is important to recognize that the implementation of evidence- based best practices is not just an individual, staff nurse–level pursuit (Prevost & Ford, 2020). Too few nurses understand what best practices and evidence-based practice are about, and many organizational cultures do not support nurses who seek out and use

research to change long-standing practices rooted in tradition rather than in science. Administrative support is needed to access the resources; provide the support personnel; and sanction the necessary changes in policies, procedures, and practices for evidence-based data gathering to be a part of every nurse’s practice (Prevost & Ford, 2020). This approach to care is even being recognized as a standard expectation of accrediting bodies such as The Joint Commission as well as an expectation for Magnet hospital designation.

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

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

Several techniques can help to generate more alternatives. Involving others in the process confirms the adage that two heads are better than one. Because everyone thinks uniquely, increasing the number of people working on a problem increases the number of alternatives that can be generated.

Brainstorming is another frequently used technique. The goal in brainstorming is to think of all possible alternatives, even those that may seem “off target.” By not limiting the possible alternatives to only apparently appropriate ones, people can break through habitual or

repressive thinking patterns and allow new ideas to surface. Although most often used by groups, people who make decisions alone also may use brainstorming.

LEARNING EXERCISE 1.2

Possible Alternatives in Problem Solving

In the personal-choice scenario presented in Learning Exercise 1.1, some of the following alternatives could have been generated:

Do not take the new position. Hire a full-time housekeeper and take the position. Ask your spouse to quit working. Have an abortion. Ask one of the parents to help. Take the position and do not hire childcare. Take the position and hire childcare. Have your spouse reduce the law practice and

continue helping with childcare. Ask the director of human resources if you can work 4

days a week and still have the position. Take the position and wait and see what happens after

the baby is born.

ASSIGNMENT:

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

Think Logically During the problem-solving process, one must draw inferences from information. An inference is part of deductive reasoning. People must carefully think through the information and the alternatives. Faulty logic at this point may lead to poor-quality decisions. Primarily, people think illogically in three ways.

1. Overgeneralizing: This type of “crooked” thinking occurs when one believes that because A has a particular characteristic, every other A also has the same characteristic. This kind of thinking is exemplified when stereotypical statements are used to justify arguments and decisions.

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

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

Various tools have been designed to assist managers with the important task of analysis. Several of these tools are discussed in this chapter. In analyzing possible solutions, individuals may want to look at the following questions:

1. What factors can you influence? How can you make the positive factors more important and minimize the negative factors?

2. What are the financial implications in each alternative? What are the political implications? Who else will be affected by the decision, and what support is available?

3. What are the weighting factors? 4. What is the best solution? 5. What are the means of evaluation? 6. What are the consequences of each alternative?

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

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

It may help the reluctant decision maker to remember that even though decisions often have long-term consequences and far- reaching effects, they are not usually cast in stone. Often, judgments

found to be ineffective or inappropriate can be changed. By later evaluating decisions, managers can learn more about their abilities and where the problem solving was faulty. However, decisions must continue to be made, although some are of poor quality, because through continued decision making, people develop improved decision-making skills.

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

Gender New research suggests that gender may play a role in how individuals make decisions, although some debate continues as to whether these differences are more gender role based than gender based. Research does suggest, however, that men and women do have different structures and wiring in the brain and that men and women may use their brains differently (Edmonds, 2018). For example, Harvard researchers have found that parts of the frontal lobe, responsible for problem solving and decision making, and the limbic cortex, responsible for regulating emotions, are larger in women (Hoag as cited in Edmonds, 2018). Men also have

approximately 6.5 times more gray matter in the brain than women, but women have about 10 times more white matter than men (Carey as cited in Edmonds, 2018). Researchers believe that men may think more with their gray matter, whereas women think more with the white matter. This use of white matter may allow a woman’s brain to work faster than a man’s (Hotz as cited in Edmonds, 2018).

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

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

Life Experience Each person brings to the decision-making task past experiences that include education and decision-making experience. The more mature the person and the broader his or her background, the more alternatives he or she can identify. Each time a new behavior or decision is observed, that possibility is added to the person’s repertoire of choices.

In addition, people vary in their desire for autonomy, so some nurses may want more autonomy than others. It is likely that people seeking autonomy may have much more experience at making decisions than those who fear autonomy. Likewise, having made good or poor decisions in the past will influence a person’s decision making.

Individual Preference With all the alternatives a person considers in decision making, one alternative may be preferred over another. The decision maker, for example, may see certain choices as involving greater personal risk than others and therefore may choose the safer alternative. Physical, economic, and emotional risks and time and energy expenditures are types of personal risks and costs involved in decision making. For example, people with limited finances or a reduced energy level may decide to select an alternative solution to a problem that would not have been their first choice had they been able to overcome limited resources.

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

whereas right-brain thinkers excelled at nonverbal ideation and creativity.

Some researchers, including Nobel Prize winner Roger Sperry, suggested that there were actually four different thinking styles based on brain dominance. Ned Herrmann, a researcher in critical thinking and whole-brain methods, also suggested that there are four brain hemispheres and that decision making varies with brain dominance (12 Manage: The Executive Fast Track, 2018). For example, Herrmann suggested that individuals with upper-left-brain dominance truly are analytical thinkers who like working with factual data and numbers. These individuals deal with problems in a logical and rational way. Individuals with lower-left-brain dominance are highly organized and detail oriented. They prefer a stable work environment and value safety and security over risk taking.

In addition, researchers suggested that individuals with upper- right-brain dominance were big picture thinkers who looked for hidden possibilities and were futuristic in their thinking. They were thought to frequently rely on intuition to solve problems and are willing to take risks to seek new solutions to problems. Individuals with lower-right-brain dominance experienced facts and problem solved in a more emotional way than the other three types. They were sympathetic, kinesthetic, and empathetic and focused more on interpersonal aspects of decision making (12 Manage: The Executive Fast Track, 2018).

Nauert (2018) suggests, however, that the existence of left or right brain dominance is too simplistic. He suggests that newer studies have failed to find evidence that individuals tend to have stronger left- or right-sided brain networks. Cherry (2019) agrees, suggesting that recent research has shown that the brain is not nearly as dichotomous as once thought. For example, abilities in subjects such as math are strongest when both halves of the brain work together. Indeed, both sides of the brain collaborate to perform a broad variety of tasks, and the two hemispheres communicate through the corpus

callosum (Cherry, 2019). Cherry notes that it is true that some brain functions occur in one or the other side of the brain (language tends to be on the left and attention more on the right), but people don’t tend to have a stronger left- or right-sided brain network.

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

LEARNING EXERCISE 1.3

Thinking Styles

In small groups, discuss individual variations in thinking. Did some individuals identify themselves as more intuitive thinkers or more linear thinkers? Did group members self- identify with one or more of the four thinking styles noted by Herrmann (12 Manage: The Executive Fast Track, 2018)? Did gender seem to influence thinking style or brain hemisphere dominance? What types of thinkers were represented in group members’ families? Did most group members view variances in a positive way?

Overcoming Individual Vulnerability in Decision Making How do people overcome subjectivity in making decisions? This can never be completely overcome or should it. After all, life would be boring if everyone thought alike. However, managers and leaders must become aware of their own vulnerability and recognize how it

influences and limits the quality of their decision making. Using the following suggestions will help decrease individual subjectivity and increase objectivity in decision making.

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

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

In addition, novice nurse-leaders of the future may increasingly choose to improve the quality of their decision making by the use of commercially purchased expert networks—communities of top thinkers, managers, and scientists—to help them make decisions. Such network panels are typically made up of researchers, health- care professionals, attorneys, and industry executives.

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

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

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

Although not all experts agree, many consider the following to be qualities of a successful decision maker:

Courage: Courage is particularly important and involves the willingness to take risks.

Sensitivity: Good decision makers seem to have some sort of antenna that makes them particularly sensitive to situations and

others. Energy: People must have the energy and desire to make things

happen. Creativity: Successful decision makers tend to be creative

thinkers. They develop new ways to solve problems.

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

Effect of Organizational Power Powerful people in organizations are more likely to have decisions made (by themselves or their subordinates) that are congruent with their own preferences and values. On the other hand, people wielding little power in organizations must always consider the preference of the powerful when they make management decisions. In organizations, choice is constructed and constrained by many factors, and therefore, choice is not equally available to all people.

In addition, not only do the preferences of the powerful influence decisions of the less powerful but the powerful also can inhibit the preferences of the less powerful. This occurs because individuals who remain and advance in organizations are those who feel and express values and beliefs congruent with the organization. Therefore, a balance must be found between the limitations of choice posed by the power structure within the organization and

totally independent decision making that could lead to organizational chaos.

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

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

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

Managers who are successful decision makers often attempt to make rational decisions, much like the economic man described in Table 1.2. Because they realize that restricted knowledge and limited alternatives directly affect a decision’s quality, these managers gather as much information as possible and generate many alternatives. Simon (1965) believed that the economic model of man, however, was an unrealistic description of organizational decision making. The complexity of information acquisition makes it impossible for the human brain to store and retain the amount of

information that is available for each decision. Because of time constraints and the difficulty of assimilating large amounts of information, most management decisions are made using the administrative man model of decision making.

TABLE 1.2 COMPARING THE ECONOMIC MAN WITH THE ADMINISTRATIVE MAN

Economic Administrative

Makes decisions in a very rational manner

Makes decisions that are good enough

Has complete knowledge of the problem or decision situation

Because complete knowledge is not possible, knowledge is always fragmented.

Has a complete list of possible alternatives

Because consequences of alternatives occur in the future, they are impossible to predict accurately.

Has a rational system of ordering preference of alternatives

Usually chooses from among a few alternatives, not all possible ones

Selects the decision that will maximize utility

The final choice is satisficing rather than maximizing.

Source: Based on Simon, H. A. (1965). The shape of automation for man and management. New York, NY: Harper & Row.

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

The administrative man never has complete knowledge and generates fewer alternatives. Simon (1965) argued that the

administrative man carries out decisions that are only satisficing, a term used to describe decisions that may not be ideal but result in solutions that have adequate outcomes. These managers want decisions to be “good enough” so that they “work,” but they are less concerned that the alternative selected is the optimal choice. The “best” choice for many decisions is often found to be too costly in terms of time or resources, so another less costly but workable solution is found.

Clear (2018) agrees, suggesting that although researchers and economists believed for some time that humans always made logical, well-considered decisions, more current research suggests that a wide range of mental errors often derail our thinking. Sometimes, we make logical decisions, but there are many times when we make emotional, irrational, and confusing choices.

Annie Duke (2018), a famous poker player, suggests this occurs because we often must make quick decisions with limited information. This means that mistakes, emotions, and poor choices are common. Judging the quality of our decision making on outcome alone then can be short sighted and counterproductive. Duke notes that sometimes, we make the best choice based on the information available, but other information is hidden. Other times, we choose a path with a high likelihood of success, but it fails. Still, other times, we make a decision that works, but other choices would have been better. So, decision making becomes less about being good or bad and more about “calibrating among all the shades of gray” (Duke, 2018, p. 34).

Decision-Making Tools There is always some uncertainty in making decisions. However, management analysts have developed tools that provide some order and direction in obtaining and using information or that are helpful in selecting who should be involved in making the decision. Because

there are so many decision aids, this chapter presents selected technology that would be most helpful to beginning- or middle-level managers, including decision grids, payoff tables, decision trees, consequence tables, logic models, and program evaluation and review technique (PERT). It is important to remember, though, that any decision-making tool always results in the need for the person to make a final decision and that all such tools are subject to human error.

Decision Grids A decision grid allows one to visually examine the alternatives and compare each against the same criteria. Although any criterion may be selected, the same criteria are used to analyze each alternative. An example of a decision grid is depicted in Figure 1.3. When many alternatives have been generated or a group or committee is collaborating on the decision, these grids are particularly helpful to the process. This tool, for instance, would be useful when changing the method of managing care on a unit or when selecting a candidate to hire from a large interview pool. The unit manager or the committee would evaluate all of the alternatives available using a decision grid. In this manner, every alternative is evaluated using the same criteria. It is possible to weigh some of the criteria more heavily than others if some are more important. To do this, it is usually necessary to assign a number value to each criterion. The result would be a numeric value for each alternative considered.

FIGURE 1.3 A decision grid.

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

If the instructor for the class costs $500, the in-service director would need to charge each of the 20 participants $25 for the class, but for 40 participants, the class would cost only $12.50 each. The in-service director would use attendance data from past classes and the number of nurses potentially available to attend to determine probable class size and thus how much to charge for the class. Payoff tables do not guarantee that a correct decision will be made, but they assist in visualizing data.

Decision Trees Because decisions are often tied to the outcome of other events, management analysts have developed decision trees.

The decision tree in Figure 1.4 compares the cost of hiring regular staff with the cost of hiring temporary employees. Here, the decision is whether to hire extra nurses at regular salary to perform outpatient procedures on an oncology unit or to have nurses available to the unit on an on-call basis and pay them on-call and overtime wages. The possible consequences of a decreased volume of procedures and an increased volume must be considered. Initially, costs would increase in hiring a regular staff, but, over a longer time, this move would mean greater savings if the volume of procedures does not dramatically decrease.

FIGURE 1.4 A decision tree.

Consequence Tables Consequence tables demonstrate how various alternatives create different consequences. A consequence table lists the objectives for

solving a problem down one side of a table and rates how each alternative would meet the desired objective.

For example, consider this problem: “The number of patient falls has exceeded the benchmark rate for two consecutive quarters.” After a period of analysis, the following alternatives were selected as solutions:

1. Provide a new educational program to instruct staff on how to prevent falls.

2. Implement a night check to ensure that patients have side rails up and beds in low position.

3. Implement a policy requiring direct patient observation by sitters on all confused patients.

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

TABLE 1.3 A CONSEQUENCE TABLE

Objectives for Problem Solving Alternative 1 Alternative 2 Alternative 3

1. Reduces the number of falls

X X X

2. Meets regulatory standards

X X X

3. Is cost-effective X X X 4. Fits present policy

guidelines X X X

Decision Score

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

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

problems are easily identified when they first occur. Flowcharts are popular, and many people use them in their personal lives.

FIGURE 1.5 Example of a program evaluation and review technique flow diagram.

Pitfalls in Using Decision-Making Tools A common flaw in making decisions is to base decisions on first impressions. This then typically leads to confirmation biases. A confirmation bias is a tendency to affirm one’s initial impression and preferences as other alternatives are evaluated. So, even the use of consequence tables, decision trees, and other quantitative decision tools will not guarantee a successful decision.

It is also human nature to focus on an event that leaves a strong impression, so individuals may have preconceived notions or biases that influence decisions. Too often, managers allow the past to unduly influence current decisions.

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

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

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

Managers who make quality decisions are effective administrators. The manager should develop a systematic, scientific approach to problem solving that begins with a fixed goal and ends with an evaluation step. Decision tools exist to help make more effective decisions; however, leader-managers must remember that they are

not foolproof and that they often do not adequately allow for the human element in management. In addition, managers should strive to make decisions that reflect research-based best practices and nursing’s scientific knowledge base. Yet, the role of intuition as an adjunct to quality decision making should not be overlooked.

The integrated leader-manager understands the significance that gender, personal values, life experience, preferences, willingness to take risks, brain hemisphere dominance, and thinking styles have on selected alternatives in making the decision. The critical thinker pondering a decision is aware of the areas of vulnerability that hinder successful decision making and will expend his or her efforts to avoid the pitfalls of faulty logic and data gathering.

Both managers and leaders understand the impact that the organization has on decision making and that some of the decisions that will be made in the organization will be only satisficing. However, leaders will strive to problem solve adequately in order to reach optimal decisions as often as possible.

Key Concepts

■ Successful decision makers are self-aware, courageous, sensitive, energetic, and creative.

■ The rational approach to problem solving begins with a fixed goal and ends with an evaluation process.

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

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

■ Typically, a PICO format is used in evidence-based practice to guide the search for the current best evidence to address a problem.

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

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

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

■ The act of making and evaluating decisions increases the expertise of the decision maker.

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

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

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

Additional Learning Exercises and Applications

LEARNING EXERCISE 1.4

Assessing Personal Decision Making ASSIGNMENT:

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

because of faulty data gathering. Have you ever made a poor decision because necessary information was intentionally or unintentionally withheld from you?

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

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

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

LEARNING EXERCISE 1.5

Sharing Workload

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

ASSIGNMENT:

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

LEARNING EXERCISE 1.6

Considering Critical Elements in Decision Making

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

ASSIGNMENT:

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

LEARNING EXERCISE 1.7

Decision Making and Risk Taking

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

It is now 2:30 PM, and you are preparing your handoff report. When you review the patient’s 2:00 PM vital signs, you note a significant rise in this patient’s blood pressure and heart rate. The patient, however, reports no distress. You remember that when you passed the morning medications, the patient was in the middle of her bath

and asked that you just set the medications on the bedside table and that she would take them in a few minutes. You meant to return to see that she did but were sidetracked by a problem with another patient.

You now go to the patient’s room to see if she, indeed, did take the pills. The pill cup and pills are not where you left them, and a search of the wastebasket, patient bed, and bedside table yields nothing. The patient is too confused to be an accurate historian regarding whether she took the pills. No one on your patient care team noticed the pills.

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

You do feel responsible, however, for the patient’s welfare. The physician might want to give additional doses of the medication if indeed the patient did not take the pills. In addition, the rise in heart rate and blood pressure has only just become apparent, and you realize

that her heart rate and blood pressure could continue to deteriorate over the next shift. The patient is not due to receive the medications again until 9:00 PM tonight (b.i.d. every 12 hours).

ASSIGNMENT:

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

LEARNING EXERCISE 1.8

Determining a Need to Know

You are a nursing student. You are also HIV positive because of some high-risk behaviors you engaged in a

decade ago. (It seems like a lifetime ago.) You are now in a committed, monogamous relationship, and your partner is aware of your HIV status. You have experienced relatively few side effects from the antiretroviral drugs you take, and you appear to be healthy. You have not shared your sexual preferences, past sexual history, or HIV status with any of your classmates, primarily because you do not feel that it is their business and because you fear being ostracized in the local community, which is fairly conservative.

Today, in the clinical setting, one of the students accidentally stuck herself with a needle right before she injected it into a patient. Laboratory follow-up was ordered to ensure that the patient was not exposed to any blood-borne disease from the student. Tonight, for the first time, you recognize that no matter how careful you are, there is at least a small risk that you could inadvertently expose patients to your bodily fluids and thus to some risk.

ASSIGNMENT:

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

LEARNING EXERCISE 1.9

Using a Flowchart for Project Management

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

ASSIGNMENT:

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

LEARNING EXERCISE 1.10

Addressing a Communication Gap (Marquis & Huston, 2012)

You are a new graduate nurse just finishing your 3- month probation period at your first job in acute care nursing. Your usual assignment is to be a team leader for eight patients, with one licensed practical nurse/licensed vocational nurse and one nursing assistant on your team. Today, your assignment included an elderly confused patient. You requested, during work assignments with

your team, that the nursing assistant pay attention to this patient’s intake and output (I & O) as you feel he may need some intravenous fluids if his I & O remain poor. You asked the nursing assistant to notify you if there was significant change, so you could notify the physician. It was a very busy day, and you have barely had a moment to reorganize and collect your thoughts.

It is now 2:30 PM, and you are preparing your end-of- shift report. When you review the patient’s 2:00 PM I & O sheet, you note a significant drop in intake and the total output for the shift is only 90 mL. You meant to check the I & O sheet during the day but kept getting sidetracked by problems with other patients. However, you are also upset that the nursing assistant did not keep you informed of this condition.

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

At this point, you are not sure what you should do next. You feel you should handle this yourself and not go to the charge nurse. You are a new nurse and do want to get started on the wrong foot by speaking too harshly to the nursing assistant, yet you feel this lack of following instructions cannot go unanswered. The reality is that if you do nothing, it is likely that no one else will ever know about the problem.

The doctor did not seem upset when you called him about the drop in output, he just ordered the fluids, but

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

ASSIGNMENT:

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

LEARNING EXERCISE 1.11

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

You have been a registered nurse (RN) for 5 years. Right after high school, you became a licensed vocational nurse (LVN) and after 6 years decided to attend a local LVN to associate degree in nursing program at a local community college. You have become increasingly interested in attending a baccalaureate university to complete requirements for your Bachelor of Science in Nursing (BSN) degree. You are still undecided; some of your friends are urging you to do this, and others ask why you need the degree.

Not only must you make up your mind about pursuing this option but you also have two different local opportunities. The regional university is 60 miles away

and would require significant amounts of driving if you did the on-campus program; however, the university’s school of nursing also offers an online course that would require only four full Saturdays of attendance each semester. Both options have pros and cons.

After making a payoff table, calculating chances for advancement and salary increase weighed against cost of your new degree, you decided that it made economic sense to get a BSN degree.

Now that you have decided to get your baccalaureate degree, you must decide between three alternatives: (a) attending a distant university 60 miles away, (b) attending your local university and enrolling in their on-campus program, or (c) enrolling as an online student.

ASSIGNMENT:

Create a decision grid for the three alternatives, weighting the same criteria for each, using such things as cost, travel, quality of campus life, reputation and quality of the university, and so on. Assign each of your criteria a weighted score for the value that you personally view it. What did your final grid look like and what was your final decision?

LEARNING EXERCISE 1.12

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

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

Statement

Not at all Rarely

Some times Often

Very often

1 I evaluate the risks associated with each alternative before making a decision.

2 After I make a decision, it is final— because I know my process is strong.

3 I try to determine the real issue before starting a decision-making process.

4 I rely on my own experience to find potential solutions to a problem.

5 I tend to have a strong “gut instinct” about problems, and I rely on it in decision-making.

6 I am sometimes surprised by the

actual consequences of my decisions.

7 I use a well-defined process to structure my decisions.

8 I think that involving many stakeholders to generate solutions can make the process more complicated than it needs to be.

9 If I have doubts about my decision, I go back and recheck my assumptions and my process.

10 I take the time needed to choose the best decision- making tool for each specific decision.

11 I consider a variety of potential solutions before I make my decision.

12 Before I communicate my decision, I create

an implementation plan.

13 In a group decision- making process, I tend to support my friends’ proposals and try to find ways to make them work.

14 When communicating my decision, I include my rationale and justification.

15 Some of the options I’ve chosen have been much more difficult to implement than I had expected.

16 I prefer to make decisions on my own, and then let other people know what I’ve decided.

17 I determine the factors most important to the decision, and then use those factors to evaluate my choices.

18 I emphasize how confident I am in

r

r

r

my decision as a way to gain support for my plans.

Total = 0

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

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

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

Establishing a Positive Decision-Making Environment (Statements 3, 7, 13, and 16) If you have ever been in a meeting where people seem to be discussing different issues, then you have seen what happens when the decision-making environment has not been established. It is so important for everyone to understand the issue before preparing to make a decision. This includes agreeing on an objective, making sure the right issue is being discussed, and agreeing on a process to move the decision forward.

You also must address key interpersonal considerations at the very beginning. Have you included all the stakeholders? And do the people involved in the decision agree to respect one another and engage in an

open and honest discussion? After all, if only the strongest opinions are heard, you risk not considering some of the best solutions available.

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

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

1. Risk—Most decisions involve some risk. However, you need to uncover and understand the risks to make the best choice possible.

2. Consequences—You cannot predict the implications of a decision with 100% accuracy. But you can be careful and systematic in the way that you identify and evaluate possible consequences.

3. Feasibility—Is the choice realistic and implementable? This factor is often ignored. You usually have to consider certain constraints when making a decision. As part of this evaluation stage, ensure that the alternative you have selected is significantly better than the status quo.

Deciding (Statements 5, 10, and 17)

Making the decision itself can be exciting and stressful. To help you deal with these emotions as objectively as possible, use a structured approach to the decision. This means taking a look at what is most important in a good decision.

Take the time to think ahead and determine exactly what will make the decision “right.” This will significantly improve your decision accuracy.

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

If the decision is a significant one, it is also worth auditing it to make sure that your assumptions are correct, and that the logical structure you have used to make the decision is sound.

Communicating and Implementing (Statements 12, 14, and 18) The last stage in the decision-making process involves communicating your choice and preparing to implement it. You can try to force your decision on others by demanding their acceptance. Or you can gain their acceptance by explaining how and why you reached your decision. For most decisions—particularly those that need participant buy-in before implementation—it is more effective to gather support by explaining your decision.

Have a plan for implementing your decision. People usually respond positively to a clear plan—one that tells

them what to expect and what they need to do. Source: Mind Tools Editorial Team. (1996–2018). How

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2

Classical Views of Leadership and Management

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

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

. . . leadership is a choice, not a position.—Stephen R. Covey

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

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

MSN Essential IX: Master’s level nursing practice

AONL Nurse Executive Competency I: Communication and relationship building

AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency III: Leadership ANA Standard of Professional Performance 11: Leadership QSEN Competency: Teamwork and collaboration

LEARNING OBJECTIVES

The learner will:

identify similarities and differences between leadership and management

differentiate between leadership roles and management functions

discuss the historical evolution of management theory correlate management theorists with their appropriate theoretical contributions

define the components of the management process discuss the historical evolution of leadership theory correlate leadership theorists with their appropriate theoretical contributions

identify common leadership styles and describe situations in which each leadership style could be used appropriately

differentiate between authoritative, democratic, and laissez-faire leadership styles

describe the differences between interactional and transformational leadership theories

identify contextual factors impacting the relationship between leaders and followers based on full-range leadership theory

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

delineate variables suggested in situational and contingency theories

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

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

Kerr (2015) suggests,

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

In fact, Kerr (2015) suggests there are 10 important distinctions between leaders and managers and these differences must be understood and recognized so that an organization can leverage each to the fullest (Display 2.1).

DISPLAY 2.1 TEN DISTINCTIONS BETWEEN LEADERS AND MANAGERS (KERR, 2015)

1. Leadership inspires change; management manages transformation.

2. Leadership requires vision; management requires tenacity. 3. Leadership requires imagination; management requires

specifics. 4. Leadership requires abstract thinking; management requires

concrete data. 5. Leadership requires ability to articulate; management requires

ability to interpret. 6. Leadership requires an aptitude to sell; management requires

an aptitude to teach. 7. Leadership requires understanding of the external

environment; management requires understanding of how work gets done inside the organization.

8. Leadership requires risk taking; management requires self- discipline.

9. Leadership requires confidence in the face of uncertainty; management requires blind commitment to completing the task at hand.

10. Leadership is accountable to the entire organization; management is accountable to the team.

So which is more important—good leadership or good management? The answer varies depending on the situation (situational leadership). We are all aware of individuals in leadership positions who cannot manage and individuals in management roles who cannot lead.

If a manager guides, directs, and motivates and a leader empowers others, however, then it could be said that every manager

should be a leader. Fowler (2015) agrees, suggesting that not only are the differences between leadership and management difficult to verbalize, but for the clinical nurse, it is even more difficult to work out what particular “hat” you are wearing or should be wearing when trying to lead and manage a team through a busy shift. Clinicians often act as both leaders and managers in the clinical setting, even if not officially recognized as doing so, and that their success in these roles is critical to high-level unit functioning and the attainment of patient goals. Indeed, Fowler suggests that good clinical leaders must continually find an intersection between good leadership and management skills to be successful.

Unfortunately, a 2016 Gallup poll found that only 18% of managers demonstrated a high level of talent for managing others—meaning a shocking 82% of managers weren’t very good at leading people (Hougaard, 2018). This may be occurring because the processes that help determine and shape leaders often produce people who behave differently from what many employees desire. In addition, managers are often promoted into their roles based on tenure or previous manager roles—with little account for whether they possess the humanistic skills and qualities of good leadership. Hougaard (2018) also notes that in many cases, the qualities that organizations actually select for and reward in most workplaces—ambition, perfectionism, competitiveness—are precisely the ones that are unlikely to produce leaders who are good for employees or for long- term organizational performance.

Paradoxically, many leaders are guilty of self-deception. In a 2016 McKinsey & Company study of more than 52,000 managers and employees, leaders rated themselves as better and more engaging than their employees did. This included 86% of leaders who believed they modeled the improvements they wanted employees to make, whereas another 77% of leaders believed they “inspired action.” These figures differ dramatically from the 2016 Gallup poll,

suggesting that a surprising number of leaders may suffer from inflated views of their abilities (Hougaard, 2018).

In the end, both leadership and management skills are needed for organizational success. The other reality is that leadership without management results in chaos and failure for both the organization and the individual executive. Boss (2018) agrees, noting that most organizations are in a perpetual state of flux—and always will be. Managers are needed to fund, allocate, or reallocate resources for the changes that continually occur. Leaders are needed, however, to strategize how best the organization can adapt. This need to envision, create, sustain, and adapt are imperative to organizational success (Boss, 2018). Thus, in the face of significant change, both sound management and strong leadership skills are essential to the long-term viability of today’s health-care organizations. Kerr (2015) agrees, suggesting that most organizations need both kinds of skills and aptitudes to secure enduring success.

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

LEARNING EXERCISE 2.1

Leadership Roles and Management Functions

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

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

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

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

To examine the word leader, however, is to note that leaders lead. Leaders are those individuals who take risks, attempt to achieve shared goals, and inspire others to action. Those individuals who choose to follow a leader do so by choice, not because they have to. Stoner (2018) notes then that leadership impact depends on the ability to influence people, not the ability to command, coerce, or manipulate.

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

How do you recognize a leader? It’s not by their location. A leader can be out in front, in the middle or following behind. You recognize a leader by the response of their followers (Stoner, 2018).

Other characteristics of leaders include the following:

Leaders often do not have delegated authority but obtain their power through other means, such as influence.

Leaders have a wider variety of roles than do managers. Leaders may or may not be part of the formal organization. Leaders focus on group process, information gathering,

feedback, and empowering others. Leaders emphasize interpersonal relationships. Leaders direct willing followers. Leaders have goals that may or may not reflect those of the

organization.

Trojani (2018) notes that leadership requires a constant exchange between leaders and followers that is both verbal and nonverbal.

The strength of the relationship depends on each party’s capacity to support the other. Trojani argues then that leadership is not about individuals; it is a shared responsibility between leaders and followers.

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

DISPLAY 2.2 TEN FATAL LEADERSHIP FLAWS

1. Lack of energy and enthusiasm 2. Acceptance of their own mediocre performance 3. Lack of a clear vision and direction 4. Having poor judgment 5. Not collaborating 6. Not walking the talk 7. Resisting new ideas 8. Not learning from mistakes 9. A lack of interpersonal skills 10. Failing to develop others

Source: Zenger, J., & Folkman, J. (2009). Ten fatal flaws that derail leaders. Harvard Business Review, 87(6), 18. Retrieved July 9, 2018, from https://hbr.org/2009/06/ten-fatal-flaws-that-derail-leaders/sb1

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

DISPLAY 2.3 COMMON LEADERSHIP ROLES

Decision maker Communicator Evaluator Facilitator Risk taker Mentor Energizer Priority setter

Coach Counselor Teacher Critical thinker Buffer Advocate Visionary Director

Forecaster Influencer Creative problem

solver Change agent Diplomat Role model Innovator Encourager

DISPLAY 2.4 A COMPARISON OF TRADITIONAL MANAGEMENT AND LEADERSHIP COMPONENTS

Managers Are assigned a position by the organization Have a legitimate source of power due to delegated authority

that accompanies their position Have specific duties and responsibilities they are expected to

carry out Emphasize control, decision making, decision analysis, and

results Manipulate people, the environment, money, time, and other

resources to achieve the goals of the organization Have a greater formal responsibility and accountability for

rationality and control than leaders Direct willing and unwilling subordinates

Leaders Often do not have delegated authority but obtain power through

other means, such as influence Have a wider variety of roles than managers Focus on group process, information gathering, feedback, and

empowering others May or may not be part of the formal hierarchy of the

organization Emphasize interpersonal relationships Direct willing followers Have goals that may or may not reflect those of the organization

Historical Development of Management Theory

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

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

Scientific Management (1900 to 1930) Frederick W. Taylor, the “father of scientific management,” was a mechanical engineer in the Midvale and Bethlehem Steel plants in Pennsylvania in the late 1800s. Frustrated with what he called “systematic soldiering,” where workers achieved minimum standards doing the least amount of work possible, Taylor postulated that if workers could be taught the “one best way to accomplish a task,” productivity would increase. Borrowing a term coined by Louis Brandeis, a colleague of Taylor’s, Taylor called these principles scientific management. The four overriding principles of scientific management as identified by Taylor (1911) are the following:

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

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

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

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

FIGURE 2.1 Factory workers use an efficient assembly line process. (Courtesy of Shutterstock.com.)

What was the result of scientific management? Productivity and profits rose dramatically. Organizations were provided with a rational means of harnessing the energy of the industrial revolution. Some experts have argued that Taylor (1911) lacked humanism and that his scientific principles were not in the best interest of unions or workers. However, it is important to remember the era in which Taylor did his work. During the Industrial Revolution, laissez-faire economics prevailed, optimism was high, and a Puritan work ethic prevailed. Taylor maintained that he truly believed managers and workers would be satisfied if financial rewards were adequate as a result of increased productivity. As the cost of labor rises in the United States, many organizations are taking a new look at scientific management with the implication that we need to think of new ways to do traditional tasks so that work is more efficient.

About the same time that Taylor (1911) was examining worker tasks, Max Weber, a well-known German sociologist, began to study large-scale organizations to determine what made some workers more efficient than others. Weber saw the need for legalized, formal authority and consistent rules and regulations for personnel in different positions; he thus proposed bureaucracy as an organizational design. His essay “Bureaucracy” was written in 1922 in response to what he perceived as a need to provide more rules, regulations, and structure within organizations to increase efficiency. Much of Weber’s work and bureaucratic organizational design are still evident today in many health-care institutions. His work is discussed further in Chapter 12.

LEARNING EXERCISE 2.2

Strategies for Efficiency

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

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

The management process, shown in Figure 2.2, is this book’s organizing framework. Brief descriptions of the five functions for each phase of the management process follow:

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

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

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

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

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

FIGURE 2.2 The management process.

Human Relations Management (1930 to 1970) During the 1920s, worker unrest developed. The Industrial Revolution had resulted in great numbers of relatively unskilled laborers working in large factories on specialized tasks. Thus, management scientists and organizational theorists began to look at the role of worker satisfaction in production. This human relations era developed the concepts of participatory and humanistic management, emphasizing people rather than machines.

Mary Parker Follett (1926) was one of the first theorists to suggest basic principles of what today would be called participative decision making or participative management. In her essay “The Giving of Orders,” Follett espoused her belief that managers should have authority with, rather than over, employees. Thus, solutions could be found that satisfied both sides without having one side dominate the other.

The human relations era also attempted to correct what was perceived as the major shortcoming of the bureaucratic system—a failure to include the “human element.” Studies done at the Hawthorne Works of the Western Electric Company near Chicago between 1927 and 1932 played a major role in this shifting focus. The studies, conducted by Elton Mayo and his Harvard associates, began as an attempt to look at the relationship between light illumination in the factory and productivity.

Mayo and his colleagues discovered that when management paid special attention to workers, productivity was likely to increase, regardless of the environmental working conditions. This Hawthorne effect indicated that people respond to the fact that they are being studied, attempting to increase whatever behavior they feel will continue to warrant the attention. Mayo (1953) also found that informal work groups and a socially informal work environment were factors in determining productivity, and Mayo recommended more employee participation in decision making.

Douglas McGregor (1960) reinforced these ideas by theorizing that managerial attitudes about employees (and, hence, how managers treat those employees) can be directly correlated with employee satisfaction. He labeled this Theory X and Theory Y. Theory X managers believe that their employees are basically lazy, need constant supervision and direction, and are indifferent to organizational needs. Theory Y managers believe that their workers enjoy their work, are self-motivated, and are willing to work hard to meet personal and organizational goals.

Chris Argyris (1964) supported McGregor (1960) and Mayo (1953) by saying that managerial domination causes workers to become discouraged and passive. He believed that if self-esteem and independence needs are not met, employees will become discouraged and troublesome or may leave the organization. Argyris stressed the need for flexibility within the organization and employee participation in decision making.

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

TABLE 2.1 THE DEVELOPMENT OF MANAGEMENT THEORY 1900 TO 1970

Theorist Theory

Taylor Scientific management Weber Bureaucratic organizations Fayol Management functions Gulick Activities of management Follett Participative management Mayo Hawthorne effect McGregor Theories X and Y Argyris Employee participation

LEARNING EXERCISE 2.3

Management Skills Assessment

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

Historical Development of Leadership Theory (1900 to Present) Because strong management skills were historically valued more than strong leadership skills, the scientific study of leadership did not begin until the 20th century. Early works focused on broad conceptualizations of leadership, such as the traits or behaviors of the leader. Contemporary research focuses more on leadership as a process of influencing others within an organizational culture and the interactive relationship of the leader and follower. To better understand newer views about leadership, it is necessary to look at how leadership theory has evolved over the last century.

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

The Great Man Theory/Trait Theories (1900 to 1940) The Great Man theory and trait theories were the basis for most leadership research until the mid-1940s. The Great Man theory, from Aristotelian philosophy, asserts that some people are born to lead, whereas others are born to be led. It also suggests that great leaders will arise when the situation demands it.

Trait theories assume that some people have certain characteristics or personality traits that make them better leaders than others. To determine the traits that distinguish great leaders, researchers studied the lives of prominent people throughout history. The effect of followers and the impact of the situation were ignored. Although trait theories have obvious shortcomings (e.g., they neglect the impact of others or the situation on the leadership role), they are

worth examining. Many of the characteristics identified in trait theories (Display 2.5) are still used to describe successful leaders today.

DISPLAY 2.5 CHARACTERISTICS ASSOCIATED WITH LEADERSHIP

Intelligence Knowledge Judgment Decisiveness Oral fluency Emotional

intelligence Independence Personable Skilled

communicator Adaptability

Creativity Cooperativeness Alertness Self-confidence Personal integrity Emotional balance

and control Risk taking Critical thinking Ability Able to enlist

cooperation

Interpersonal skills Tact Diplomacy Prestige Social participation Charisma Collaborative

priority setting Resilience

Contemporary opponents of trait theories argue, however, that leadership skills can be developed, not just inherited. That is not to say that some people don’t have certain characteristics or personality traits that may make it easier for them to lead. For example, Huston (2018) notes that some people, even at very young ages, are more fearless. Others are just naturally more outgoing; they’re more curious; they take more risks. But not all leaders need to be gregarious by nature. There’s lots of room for quiet leadership. In fact, some of the most effective leaders are individuals who didn’t seek out that role—they simply grew into it because they stepped forth to do what had to be done when no one else would (Huston, 2018).

Perhaps leaders are both born and made that way.

Behavioral Theories (1940 to 1980) During the human relations era, many behavioral and social scientists studying management also studied leadership. For example, McGregor’s (1960) theories had as much influence on leadership research as they did on management science. As leadership theory developed, researchers moved away from studying what traits the leader had and placed emphasis on what he or she did—the leader’s style of leadership.

A breakthrough occurred when Lewin (1951) and White and Lippitt (1960) isolated common leadership styles. Later, these styles came to be called authoritarian, democratic, and laissez-faire.

The authoritarian leader is characterized by the following behaviors:

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

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

The democratic leader exhibits the following behaviors:

Less control is maintained.

Economic and ego awards are used to motivate. Others are directed through suggestions and guidance. Communication flows up and down. Decision making involves others. Emphasis is on “we” rather than I and you. Criticism is constructive.

In other words, democratic leaders seek input from their followers and include them in decision making whenever possible. Stoker (2018) suggests that when you ask a person for his or her ideas or to help you solve a problem, you are sending the message that you value the person’s ideas and experience and you are also creating a learning opportunity to hear something you need to know.

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

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

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

Takes a hands-off approach. Is permissive, with little or no control. Motivates by support when requested by the group or

individuals. Provides little or no direction. Uses upward and downward communication between members

of the group.

Disperses decision making throughout the group. Places emphasis on the group. Does not criticize.

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

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

Situational and Contingency Leadership Theories (1950 to 1980) The idea that leadership style should vary according to the situation or the individuals involved was first suggested almost 100 years ago by Mary Parker Follett, one of the earliest management consultants and among the first to view an organization as a social system of contingencies. Her ideas, published in a series of books between 1896 and 1933, were so far ahead of their time that they did not gain appropriate recognition in the literature until the 1970s. Her law of the situation, which said that the situation should determine the

directives given after allowing everyone to know the problem, was contingency leadership in its humble origins.

LEARNING EXERCISE 2.4

Leadership Skills Assessment

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

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

Fiedler’s (1967) contingency approach reinforced these findings, suggesting that no one leadership style is ideal for every situation. Fiedler felt that the interrelationships between the group’s leader and its members were most influenced by the manager’s ability to be a good leader. The task to be accomplished and the power associated with the leader’s position also were cited as key variables.

In contrast to the continuum from autocratic to democratic, Blake and Mouton’s (1964) grid showed various combinations of concern or focus that managers had for or on productivity, tasks, people, and relationships. In each of these areas, the leader-manager may rank

high or low, resulting in numerous combinations of leadership behaviors. Various formations can be effective depending on the situation and the needs of the worker.

Hersey and Blanchard (1977) also developed a situational approach to leadership. Their tridimensional leadership effectiveness model predicts which leadership style is most appropriate in each situation on the basis of the level of the followers’ maturity. As people mature, leadership style becomes less task focused and more relationship oriented.

Tannenbaum and Schmidt (1958) built on the work of Lewin (1951) as well as White and Lippitt (1960), suggesting that managers need varying mixtures of autocratic and democratic leadership behavior. They believed that the primary determinants of leadership style should include the nature of the situation, the skills of the manager, and the abilities of the group members.

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

This complexity of variables suggests there is likely no “one-size- fits-all” answer to the question of what leadership style is most effective. In the face of ambiguity and complexity, it seems that good leadership is nuanced and requires careful consideration (see Examining the Evidence 2.1).

Not all leadership is virtuous leadership (Haden, 2017).

EXAMINING THE EVIDENCE 2.1 Source: Maxwell, E. (2017). Good leadership in nursing: What is the most effective approach? Nursing Times, 113(8), 18–21. Retrieved July 16, 2018, from https://www.nursingtimes.net/clinical- archive/leadership/good-leadership-in-nursing-what- is-the-most-effective-approach/7019475.article

What Makes Good Leadership in Nursing? Despite overwhelming interest in leadership within the nursing profession, there is surprisingly little evidence about what approach to leadership actually works best in nursing. Maxwell notes there is evidence to suggest that nurse leadership has a significant impact in two main areas: patient experience and outcomes and nurse satisfaction and retention. There is some suggestion that the latter then influences the former.

There is also a body of evidence indicating that nurse leadership styles have a strong influence on nurse morale and retention. Finally, Maxwell notes that some evidence exists that good leadership can have a positive impact on patient outcomes through creating the conditions, which allow nurses to reach their full potential and build both personal and organizational resilience in the face of unexpected or increased workload.

The author concludes that determining what makes good nurse leadership is challenging, and this complexity means there is likely no “one-size-fits-all” answer to the question. In the

face of ambiguity and complexity, it seems that good leadership is nuanced and requires careful consideration.

Interactional Leadership Theories (1970 to Present) The basic premise of interactional theory is that leadership behavior is generally determined by the relationship between the leader’s personality and the specific situation. Schein (1970), an interactional theorist, was the first to propose a model of humans as complex beings whose working environment was an open system to which they responded. A system may be defined as a set of objects, with relationships between the objects and between their attributes. A system is considered open if it exchanges matter, energy, or information with its environment. Schein’s model, based on systems theory, had the following assumptions:

People are very complex and highly variable. They have multiple motives for doing things. For example, a pay raise might mean status to one person, security to another, and both to a third.

People’s motives do not stay constant; instead, they change over time.

Goals can differ in various situations. For example, an informal group’s goals may be quite distinct from a formal group’s goals.

A person’s performance and productivity are affected by the nature of the task and by his or her ability, experience, and motivation.

No single leadership strategy is effective in every situation.

To be successful, the leader must diagnose the situation and select appropriate strategies from a large repertoire of skills. Hollander (1978) was among the first to recognize that both leaders

and followers have roles outside of the leadership situation and that both may be influenced by events occurring in their other roles.

With leader and follower contributing to the working relationship and both receiving something from it, Hollander (1978) saw leadership as a dynamic two-way process. According to Hollander, a leadership exchange involves three basic elements:

The leader, including his or her personality, perceptions, and abilities

The followers, with their personalities, perceptions, and abilities The situation within which the leader and the followers function,

including formal and informal group norms, size, and density

Leadership effectiveness, according to Hollander (1978), requires the ability to use the problem-solving process; maintain group effectiveness; communicate well; demonstrate leader fairness, competence, dependability, and creativity; and develop group identification.

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

In the 1990s, Theory Z lost its favor with many management theorists. American managers seemed unable to put these same ideas into practice in the United States. Instead, many continued to

boss-manage workers in an attempt to make them do what they do not want to do. Although Theory Z is more comprehensive than many of the earlier theories, it too neglects some of the variables that influence leadership effectiveness. It has the same shortcomings as situational theories in inadequately recognizing the dynamics of the interaction between the worker and the leader.

One of the pioneering leadership theorists of this time was Kanter (1977), who developed the theory that the structural aspects of the job shape a leader’s effectiveness. She postulated that the leader becomes empowered through both formal and informal systems of the organization. A leader must develop relationships with a variety of people and groups within the organization in order to maximize job empowerment and be successful. The three major work empowerment structures within the organization are opportunity, power, and proportion. Kanter asserts that these work structures have the potential to explain differences in leader responses, behaviors, and attitudes in the work environment.

Nelson and Burns (1984) suggested that organizations and their leaders have four developmental levels and that these levels influence productivity and worker satisfaction. The first of these levels is reactive. The reactive leader focuses on the past, is crisis driven, and is frequently abusive to subordinates. In the next level, responsive, the leader is able to mold subordinates to work together as a team, although the leader maintains most decision-making responsibility. At the proactive level, the leader and followers become more future oriented and hold common driving values. Management and decision making are more participative. At the last level, high-performance teams, maximum productivity and worker satisfaction are apparent.

Kanter (1989) perhaps best summarized the work of the interactive theorists by her assertion that title and position authority were no longer sufficient to mold a workforce where subordinates

are encouraged to think for themselves, and instead, managers must learn to work synergistically with others.

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

TABLE 2.2 TRANSACTIONAL AND TRANSFORMATIONAL LEADERS

Transactional Leader Transformational Leader

Focuses on management tasks Identifies common values Is directive and results oriented Is a caretaker Uses trade-offs to meet goals Inspires others with vision Does not identify shared values Has long-term vision Examines causes Looks at effects Uses contingency reward Empowers others

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

Similarly, Bass and Avolio (1994) suggested that transformational leadership leads followers to levels of higher morals because such leaders do the right thing for the right reason, treat people with care and compassion, encourage followers to be more creative and innovative, and inspire others with their vision. This new shared vision provides the energy required to move toward the future. Similarly, the American Nurses Association California (2019) suggests that leaders do more than delegate, dictate, and direct; they help others achieve their highest potential.

Kouzes and Posner (2017) are perhaps the best known authors to further the work on transformational leadership in the past decade. Kouzes and Posner suggest that exemplary leaders foster a culture in which relationships between aspiring leaders and willing followers can thrive. This requires the development of the five practices shown in Display 2.6. Kouzes and Posner suggest that when these five practices are employed, anyone can further their ability to lead others to get extraordinary things done.

DISPLAY 2.6 KOUZES AND POSNER’S FIVE PRACTICES FOR EXEMPLARY LEADERSHIP

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

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

3. Challenging the process: identifies opportunities and taking action

4. Enabling others to act: fosters collaboration, trust, and the sharing of power

5. Encouraging the heart: recognizes, appreciates, and celebrates followers and the achievement of shared goals

Source: Kouzes, J., & Posner, B. (2017). The leadership challenge (6th ed.). San Francisco, CA: Jossey-Bass.

Although the transformational leader is held as the current ideal, many management theorists sound a warning about transformational leadership. Although transformational qualities are highly desirable, they must be coupled with the more traditional transactional qualities of the day-to-day managerial role. In addition, both sets of characteristics need to be present in the same person in varying degrees. The transformational leader will fail without traditional management skills. Indeed, some leaders are not very visionary or inspiring. Still, others are inspiring and passionate, but their vision and desired outcomes are flawed.

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

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

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

Thus, the transformational leadership helps the full-range leader motivate his or her team and allows the leader to be viewed as an example of what they can become. Transactional leadership, however, is still needed to reinforce or modify behavior respectively, and laissez-faire leadership is included because there will be times when the full-range leader needs to step back and do nothing because the team is fully capable of doing the work on its own. Thus, full-range leaders evolve and adapt their leadership style based on which leadership styles are needed for a given situation.

Further work by Antonakis, Avolio, and Sivasubramaniam (2003) suggested there are nine factors impacting leadership style and its impact on followers in the FRLM; five are transformational, three are transactional, and one is a nonleadership or laissez-faire leadership factor (Display 2.7; Rowold & Schlotz, 2009).

DISPLAY 2.7 NINE FACTORS IN THE FULL-RANGE LEADERSHIP MODEL (AS DESCRIBED BY ROWOLD & SCHLOTZ, 2009)

Factor 1 Inspirational motivation Transformational Factor 2 Idealized influence (attributed) Transformational Factor 3 Idealized influence (behavior) Transformational Factor 4 Intellectual stimulation Transformational Factor 5 Individualized consideration Transformational Factor 6 Contingent reward Transactional Factor 7 Active management-by-exception Transactional Factor 8 Management-by-exception

passive Transactional

Factor 9 Nonleadership Laissez-faire

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

recognizing and appreciating their unique needs, strengths, and challenges.

The first transactional factor, as described by Rowold and Schlotz (2009), is contingent reward. Here, the leader is task oriented in providing followers with meaningful rewards based on successful task completion. Active management-by-exception, the second transactional factor, suggests that the leader watches and searches actively for deviations from rules and standards and takes corrective actions when necessary. In contrast, the third transactional factor, management-by-exception passive, describes a leader who intervenes only after errors have been detected or standards have been violated. Finally, the ninth factor of full-range leadership theory is the absence of leadership. Thus, laissez-faire is a contrast to the active leadership styles of transformational and transactional leadership exemplified in the first eight factors.

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

Integrating Leadership Roles and Management Functions Because rapid, dramatic change will continue in nursing and the health-care industry, it has grown increasingly important for nurses to develop skill in both leadership roles and management functions. For managers and leaders to function at their greatest potential, the two must be integrated.

Gardner (1990) asserted that integrated leader-managers possess six distinguishing traits:

1. They think longer term: They are visionary and futuristic. They consider the effect that their decisions will have years from now as well as their immediate consequences.

2. They look outward, toward the larger organization: They do not become narrowly focused. They are able to understand how their unit or department fits into the bigger picture.

3. They influence others beyond their own group: Effective leader- managers rise above an organization’s bureaucratic boundaries.

4. They emphasize vision, values, and motivation: They understand intuitively the unconscious and often nonrational aspects that are present in interactions with others. They are very sensitive to others and to differences in each situation.

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

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

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

TABLE 2.3 LEADERSHIP THEORISTS AND THEORIES

Theorist Theory

Aristotle Great Man theory Lewin and White Leadership styles Follett Law of the situation Fiedler Contingency leadership Blake and Mouton Task versus relationship in determining

leadership style Hersey and Blanchard

Situational leadership theory

Tannenbaum and Schmidt

Situational leadership theory

Kanter Organizational structure shapes leader effectiveness

Burns Transactional and transformational leadership

Bass and Avolio Transformational leadership Full-range leadership theory

Kouzes and Posner Five practices for exemplary leadership Gardner The integrated leader-manager

In examining leadership and management, it becomes clear that these two concepts have a symbiotic or synergistic relationship. Every nurse is a leader and manager at some level, and the nursing

role requires leadership and management skills. The need for visionary leaders and effective managers in nursing precludes the option of stressing one role over the other. Highly developed management skills are needed to maintain healthy organizations. So too are the visioning and empowerment of subordinates through an organization’s leadership team. Because rapid, dramatic change will continue in nursing and the health-care industry, it continues to be critically important for nurses to develop skill in both leadership roles and management functions and to strive for the integration of leadership characteristics throughout every phase of the management process.

Key Concepts

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

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

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

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

■ Research has shown that the leader-manager must assume a variety of leadership styles, depending on the needs of the worker, the task to be performed, and the situation or

environment. This is known as situational or contingency leadership theory.

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

■ Early leadership theories focused on the traits and characteristics of leaders.

■ Interactional leadership theory focuses more on leadership as a process of influencing others within an organizational culture and the interactive relationship of the leader and follower.

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

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

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

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

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

Additional Learning Exercises and Applications

LEARNING EXERCISE 2.5

When Culture and Policy Clash

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

The nursing staff has come to you on two occasions and complained about the family’s noncompliance with visiting hours and unauthorized food. Normally, the nursing staff on your unit has tried to develop culturally sensitive nursing care plans, so their complaints have taken you by surprise.

Yesterday, two of the family members visited you and complained about hospital visitor policies and what they took to be rudeness by two different staff members. You spent time talking to the family, and when they left, they seemed agreeable and understanding.

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

ASSIGNMENT:

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

Then, list at least five management functions and five leadership roles that you could delineate in this scenario. How would you divide the management functions and leadership roles? For example, you might say that having the nurse-manager adhere to hospital policy was a management function and that counseling staff was a leadership role.

LEARNING EXERCISE 2.6

Leadership Challenges for Health-Care Leaders

Mary Starmann Harrison, president and chief executive officer (CEO) of Hospital Sisters Health System, was quoted in an article by Smith (2012) that the greatest challenge for health-care leaders today is the transition from volume to value, including a determination of how best to guide the organization through that transition as

well as the timing to do so. Doug Smith, president and CEO of B.E. Smith, suggests that the greatest challenges for contemporary health-care leaders are large turnover numbers and an inability or unwillingness to change. Carol Dozer, CEO of Ivinson Memorial Hospital, suggests it is the need to cut costs and preserve resources while bringing in the resources needed to operate under a value-based system.

ASSIGNMENT:

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

LEARNING EXERCISE 2.7

Quiet at Night?

You are the night shift charge nurse on a busy surgical unit in a large, urban teaching hospital. Surgeries occur around the clock, and frequently, noise levels are higher than desired because of the significant number of nurses,

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

ASSIGNMENT:

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

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

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

LEARNING EXERCISE 2.8

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

Sally Jones is a 36-year-old new registered nurse (RN) who graduated 6 months ago from a community college with an associate degree in nursing. Sally worked her way through school as a licensed practical nurse in a pediatric unit of a local hospital. After passing her RN exams, she moved to a larger city and was hired to work

the evening shift on the pediatric unit as a primary care nurse. Her patient load is usually six pediatric patients, and she has a nursing assistant working under her supervision.

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

ASSIGNMENT:

If you were Sally, what would you do in this situation? Answer the following questions to help decide what to do. 1. Is it appropriate for a new nurse to take a

leadership role in addressing this problem? 2. What are some possible steps you could take in

correcting this situation? 3. Would a followership role be better suited to

solve this issue? 4. Should you act alone or involve others?

LEARNING EXERCISE 2.9

Choosing a Leadership Style (Marquis & Huston, 2012)

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

ASSIGNMENT:

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

LEARNING EXERCISE 2.10

Prescription Misuse and the Opioid Crisis

Kacik (2018) reported that more than half (52%) of Americans tested by Quest Diagnostics in 2017 misused prescription drugs, suggesting that medication adherence is increasingly more difficult as the opioid epidemic

swells. Most of the misuse stemmed from positive results for nonprescribed or illegal drugs in addition to their prescriptions.

Indeed, about 10% of hospitalizations and 125,000 deaths annually in the United States stem from not taking medications as prescribed, according to one estimate. That can translate to as much as $289 billion per year in excess health-care costs (Kacik, 2018).

ASSIGNMENT:

Assume you are an office nurse in a small family practice. The physicians in the practice have recently attempted to alter their prescribing patterns to address a clearly mounting national problem. Sharp restrictions on opioid prescribing alone, however, will not solve the prescription drug epidemic. Because you have so much direct contact with patients in the practice, you want to be a part of the solution. Identify at least three leadership roles and three management functions that might allow you, as a member of the interprofessional team, to help address the problem. What interprofessional collaboration might be needed to help you implement these leadership roles and management functions?

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3

Twenty-First-Century Thinking About Leadership and Management

. . . No institution can possibly survive if it needs geniuses or supermen to manage it. It must be organized in such a way as to be able to get along under a leadership composed of average human beings.—Peter Drucker

. . . It is better to lead from behind and to put others in front, especially when you celebrate victory when nice things occur. You take the front line when there is danger. Then people will appreciate your leadership.— Nelson Mandela

. . . The leaders of tomorrow will face ever-changing team structures, with more remote workers and more diverse skill sets than ever before.—Catherine Wong

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

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

MSN Essential IX: Master’s level nursing practice AONL Nurse Executive Competency I: Communication and relationship building

AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency III: Leadership ANA Standard of Professional Performance 9: Communication

ANA Standard of Professional Performance 10: Collaboration

ANA Standard of Professional Performance 11: Leadership QSEN Competency: Teamwork and collaboration

LEARNING OBJECTIVES

The learner will:

analyze how current and future paradigm shifts in health care affect the leadership skills that will be needed by nurses in the coming decade

compare strengths-based leadership, which focuses on the development or empowerment of workers’ strengths, with the traditional management practices of identifying problems, improving underperformance, and addressing weaknesses and obstacles

identify Level 5 leadership skills (as espoused by Jim Collins), which differentiate great companies from good companies

identify the characteristics of a servant leader and suggest strategies for encouraging a service inclination in others

explore elements of human and social capital, which impact resource allocation in organizations

describe situations where followers (agents) might not be inherently motivated to act in the best interest of the principal (leader or employer)

describe components of emotional intelligence, which promote the development of productive work teams

identify characteristics of authentic leadership and discuss the consequences to the leader–follower relationship when leaders are not authentic

identify contemporary nurse-leaders who exemplify thought leadership and the innovative ideas they have suggested

describe why quantum leaders need flexibility in responding to the complex relationships that exist between environment and context in work environments

describe complexities that exist in the relationship between followers and leaders

provide examples of the 21st-century shift from industrial age leadership to relationship age leadership

develop insight into his or her individual leadership strengths

Introduction Throughout history, nursing has been required to respond to changing technological and social forces. In the last decade alone, a growing elderly population, health-care reform, reductions in federal and state government reimbursement as well as commercial insurance, and new quality imperatives such as value-based purchasing and pay for performance have resulted in major redesigns of most health-care organizations. In addition, the locus of

care continues to shift from acute care hospitals to community and outpatient settings, innovation and technological advances are transforming the workplace, and organizational cultures are increasingly focusing on externally regulated, safety-driven, customer-focused care. All these changes have brought about a need for leader-managers to learn new roles and develop new skills.

The new managerial responsibilities placed on organized nursing services call for nurse administrators who are knowledgeable, skilled, and competent in all aspects of management. Now more than ever, there is a greater emphasis on the business of health care, with managers being involved in the financial and marketing aspects of their respective departments. Managers are expected to be skilled communicators, organizers, and team builders and to be visionary and proactive in preparing for emerging new threats such as domestic terrorism, biological warfare, and global pandemics.

In addition, the need to develop nursing leadership skills has never been greater. At the national level, nurse-leaders and nurse- managers are actively involved in determining how best to implement health-care reform and in addressing health-care worker shortages. At the organizational and unit levels, nurse-leaders are being directed to address turnover rates by staff, an emerging shortage of qualified top-level nursing administrators, unionization, and intensified efforts to legislate minimum staffing ratios and eliminate mandatory overtime while maintaining civil and productive work environments. Moreover, ensuring successful recruitment, creating shared governance models, and maintaining high-quality practice depend on successful interprofessional team building, another critical leadership skill in contemporary health-care organizations. This challenging and changing health-care system requires leader-managers to use their scarce resources appropriately and to be visionary and proactive in planning for challenges yet to come.

In addition, Strock (2018) points out that the 21st century has seen a breakdown of some of the long-standing barriers that defined leadership. “For example, individuals holding high positions of power traditionally tended to be distant from the those they served. Today, anyone can find a way to communicate with almost anyone else through new technologies. Such individuals no longer have the zones of privacy that separated their personal and professional lives” (Prichard, 2018, “21st Century Leadership,” para. 2). The new trends are part of a transformational change wrought by digital technology.

Prichard (2018) notes that in the 20th century, interactions were generally transactional but that now, we’re in a web of relationships. Those relationships can be established or defined by individuals rather than by large public and private institutions. This ongoing empowerment of individuals and previously isolated or marginalized groups through new technology has accelerated leadership exerted through influence rather than domination or dictation. Thus, leadership roles are subject to greater accountability, and the tools of workaday management and service are in transition.

Indeed, a recent survey found that millennials expect and demand different things from their employer, their job, and, most certainly, their leaders today than they did 20 years ago (Elliott & Corey, 2018). In this new world of work, leader-managers need to eliminate the barriers that separate them from their followers, using every tool they have at their disposal to cut through the hierarchy and bring themselves closer to their people (Elliott & Corey, 2018). By doing this, they will significantly improve upward feedback and employee engagement as well as loyalty (see Examining the Evidence 3.1).

EXAMINING THE EVIDENCE 3.1 Source: Elliott, G., & Corey, D. (2018). 10 Traits of great leaders in this new world of work. Retrieved November 18, 2018, from http://www.greatleadershipbydan.com/2018/08/10- traits-of-great-leaders-in-this-new.html

Leadership Traits Most Respected and Valued by Millennials The world of work has changed dramatically and continues to change. The workforce, which now consists of five generations working side by side, expects and demands different things from its organization, its job, and, most certainly, its leaders today than it did 20 years ago. This study asked 350 millennials to answer the question: What do you want and expect from your leaders?

The 10 traits millennials identified as expecting from their leaders included

1. Own and live the company values 2. Communicate openly and early 3. Inspire people to reach higher 4. Own their mistakes 5. Recognize big wins, small wins, and hard

work 6. Trust people 7. Make the right decision, not the popular

decision 8. Add value to their teams, helping them to

succeed

9. Have the courage to be genuine and visible

10. Take care of people

In confronting these new and expanding responsibilities and demands, many leader-managers turn to the experts for tools or strategies to meet these expanded role dimensions. What they have found is some new and innovative thinking about how best to manage organizations and lead people as well as some reengineered interactive leadership theories from the later 20th century. This chapter explores this contemporary thinking about leadership and management, with specific attention given to emergent 21st-century thinking.

New Thinking About Leadership and Management Given current health-care system and organizational complexity, most 21st-century nurse leader-managers will need to improve and add to their leadership skill toolbox to meet emerging challenges in the coming decade. In addition, they will be required to embrace new roles in new settings. Some leader-managers, however, will undoubtedly try to use a traditional top-down hierarchical approach in leading and managing others but will likely find that it no longer works well, if at all. Instead, they must seek out more participatory, transdisciplinary, and collaborative models that are not easy to develop.

For example, new research on leadership, including full-range leadership theory (see Chapter 2), is rediscovering the importance of organizational context, levels of analysis, and potential boundary conditions on transformational leadership. Indeed, many recent leadership and management concepts focus on the complexity of the

relationship between the leader and the follower, and much of the leadership research emerging in the second decade of the 21st century builds on the interactive leadership theories developed in the latter part of the 20th century. As a result, concepts such as strengths-based leadership, Level 5 Leadership, servant leadership, principal agent theory, human and social capital theory, emotional intelligence (EI), authentic leadership, quantum leadership, and thought leadership have emerged as part of the leader-manager’s repertoire for the 21st century.

Strengths-Based Leadership and the Positive Psychology Movement Strengths-based leadership, which grew out of the positive psychology movement (which began in the late 1990s), focuses on the development or empowerment of strengths as opposed to weaknesses or areas of needed growth. Thus, strengths-based leadership is part of the development of positive organizational scholarship, which focuses on successful performance that exceeds the norm and embodies an orientation toward strengths and developing collective efficacy.

Research suggests that using a strengths-based approach, even at a young age, can have a profound impact on the ability of individuals to self-manage and to regulate their emotions. A study by Dennison, Daniel, Gruber, Cavanaugh, and Mayfield (2018) of fifth and seventh graders exposed to a brief strengths-based leadership training group found significant positive changes in the children regarding internal areas of functioning and social skills, anger management skills, and school attitude. Just changing the framework in which the children were approached from “at risk” to “at promise” seemed to make a difference (see Examining the Evidence 3.2).

EXAMINING THE EVIDENCE 3.2 Source: Dennison, S. T., Daniel, S. S., Gruber, K. J., Cavanaugh, A. M., & Mayfield, A. (2018). A leadership training group for at risk fifth & seventh graders: Results from a brief strength-based group program. Social Work With Groups, 41(3), 181–197. doi:10.1080/01609513.2017.1330170

Using Strengths-Based Leadership Training to Move Students From “At Risk” to “At Promise” An increasing number of school-age youth exhibit social, emotional, and behavioral problems that place them at risk for not meeting the demands of the classroom or performing at grade level. A total of 225 students from grades 5 and 7 were recruited to participate in an 8-week school-based group strengths-based leadership training program, and an additional 100 fifth and seventh grade students were enrolled in the matched comparison group (students who received only pre- and post-assessments but no training intervention). A mixed-methodology design was used; three standardized scales were administered pre- and post-group intervention, and a focus group was conducted with each group after their eighth group session.

Findings from this study suggested that fifth and seventh grade students were able to make significant positive changes over 8 weeks regarding their peer skills, anger management, and school attitude. Furthermore, these

findings suggest there is value in conducting early intervention programs where services often have less stigma attached to them and they can be delivered to a larger number of students, particularly minority and poor. The researchers concluded that it is imperative that group interventions like strengths-based leadership training be replicated and further studied to contribute to our knowledge regarding evidence-based treatment for K to 12 at risk youth.

The importance of strengths-based leadership in organizations was noted by Rath and Conchie (2008) who completed a review of 30 years of research by Gallup including over 40,000 personal interviews with leaders from around the world and 20,000 interviews with followers to ask why they follow a leader. They found that effective leaders are always investing in strengths but that they consciously and consistently work to use their key strengths to their advantage rather than putting significant effort into being better rounded (Ambler, 2015).

In addition, Rath and Conchie (2008) found that the most effective leaders surround themselves with the right people (people who have different strengths than they do) and that they maximize their team (Ambler, 2015). This typically requires that leaders create teams that have a balance of strengths in the following four leadership domains:

1. Strategic thinking: Effective leaders keep everyone focused on a long-term future.

2. Influence: Effective leaders can sell ideas, develop political support, and get people to rally behind a project or an initiative.

3. Relationship building: Effective leaders are able to unite a group of disparate individuals into a team that works toward a

common goal. 4. Execution: Effective leaders know how to get things done by

translating plans into action.

Finally, Rath and Conchie (2008) found that the most effective leaders understand their follower’s needs (Ambler, 2015). The researchers asked followers to choose three words that best describe the contribution that a leader makes to their life. Many of them used the same words to describe what they seek from their leaders. The four most common responses follow:

1. Trust: Nothing happens without a sense of trust between leaders and followers.

2. Compassion: Followers want to know that their leaders care about them.

3. Stability: Followers want leaders who they can depend on. 4. Hope: Followers want to feel positive about their future

prospects.

Effective leaders then understand their followers’ needs as well as strengths and engage them in activities that allow these strengths to grow and for employees to be empowered and successful. Ambler (2015) identifies 10 questions emerging leaders can ask to assess their strengths-based leadership skills (Display 3.1).

DISPLAY 3.1 ASSESSING YOUR STRENGTHS-BASED LEADERSHIP SKILLS (AMBLER, 2015)

1. Do you have a good understanding of your personal strengths and weaknesses?

2. What are your top three strengths and are you using them on a daily basis?

3. Are you deliberately investing in your strengths? 4. Are you building a team that compensates for your

weaknesses? 5. Do you select team members for their leadership strengths as

opposed to their knowledge and technical expertise? 6. Are you developing your team members’ strengths? 7. What is the level of trust between you and your team? 8. Does your team feel that you care for them on a personal

level? 9. Does your team know what to expect from you? 10. Is your team inspired by a positive future?

Level 5 Leadership The concept of Level 5 leadership was developed by Jim Collins and published in his classic book, Good to Great: Why Some Companies Make the Leap . . . and Others Don’t (Collins, 2001). Collins (2001) studied 1,435 companies to determine what separates great companies from good companies. What he found was that five levels of leadership skill (Display 3.2) may be present in any organization. Truly great organizations, however, typically have leaders who possess the qualities found in all five levels. Thus, not only do Level 5 leaders have the knowledge to do the job, but they also have team building skills and can help groups achieve shared goals. They also, though, demonstrate humility and seek success for the team, rather than for self-serving purposes, a core component of another 21st-

century leadership theory known as servant leadership. Level 5 leaders also know when to ask for help, accept responsibility for the errors they or their team make, and are incredibly disciplined in their work.

DISPLAY 3.2 JIM COLLINS’S LEVEL 5 LEADERSHIP

Level 1: Highly Capable Individual Leader makes high-quality contributions to his or her work, possesses useful levels of knowledge, and has the talent and skills needed to do a good job.

Level 2: Contributing Team Member Leader uses knowledge and skills to help his or her team succeed and works effectively, productively, and successfully with other people in his or her group.

Level 3: Competent Manager Leader is able to organize a group effectively to achieve specific goals and objectives.

Level 4: Effective Leader Leader is able to galvanize a department or organization to meet performance objectives and achieve a vision.

Level 5: Great Leader Leader has all of the abilities needed for the other four levels, plus a unique blend of humility and will that is required for true greatness.

Source: Collins, J. (2001). Level 5 leadership: The triumph of humility and fierce resolve. Harvard Business Review, 79(1), 66–76.

Level 5 leaders also possess qualities found in the four other levels of leadership that Collins (2001) identified. It is not necessary to pass sequentially through each individual level before becoming a

Level 5 leader, but the leader must have the skills and capabilities found in each level of the hierarchy to be a top performing leader (Mind Tools Content Team, n.d.).

Servant Leadership Although Greenleaf (1977) developed the idea of servant leadership more than 35 years ago, it continues to greatly influence leadership thinking in the 21st century. In more than four decades of working as director of leadership development at AT&T, Greenleaf noticed that most successful managers lead in a different way from traditional managers. These managers, which he termed servant leaders, put serving others, including employees, customers, and the community, as the number one priority.

This choice between personal advantage and organizational advantage speaks to the heart of servant leadership. “‘Win-win’ is challenging when YOU win later and OTHERS win sooner” (When Servant-Leaders, 2018, para. 3). In addition, servant leaders foster a service inclination in others that promotes collaboration, teamwork, and collective activism. Other defining qualities of servant leadership are shown in Display 3.3.

DISPLAY 3.3 DEFINING QUALITIES OF SERVANT LEADERS

1. The ability to listen on a deep level and to truly understand 2. The ability to keep an open mind and hear without judgment 3. The ability to deal with ambiguity, paradoxes, and complex

issues 4. The belief that honestly sharing critical challenges with all

parties and asking for their input is more important than personally providing solutions

5. Being clear on goals and good at pointing the direction toward goal achievement without giving orders

6. The ability to be a servant, helper, and teacher first and then a leader

7. Always thinking before reacting 8. Choosing words carefully so as not to damage those being

led 9. The ability to use foresight and intuition 10. Seeing things whole and sensing relationships and

connections

LEARNING EXERCISE 3.1

Creating a Service Inclination

An important part of servant leadership is the servant leader’s ability to create a service inclination in others. In doing so, more leaders are created for the organization.

ASSIGNMENT:

Identify servant leaders who you have worked with. Did they motivate followers to be service oriented? If so, what strategies did they use? Does servant leadership result in a greater number of leaders within an organization? If so, why do you think that this happens?

Ken Blanchard, author of Servant Leadership in Action: How You Can Achieve Great Relationships and Results, notes, however, that although servant leadership is about leading from the ground up, it still requires leadership and that aspect is often forgotten (Kruse, 2018). Servant leaders must still create and communicate their vision, direction, and goals. Followers must be clear about what the leader is trying to accomplish as well as their values and goals. Once that is clear, the pyramid can be turned upside down so that the leader can begin to help followers live according to the vision of values and goals and be successful.

Values are the pillars that uphold the entire structure of servant leadership. Honesty, truth, compassion, and acceptance are some of the intrinsic core values shared by servant leaders (Eswaran, 2018).

For example, Trojani (2018) shared a story about the first time President John F. Kennedy visited National Aeronautics and Space Administration’s headquarters and met a janitor mopping the floor. When President Kennedy asked him what he was doing, he replied, “I’m helping to put a man on the moon.” President Kennedy provided the vision, but the janitor felt empowered to do his part to achieve the goal.

LEARNING EXERCISE 3.2

Servant Leadership in Nursing and Medicine

ASSIGNMENT:

Write a one-page essay that addresses the following: 1. Both nursing and medicine are helping service-

oriented professions. Do you believe there are inherent differences in service inclination between individuals who choose nursing for a profession rather than medicine?

2. Do you believe that nursing education fosters a greater service inclination than medical education?

3. Do you believe the female majority (gender) of the nursing profession influences nursing’s propensity to be service oriented?

Principal Agent Theory Principal agent theory, which first emerged in the 1960s and 1970s, is another interactive leadership theory being actively explored in the 21st century. The principal agent problem occurs when one person (the agent) can make decisions on behalf of another person (the principal) (Agarwal, 2019). In this situation, there are issues of moral hazard and conflicts of interest.

This occurs because not all followers (agents) are inherently motivated to act in the best interest of the leader or employer

(principal). This is because followers may have an informational (expertise or knowledge) advantage over the leader as well as their own preferences, which may deviate from the principal’s preferences. The risk then is that agents will pursue their own objectives or interests instead of that of their principal.

Principals then must identify and provide agents with appropriate incentives to act in the organization’s best interest. For example, consumers with good health insurance and small out-of-pocket expenses may have little motivation to act prudently in accessing health-care resources because payment for services used will come primarily from the insurer. The insurer then must create incentives for agents to access only needed services.

Another example might be end-of-shift overtime. Although most employees do not intentionally seek or want to work overtime after a long and busy shift, the reality is that doing so typically results in financial rewards. Employers then must either create incentives that reward employees who are able to complete their work in the allotted shift time or create disincentives for those who do not.

LEARNING EXERCISE 3.3

The Agent’s Motives

You are a team leader for 10 patients on a busy medical unit. Your team includes Lori, a licensed vocational nurse, passing medications and assisting with patient treatments, and Tom, an experienced certified nursing assistant, who provides basic care such as monitoring vital signs, ambulating patients, and assisting with hygiene. On several occasions in the past, Tom has failed

to report significant changes in patients’ vital signs to you until significant time had elapsed or you discovered them yourself. Despite confronting Tom about the need to report these changes and the specific vital sign parameters that need to be reported, this behavior has continued. You have become concerned that patient harm might occur if this pattern of behavior can continue.

ASSIGNMENT:

Identify possible motives that Tom (the agent) may have for failing to share this information with you (the principal). What incentives might you employ to modify his behavior?

Human and Social Capital Theory The traditional view of employees as costs is now obsolete. Instead, employees are now viewed as assets or capital that can be developed and nurtured. Human capital refers to the collective skills, knowledge, or other intangible assets of individuals that can be used to create economic value for the individuals, their employers, or their community (Dictionary.com, 2018, para. 1). For example, formal educational attainment generally increases human capital because the returns are in the form of wage, salary, or other compensation. Human capital can be viewed, however, from an organizational perspective as well. In this case, human capital would refer to the group’s collective knowledge or experience.

Human capital can refer to a group’s collective knowledge, skills, and abilities.

Human capital theory suggests that individuals and/or organizations will invest in education and professional development if they believe that such an investment will have a future payoff. For example, a health-care organization that provides tuition reimbursement for nurses to go back to school to earn higher degrees is likely doing so in anticipation that a more highly educated nursing staff will result in increased quality of care and higher retention rates—both of which should translate into higher productivity and financial return.

Investing in human capital development was identified as a leadership trend shaping contemporary organizations (Forbes Coaches Council, 2018a). Leaders and companies who recognize the long-term benefit of focusing on human capital development and take a vested interest in helping employees thrive in all areas of their lives (not just work) will create more engagement, productivity, and overall happier employees.

Emotional Intelligence Another leadership theory gaining prominence in the 21st century is that of EI (also known as EQ). Broadly defined, EI refers to the ability to perceive, understand, and control one’s own emotions as well as those of others. Gabriel (2018) suggests that it’s our EI that gives us the ability to read our instinctive feelings and those of others. It also allows us to understand and label emotions as well as express and regulate them.

Gabriel (2018) suggests that many people overestimate their EI because they think it is the ability or tendency to be nice. It’s not. Instead, it is about being empathetic, being able to look at situations from alternative points of view, being open minded, bouncing back from challenges, and pursuing goals despite challenges. Some proponents of EI have suggested that having EI may be even more critical to leadership success than intellectual intelligence (IQ).

In their original work on EI in 1990, Mayer and Salovey (1997) suggested that EI consists of three mental processes:

Appraising and expressing emotions in the self and others Regulating emotion in self and others Using emotions in adaptive ways

In 1997, they further refined EI into four mental abilities: perceiving/identifying emotions, integrating emotions into thought processes, understanding emotions, and managing emotions.

Goleman (1998), in his best seller Working With Emotional Intelligence, built on this work in his identification of five components of EI: self-awareness, self-regulation, motivation, empathy, and social skills (Display 3.4).

DISPLAY 3.4 FIVE COMPONENTS OF EMOTIONAL INTELLIGENCE

1. Self-awareness: the ability to recognize and understand one’s moods, emotions, and drives as well as their effects on others

2. Self-regulation: the ability to control or redirect disruptive impulses or moods as well as the propensity to suspend judgment

3. Motivation: a passion to work for reasons that go beyond money or status; a propensity to pursue goals with energy and commitment

4. Empathy: the ability to understand and accept the emotional makeup of other people

5. Social skills: proficiency in handling relationships and building networks; an ability to find common ground

Source: Goleman, D. (1998). Working with emotional intelligence. New York, NY: Bantam Books.

Goleman (1998) argued that all individuals have a rational thinking mind and an emotional feeling mind and that both influence action. The goal, then, in EI is emotional literacy—being self-aware about one’s emotions and recognizing how they influence subsequent action. Unlike Mayer and Salovey (1997), who suggested that EI develops with age, Goleman argued that EI could be learned, although he too felt that it improves with age. Tyler (2015) agrees, arguing that although EI tends to increase with age, we do not have to wait until we grow older to improve this skill set. To do so, however, we must be willing to change, practice changed behaviors, and receive feedback regarding our progress.

Authentic Leadership Another emerging leadership theory for the contemporary leader- manager’s arsenal is that of authentic leadership (also known as congruent leadership). Authentic leadership suggests that in order to lead, leaders must be true to themselves and their values and act accordingly. Integrity is conformance between what leaders profess and how they actually act (Kador, 2018).

It is important to remember that authentic or congruent leadership theory differs somewhat from more traditional transformational leadership theories, which suggest that the leader’s vision or goals are often influenced by external forces and that there must be at least some “buy-in” of that vision by followers. In authentic leadership, it is the leaders’ principles and their conviction to act accordingly that inspire followers.

In authentic leadership, it is the leaders’ principles and their conviction to act accordingly that inspire followers.

LEARNING EXERCISE 3.4

Emotions and Decision Making

Think back on a recent decision you made that was more emotionally laden than usual. Were you self-aware about what emotions were influencing your thinking and how your emotions might have influenced the course(s) of action you chose? Were you able to objectively identify the emotions that others were experiencing and how these emotions may have influenced their actions?

Sostrin (2017) suggests that sustaining an enduring alignment between your values and your actions is vital for leadership success. “It’s what lets you be you and it serves as a bond of integrity that enables your followers to trust you. Increase the alignment between your values and behaviors by understanding what makes you tick—defining the specific values that animate you—then making them apparent to your clients and teams. This integrity will produce a more consistent, authentic expression of who you are in the moments that matter” (para. 7).

Hoff (2018) agrees, noting that authenticity breeds trust, which is a crucial element in the workplace. Leaders who demonstrate integrity and character command the support and fidelity of their followers, who are then much more likely to go the extra mile and stand by their leader regardless of circumstance. In contrast, the absence of trust can make it very difficult for leaders to gain support (Hoff, 2018).

Forbes Coaches Council (2018a) suggests that unfortunately, “leaders have long gotten away with vocally supporting policies

and procedures, but their actions say otherwise. That tide will turn. With so much light being shed on unacceptable behavior in all workplaces, leaders must begin to understand they need to not only hold their teams accountable for proper behavior but hold themselves accountable as well” (para. 7).

The reality, though, is that authentic leadership is not easy. It takes great courage to be true to one’s convictions when external forces or peer pressure encourages an individual to do something he or she feels morally would be inappropriate. For example, there is little doubt that some nurse-leaders experience intrapersonal value conflicts between what they believe to be morally appropriate and a need to deliver results in a health-care system increasingly characterized by pay for performance and rewarded by cost containment.

The trust that is such an important part of authentic leadership may also take time to develop. Although Kador (2018) notes that trust can occur very quickly under the right circumstances, generally, it takes time as well as a lifelong commitment to self- reflection. Trust is also easier to experience than to precisely measure (Kador, 2018). Five questions an individual might use to assess his or her trustworthiness as an authentic leader are shown in Display 3.5.

DISPLAY 3.5 QUESTIONS TO ASK IN ASSESSING TRUSTWORTHINESS AS AN AUTHENTIC LEADER

1. Do I act with integrity? 2. Do I welcome ideas and opinions different from my own? 3. Do I appreciate employees who are willing to bring bad news

to my attention? 4. Do I admit my own mistakes? 5. Do I always tell the truth, even if it is inconvenient? 6. Do I publicly encourage suggestions from everyone on the

team, from the top performers to the most junior employees, and then do I listen to the contributions with equal respect?

Source: Kador, J. (2018). Are you a trusted leader? Retrieved July 15, 2018, from https://chiefexecutive.net/are-you-a-trusted-leader

Finally, one must not be so idealistic as to assume that all leaders strive to be authentic. Indeed, many are flawed, at least at times. Leaders may be deceitful and trustworthy, greedy and generous, and cowardly and brave. To assume that all good leaders are good people is foolhardy and makes us blind to the human condition. Future leadership theory may well focus on why leaders behave badly and why followers continue to follow bad leaders.

LEARNING EXERCISE 3.5

Inconsistency in Word and Action

There are many examples of internationally or nationally recognized leaders who have lost their followers because

of their actions being inconsistent with personally stated convictions. An example might be a world-class athlete and advocate for healthy lifestyles who is found to be using steroids to enhance physical performance. Or it might be a political figure who preaches morality and becomes involved in an extramarital affair or a religious leader who promotes celibacy and then becomes involved in a sex scandal.

ASSIGNMENT:

Think of a leader who espoused one message and then acted in a different manner. How did it affect the leader’s ability to be an effective leader? How did it change how you personally felt about that leader? Do you feel that leaders who have lost their “authenticity” can ever regain the trust of their followers?

Thought Leadership and Rebel Leadership Another relatively new leadership theory to emerge in the 21st century is that of thought leadership, which applies to a person who is recognized among his or her peers for innovative ideas and who demonstrates the confidence to promote those ideas. Thus, thought leadership refers to any situation in which one individual convinces another to consider a new idea, product, or way of looking at things.

Thought leaders challenge the status quo and attract followers not by any promise of representation or empowerment but by their risk taking and vision in terms of being innovative. The ideas put forth by thought leaders typically are future oriented and make a significant impact. In addition, they are generally problem oriented, which increases their value to both individuals and organizations.

For example, in her book, Rebel Talent: Why It Pays to Break the Rules at Work and in Life, Gino (2018) argues companies should encourage employees to pursue core strengths of novelty, curiosity, perspective, diversity, and authenticity because success is often linked with breaking rules and breaking traditions (Nobel, 2018). Gino suggests that business leaders should strive for and encourage rebellion in their workplaces because when people break rules to explore new ideas and create positive change, everyone benefits (Nobel, 2018). Gino’s eight principles of rebel leadership are shown in Display 3.6.

DISPLAY 3.6 BECOMING A THOUGHT LEADER: FRANCESCA GINO’S EIGHT PRINCIPLES OF REBEL LEADERSHIP

1. Seek out the new. 2. Encourage constructive dissent. 3. Open conversations—don’t close them. 4. Reveal yourself—and reflect. 5. Learn everything—then forget everything. 6. Find freedom in constraints. 7. Lead from the trenches. 8. Foster happy accidents (mistakes may unlock a breakthrough).

Source: Gino, F. (2018). Rebel talent: Why it pays to break the rules at work and in life. New York, NY: HarperCollins.

Organizations can also be thought leaders. For example, Blue Cross and Blue Shield were early thought leaders in the development of private health insurance in the late 1920s. Johnson & Johnson launched the Discover Nursing campaign earlier this decade to champion the nursing profession and promote the recruitment and retention of nurses. Thought leaders in the coming decade will likely focus on enduring issues that continue to be of

critical importance to nursing and health care and address new, emerging problems of significance. For example, thought leadership is still greatly needed in identifying and adopting innovative safety and quality improvement approaches that actually reduce the risk of harm to patients and health-care workers. In addition, the threat of an international nursing shortage continues to loom, and an inadequate number of innovative solutions have been suggested for addressing the dire nursing faculty shortage that is expected to occur in the next 5 to 10 years.

LEARNING EXERCISE 3.6

Technological Innovation and Thought Leadership

Technological innovations continue to change the face of health care, and the pace of such innovations continues to increase exponentially. For example, wireless communication, computerized charting, and the barcode scanning of medications have all greatly affected the practice of nursing.

ASSIGNMENT:

Choose at least one of the following technological innovations and write a one-page report on how this technology is expected to impact nursing and health care in the coming decade. See if you can identify the thought leader(s) credited with developing these technologies and explore the process that they used to both develop and market their innovations.

Biometrics to ensure patient confidentiality

Computerized physician order entry Point-of-care testing Bluetooth technology Electronic health records Artificial intelligence Robotic surgery Nursebots (prototype nurse robots) Genetic and genomic testing

Agile Leadership Another newer leadership theory is agile leadership, a term borrowed from the software world. Agile leaders have the ability (and agility) to think in many ways so that they can be flexible, adaptable, and fast in their decision making (Forbes Coaches Council, 2018b). The Center for Agile Leadership (2018) concurs, noting that agile leaders are inclusive, democratic leaders who exhibit a greater openness to ideas and innovations. With a passion for learning, a focus on developing people, and a strong ability to define and communicate a desired vision, they possess the tools necessary to inspire others and become an agent for change within any organization.

Agile leaders listen deeply and ask powerful questions to gain insights and make the right decision to help the organization move forward through problems. Agile leaders also quickly adapt to situations as they come along and are flexible and open to change and growth (Forbes Coaches Council, 2018b).

In addition, agile leaders demonstrate agility with their employees. Indeed, agile leadership was proposed to meet the needs of the millennial workforce, which has different needs, different wants, and different motivators than any generation before them (Center for Agile Leadership, 2018). People like to be communicated with and recognized differently. It is never a one-size-fits-all model. When agile leaders show how much they value their team’s contribution by understanding and being what they need, productivity and engagement rise (Forbes Coaches Council, 2018b).

Reflective Thinking and Practice Other leadership theories that have gained prominence in the past decade are those of reflective thinking and practice. Sherwood and Horton-Deutsch (2015) note that today’s chaotic health-care environment requires nurse-leaders to be nimble, flexible, and responsive to change. “The need for change arises from the awareness that current practices or processes aren’t working—that results are not the desired outcomes” (p. xiii). Thus, the goal for nurse-leaders must be to become so agile that they are able to continually adapt, reflect on progress and setbacks, and adjust their course as needed (Sherwood & Horton-Deutsch, 2015).

Sherwood and Horton-Deutsch (2015) suggest that reflection provides an opportunity to apply theory from all ways of knowing and learning as an extension of evidence-based practices and research. It also allows individuals to learn from experience by considering what they know, believe, and value within the content of current situations and then to reframe to develop future responses or

actions. Sherwood and Horton-Deutsch suggest two questions nurse-leaders can use to increase their reflective practice (Display 3.7).

DISPLAY 3.7 USING REFLECTIONS IN LEADERSHIP

1. How can you bring the power of reflection to bear on your day- to-day work?

2. How could you amplify the effectiveness of your decision making and empower your teams to step up and participate in the decision-making process?

Source: Sherwood, G. D., & Horton-Deutsch, S. (2015). Reflective organizations. On the front lines of QSEN & reflective practice implementation. Indianapolis, IN: Nursing Knowledge International.

Quantum Leadership Quantum leadership is another relatively new leadership theory that is being used by leader-managers to better understand dynamics of environments, such as health care. This theory, which emerged in the 1990s, builds on transformational leadership and suggests that leaders must work together with subordinates to identify common goals, exploit opportunities, and empower staff to make decisions for organizational productivity to occur. This is especially true during periods of rapid change and needed transition.

Building on quantum physics, which suggests that reality is often discontinuous and deeply paradoxical, quantum leadership suggests that the environment and context in which people work is complex and dynamic and that this has a direct impact on organizational productivity. The theory also suggests that change is constant. Today’s workplace is a highly fluid, flexible, and mobile environment, and this calls for an entirely innovative set of interactions and

relationships as well as the leadership necessary to create them (Porter-O’Grady & Malloch, 2015).

Quantum leadership suggests that the environment and context in which people work is complex and dynamic and that this has a direct impact on organizational productivity.

Because the health-care industry is characterized by rapid change, the potential for intraorganizational conflict is high. Porter- O’Grady and Malloch (2015) suggest that because the unexpected is becoming the normative, the quantum leader must be able to address the unsettled space between present and future and resolve these conflicts appropriately. In addition, they suggest that the ability to respond to the dynamics of crisis and change is not only an inherent leadership skill but must now also be inculcated within the very fabric of the organization and its operation.

Transition From Industrial Age Leadership to Relationship Age Leadership In considering all of these emerging leadership theories, it becomes apparent that a paradigm shift has taken place early in the 21st century—a transition from industrial age leadership to relationship age leadership (Scott, 2006). Scott (2006) contends that industrial age leadership focused primarily on traditional hierarchical management structures, skill acquisition, competition, and control. These are the same skills traditionally associated with management. Relationship age leadership focuses primarily on the relationship between the leader and his or her followers, on discerning common purpose, working together cooperatively, and seeking information rather than wealth (Table 3.1). Servant leadership, authentic

leadership, reflective thought and practice, human and social capital, and EI are all relationship-centered theories that address the complexity of the leader–follower relationship.

TABLE 3.1 A SHIFT IN PARADIGMS: THE CONTEXT FOR THE NEW LEADERSHIP

Scientific/Industrial Age Relationship/Information Age

Technical skills Adaptive skills Command and control Invitation and interdependence Competition Cooperation Gaining advantage Discerning purpose Gathering facts Finding meaning What you have (wealth) What you know (information) Hierarchy (top-down) Circular (egalitarian) Metaphor for organizations: machine (separate parts)

Metaphor: organic network (connected parts)

Leadership: position Leadership: trusteeship Source: Adapted from Scott, K. T. (2006, September). The gifts of leadership. Paper presented at the Sigma Theta Tau International Regional Meeting, Indianapolis, IN. © 2000, Ki ThoughtBridge, LLC. Author, Katherine Tyler Scott. All rights reserved. Permission for use in this publication granted by Ki ThoughtBridge, LLC.

A paradigm shift is taking place early in the 21st century —a transition from industrial age leadership to relationship age leadership.

Covey (2011) concurs, noting that the primary drivers of economic prosperity in the industrial age were machines and capital—in other words, things. People were necessary but replaceable. Covey

argues that many current management practices come from the industrial age where the focus was on controlling workers, fitting them into a slot, and using reward and punishment for external motivation. In contrast, relationship age leadership is all about leading people who have the power to choose. It is about requiring leaders to embrace the whole person paradigm (Covey, 2011).

Fred Kofman, a leader development expert from Google, agrees, suggesting that many employers are trying to attract the new generation with the same technologies that attracted the past generation (Should Leadership Feel, 2018). The result is abysmal levels of engagement. Employee engagement in the United States, which is probably one of the highest in the world, is about 30%. So, 70% of the people either don’t care or dislike their jobs and the people they work for, the people they work with, the places where they work, and the customers they are supposed to serve (Should Leadership Feel, 2018).

Indeed, Tamara McCleary, speaker, author, and business expert, suggests that employee engagement is the key to relationship building in the 21st century (Edmonds, 2018). To build this engagement, McCleary invests time, energy, and passion into caring about employees. She also constantly checks to see whether her plans, decisions, and actions are building relationships effectively, and she refines those actions if they don’t (Edmonds, 2018). McCleary’s three-step action plan for engaging employees to build relationships is shown in Display 3.8.

DISPLAY 3.8 TAMARA MCCLEARY’S THREE STEPS FOR ENGAGING EMPLOYEES THROUGH RELATIONSHIP BUILDING

1. Invest the time. Pay attention to more than just results. Connect with people at all levels in the organization every day. Learn their names and their passions. Learn what gets in their way of cooperative teamwork and top performance. Act to reduce those frustrations.

2. Get the data. Don’t just monitor performance metrics—monitor data that indicates how happy employees are working in your organization. Use reliable data, like turnover, exit interviews, service levels, and more. Also try to measure other satisfaction metrics, like the degree of trust, the frequency of proactive problem solving, etc.

3. Evaluate the progress of employee engagement, service, and results. Embrace proactive relationship management and pay close attention to my “big three”—engagement, service, and results. If the results are not what you want, refine your approaches, then monitor the impact. Keep those practices that help.

Source: Edmonds, S. C. (2018). To be the best, invest in relationships AND results. Retrieved July 15, 2018, from http://www.greatleadershipbydan.com/2018/05/to-be-best-invest-in-relationships- and.html

Yet, the leader-manager in contemporary health-care organizations cannot and must not focus solely on relationship building. Ensuring productivity and achieving desired outcomes are essential to organizational success. The key, then, likely lies in integrating the two paradigms. Scott (2006) suggests that such integration is possible (Fig. 3.1).

FIGURE 3.1 Integrated model of leadership. (Reproduced with permission from Ki ThoughtBridge, LLC, & Scott, K. T. [2006, September]. The gifts of leadership. Paper presented at the Sigma Theta Tau International Regional Meeting, Indianapolis, IN. © Ki ThoughtBridge, LLC. All rights reserved.)

Technical skills and competence seeking must be balanced with the adaptive skills of influencing followers and encouraging their abilities. Performance and results priorities must be balanced with authentic leadership and character. In other words, leader-managers must seek the same tenuous balance between leadership and management that has existed since time began.

This certainly was the case in research conducted by Blanchard (2015) that compared strategic leadership with operational leadership (management focused). Strategic leadership included activities such as establishing a clear vision, maintaining a culture that aligns a set of values with that vision, and declaring must-do or strategic imperatives the organization needed to accomplish. Operational leadership provided the “how” for the organization: policies, procedures, systems, and leader behaviors that cascade from senior management to frontline workers (day-to-day management practices).

Researchers found that although strategic leadership is a critical building block to set tone and direction, it has only an indirect effect on organizational vitality. The real key to organizational vitality was operational leadership. If this aspect of leadership is done effectively, employee passion and customer devotion will follow the positive experiences and overall satisfaction people have with the organization. Researchers concluded that both strategic and operational leadership were important—in the right amount, at the right time, and that both are needed for success in an organization.

LEARNING EXERCISE 3.7

Balancing the Focus Between Productivity and Relationships

You are a top-level nursing administrator in a large, urban medical center in California. As in many acute care hospitals, your annual nursing turnover rate is more than 15%. At this point, you have many unfilled licensed nursing positions, and local recruitment efforts to fill these positions have been largely unsuccessful.

During a meeting with the chief executive officer (CEO) today, you are informed that the hospital vacancy rate for licensed nurses is expected to rise to 20% with the opening of an additional regional hospital in 3 months. The CEO states that you must reduce turnover or increase recruitment efforts immediately or the hospital will have to consider closing units or reducing available beds when the new ratios take effect.

You consider the following “industrial leadership” paradigm options:

1. You could aggressively recruit international nurses to solve at least the immediate staffing problem.

2. You could increase sign-on bonuses and offer other incentives for recruiting new nurses.

3. You could expand the job description for unlicensed assistive personnel and licensed vocational nurses to relieve the registered nurses of some of their duties.

4. You could make newly recruited nurses sign a minimum 2-year contract upon hire.

You also consider the following “relationship leadership” paradigm options:

1. You could hold informal meetings with current staff to determine major variables affecting their current satisfaction levels and attempt to increase those variables that increase worker satisfaction.

2. You could develop an open-door policy in an effort to be more accessible to workers who wish to discuss concerns or issues about their work environment.

3. You could implement a shared governance model to increase worker participation in decision making on the units in which they work.

4. You could make daily rounds on all the units in an effort to get to know your nursing staff better on a one- to-one basis.

ASSIGNMENT:

Decide which of the options you would select. Rank order them in terms of what you would do first. Then look at your list. Did it reflect more of the industrial leadership paradigm or a relationship leadership paradigm? What inferences might you draw from your rank ordering in terms of your leadership skills? Do you think that your rank ordering might change with your age? Your experience?

Integrating Leadership Roles and Management Functions in the 21st Century Seemingly insurmountable problems, a lack of resources to solve these problems, and individual apathy have been and will continue to

be issues that contemporary leader-managers face. Effective leadership is absolutely critical to organizational success in the 21st century. Becoming a better leader-manager begins with a highly developed understanding of what leadership and management are and how these skills can be developed. The problem is that these skills are dynamic, and what we know and believe to be true about leadership and management changes constantly in response to new research and visionary thinking.

Contemporary leader-managers, then, are challenged not only to know and be able to apply classical leadership and management theory but also to keep abreast of new insights, new management decision-making tools, and new research in the field. It is more important than ever that leader-managers be able to integrate leadership roles and management functions and that some balance be achieved between industrial age leadership and relationship age leadership skills. Leading and managing in the 21st century promises to be more complex than ever before, and leader- managers will be expected to have a greater skill set than ever before. The key to organizational success will likely be having enough highly qualified and visionary leader-managers to steer the course.

Key Concepts

■ Many new leadership and management theories have emerged in the 21st century to explain the complexity of the leader–follower relationship and the environment in which work is accomplished and goals are achieved.

■ Strengths-based leadership focuses on the development or empowerment of workers’ strengths as opposed to identifying

problems, improving underperformance, and addressing weaknesses and obstacles.

■ Level 5 leadership is characterized by knowledge, team building skills, the ability to help groups achieve goals, humility, and the empowerment of others through servant leadership.

■ Servant leadership is a contemporary leadership model that puts serving others as the first priority.

■ Followers can and do influence leaders in both positive and negative ways.

■ Principal agent theory suggests that followers may have an informational (expertise or knowledge) advantage over the leader as well as their own preferences, which may deviate from those of the principal. This may lead to a misalignment of goals.

■ Human capital represents the capability of the individual. Social capital represents what a group can accomplish together.

■ Emotional intelligence refers to the ability to use emotions effectively and is considered by many to be critical to leadership and management success.

■ Authentic leadership suggests that in order to lead, leaders must be true to themselves and their values and act accordingly.

■ Thought leadership refers to any situation whereby one individual convinces another to consider a new idea, product, or way of looking at things.

■ Thought leaders attract followers not by any promise of representation or empowerment but by their risk taking and vision in terms of being innovative.

■ Quantum leadership suggests that the environment and context in which people work is complex and dynamic and that this has a direct impact on organizational productivity.

■ A transition has occurred in the 21st century from industrial age leadership to relationship age leadership.

Additional Learning Exercises and Applications

LEARNING EXERCISE 3.8

Reflecting on Emotional Intelligence in Self

Do you feel that you have emotional intelligence? Do you express appropriate emotions such as empathy when taking care of patients? Are you able to identify and control your own emotions when you are in an emotionally charged situation?

ASSIGNMENT:

Describe a recent emotional experience. Write two to four paragraphs reporting how you responded in this experience. Were you able to read the emotions of the other individuals involved? How did you respond, and were you later able to reflect on this incident?

LEARNING EXERCISE 3.9

Self-Regulation and Emotional Intelligence

You have just come from your 6-month performance evaluation as a new charge nurse in a long-term care facility. Although the director of nursing stated that he was very pleased in general with how you are performing in this new role, one area that he suggested you work on was to learn to be calmer in hectic clinical situations. He suggested that your anxiety could be transmitted to patients, coworkers, and subordinates who look to you to be their role model. He feels that you are especially anxious when staffing is short and that at times you vent your frustrations to your staff, which only adds to the general anxiety level on the unit.

ASSIGNMENT:

Create a specific plan of 6 to 10 things you can do to bolster your emotional intelligence in terms of self-regulation during stressful times.

LEARNING EXERCISE 3.10

Human and Social Capital

Examine the institution in which you work or go to school. Assess both the human capital and social capital

present. Which is greater? Which do you believe contributes most to this institution in being able to accomplish its stated mission and goals?

LEARNING EXERCISE 3.11

Assessing Emotional Intelligence (Marquis & Huston, 2012)

You have just completed your first year as a registered nurse and have begun to think about applying for the next charge position that opens on your unit. You really like your unit manager and one of the charge nurses. However, a couple of the charge nurses are rather rude and not very empathetic when they are harried and overworked. At times, the charge nurses are very frustrated, the team members pick up their frustration, and the unit becomes chaotic. You feel that although these nurses are very good clinicians, they are not effective charge nurses. You know that you do not want to be like them should you be promoted. You would love to emulate your manager who is calm, supportive, and well-grounded emotionally. She is an excellent role model of a person with emotional intelligence, something you are not sure you have.

ASSIGNMENT:

Decide what you can do to determine your emotional intelligence and identify at least three strategies you could use to reduce any deficiencies.

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U N I T I I

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

4

Ethical Issues . . . When organizations go astray ethically, it is usually due to a lack of ethical competence, not bad people.— John Hooker

. . . All my growth and development led me to believe that if you really do the right thing, and if you play by the rules, and if you’ve got good enough, solid judgment and common sense, that you’re going to be able to do whatever you want to do with your life.—Barbara Jordan

. . . Ethics is knowing the difference between what you have a right to do and what is right to do.—Potter Stewart

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential VIII: Professionalism and professional values BSN Essential IX: Baccalaureate generalist nursing practice MSN Essential II: Organizational and systems leadership MSN Essential VI: Health policy and advocacy MSN Essential IX: Master’s level nursing practice

AONL Nurse Executive Competency III: Leadership AONL Nurse Executive Competency IV: Professionalism ANA Standard of Professional Performance 7: Ethics ANA Standard of Professional Performance 10: Collaboration

ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 15: Professional practice evaluation

QSEN Competency: Patient-centered care

LEARNING OBJECTIVES

The learner will:

define ethics and ethical dilemmas compare and contrast the utilitarian, duty-based, rights-based, and intuitionist frameworks for ethical decision making

identify and define nine different principles of ethical reasoning use a systematic problem-solving or decision-making model to determine appropriate action for select ethical problems

evaluate the quality of ethical problem solving in terms of both outcome and the process used to make the decision

describe the limitations of using outcome as the sole criterion for the evaluation of ethical decision making

distinguish between legal and ethical obligations in decision making

identify strategies leader-managers can use to promote ethical behavior as the norm

describe how differences in personal, organizational, subordinate, and patient obligations increase the risk of intrapersonal conflict in ethical decision making

demonstrate self-awareness regarding the ethical frameworks and ethical principles that most strongly influence his or her personal decision making

role model ethical decision making congruent with the American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements and current professional standards

Introduction Unit II examines ethical, legal, and legislative issues affecting leadership and management as well as professional advocacy. This chapter focuses on applied ethical decision making as a critical leadership role for managers. Chapter 5 examines the impact of legislation and the law on leadership and management, and Chapter 6 focuses on advocacy for patients and subordinates and for the nursing profession in general.

Ethics is the systematic study of what a person’s conduct and actions should be with regard to self, other human beings, and the environment; it is the justification of what is right or good and the study of what a person’s life and relationships should be, not necessarily what they are. Ethics is a system of moral conduct and principles that guide a person’s actions in regard to right and wrong and in regard to oneself and society at large.

Ethics is concerned with doing the right thing, although it is not always clear what that is.

Applied ethics requires application of normative ethical theory to everyday problems. The normative ethical theory for each profession arises from the purpose of the profession. The values and norms of the nursing profession, therefore, provide the foundation and filter from which ethical decisions are made. The nurse-manager,

however, has a different ethical responsibility than the clinical nurse and does not have as clearly defined a foundation to use as a base for ethical reasoning.

In addition, because management is a discipline and not a profession, its purpose is not as clearly defined as medicine or law; therefore, the norms that guide ethical decision making are less clear. Instead, the organization reflects norms and values to the manager, and the personal values of managers are reflected through the organization. The manager’s ethical obligation is tied to the organization’s purpose, and the purpose of the organization is linked to the function that it fills in society and the constraints society places on it. So, the responsibilities of the nurse-manager emerge from a complex set of interactions.

Society helps define the purposes of various institutions, and the purposes, in turn, help ensure that the institution fulfills specific functions. However, the specific values and norms in any institution determine the focus of its resources and shape its organizational life. The values of people within institutions influence actual management practice. In reviewing this set of complex interactions, it becomes evident that arriving at appropriate ethical management decisions can be a difficult task.

In addition, nursing management ethics are distinct from clinical nursing ethics. Although significant research exists regarding ethical dilemmas and moral distress experienced by staff nurses in clinical roles, less research exists regarding the ethical distress experienced by nursing managers.

Nursing management ethics are also distinct from other areas of management. Although there are many similar areas of responsibility between nurse-managers and non–nurse-managers, many leadership roles and management functions are specific to nursing. These differences require the nurse-manager to deal with unique obligations and ethical dilemmas that are not encountered in nonnursing management.

In addition, because personal, organizational, subordinate, and consumer responsibilities differ, there is great potential for nursing managers to experience intrapersonal conflict about the appropriate course of action. Multiple advocacy roles and accountability to the profession further increase the likelihood that all nurse-managers will be faced with ethical dilemmas in their practice. Nurses often find themselves viewed simultaneously as advocates for physicians, patients, and the organization—all of whose needs and goals may be dissimilar.

Nurses are often placed in situations where they are expected to be agents for patients, physicians, and the organization simultaneously, all of which may have conflicting needs, wants, and goals.

To make appropriate ethical decisions then, the manager must have knowledge of ethical principles and frameworks, use a professional approach that eliminates trial and error and focuses on proven decision-making models, and use available organizational processes to assist in making such decisions. Such organizational processes include institutional review boards (IRBs), ethics committees, and professional codes of ethics. Using both a systematic approach and proven ethical tools and technology allows managers to make better decisions and increases the probability that they will feel confident about the decisions they have made. Leadership roles and management functions associated with ethics are shown in Display 4.1.

DISPLAY 4.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH ETHICS

Leadership Roles 1. Is self-aware regarding own values and basic beliefs about

the rights, duties, and goals of human beings 2. Accepts that some ambiguity and uncertainty must be a part

of all ethical decision making 3. Accepts that negative outcomes occur in ethical decision

making despite high-quality problem solving and decision making

4. Demonstrates risk taking in ethical decision making 5. Role models ethical decision making, which is congruent with

the American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements (ANA, 2015), the ANA Nursing Administration: Scope and Standards of Practice (2016), and professional standards

6. Clearly communicates expected ethical standards of behavior 7. Role models behavior that eliminates theory–practice–ethics

gaps and promotes ethical behavior as the norm 8. Promotes patients’ self-determination and informed decision

making 9. Collaborates with others to protect human rights and promote

social justice 10. Assures that nurses are represented on interprofessional

teams addressing ethical risks, benefits, and outcomes

Management Functions 1. Uses a systematic approach to problem solving and decision

making when faced with management problems with ethical ramifications

2. Identifies outcomes in ethical decision making that should always be sought or avoided

3. Uses established ethical frameworks to clarify values and beliefs

4. Applies principles of ethical reasoning to define what beliefs or values form the basis for decision making

5. Is aware of legal precedents that may guide ethical decision making and is accountable for possible liabilities should they go against the legal precedent

6. Continually reevaluates the quality of personal ethical decision making based on the process of decision making or problem solving used

7. Constantly assesses levels of moral uncertainty, moral distress, and moral outrage in subordinates and intervenes as necessary to protect quality patient care and worker’s well- being

8. Establishes systems whereby ethical issues impacting stakeholders (health-care consumers, workers, community, etc.) can be addressed and resolved

9. Recognizes and rewards ethical conduct of subordinates 10. Takes appropriate action when subordinates demonstrate

unethical conduct

Moral Issues Faced by Nurses Despite 2017 Gallup poll findings that show Americans have ranked nursing as the most honest ethical profession for the 16th consecutive year (Jimenez, 2018), ethical issues are commonplace in nursing. Peter (2018) agrees, noting that “nurses’ moral lives are growing in complexity given rapid changes that are the result of scientific advances, a growing business ethos, and technological processes aimed at standardizing patient care. At times, nurses believe that they cannot respond adequately to the ethical issues that they encounter because of their enormity and nurses’

responsibility to continue to care for patients despite the obstacles” (para. 1).

There are many terms used to describe these moral issues including moral indifference, moral uncertainty, moral conflict, moral distress, moral outrage, and ethical dilemmas. Moral indifference occurs when an individual questions why morality in practice is even necessary. Moral uncertainty or moral conflict occurs when an individual is unsure which moral principles or values apply and may even include uncertainty as to what the moral problem is.

On the other hand, moral distress occurs when the individual knows the right thing to do, but organizational constraints make it difficult to take the right course of action. Thus, morally distressed nurses often demonstrate biological, emotional, and moral stress because of this intrapersonal conflict (Edmonson, 2015). Indeed, morally distressed nurses often experience anger, loneliness, depression, guilt, powerlessness, anxiety, and even emotional withdrawal. This then leads to turnover as the nurse leaves the stressful situation for a less stressful environment (Edmonson, 2015). Barlem and Ramos (2015) suggest that moral distress is one of the main ethical problems affecting nurses in all health systems and thus is a threat to nurses’ integrity and to the very essence of quality of patient care.

Moral outrage occurs when an individual witnesses the immoral act of another but feels powerless to stop it. Lastly, the most difficult of all moral issues is termed a moral or ethical dilemma, which is being forced to choose between two or more undesirable alternatives. For example, a nurse might experience a moral or ethical dilemma if he or she was required to provide care or treatments that conflicted with his or her own religious beliefs. In this case, the nurse would likely experience an intrapersonal moral conflict about whether his or her values, needs, and wants can or should supersede those of the patient. Because ethical dilemmas

are so difficult to resolve, many of the learning exercises in this chapter are devoted to addressing this type of moral issue.

Individual values, beliefs, and personal philosophy play a major role in the moral or ethical decision making that is part of the daily routine of all nurses as well as managers.

How do managers decide what is right and what is wrong? What does the manager do if no right or wrong answer exists? What if all solutions generated seem to be wrong? Remember that the way managers approach and solve ethical issues is influenced by their values and basic beliefs about the rights, duties, and goals of all human beings. Self-awareness, then, is a vital leadership role in ethical decision making, just as it is in so many other aspects of management.

No rules, guidelines, or theories exist that cover all aspects of the ethical problems that managers face. However, it is the manager’s responsibility to understand the ethical problem-solving process, to be familiar with ethical frameworks and principles, and to know ethical professional codes and standards. It is these tools that will assist managers in effective problem solving and prevent ethical failure within their organization. Critical thinking occurs when managers are able to engage in an orderly process of ethical problem solving to determine the rightness or wrongness of different courses of action.

Ethical Frameworks for Decision Making Ethical frameworks guide individuals in solving ethical dilemmas. These frameworks do not solve the ethical problem but assist the manager in clarifying personal values and beliefs. Four of the most commonly used ethical frameworks are utilitarianism, duty-based reasoning, rights-based reasoning, and intuitionism (Table 4.1).

TABLE 4.1 ETHICAL FRAMEWORKS

Framework Basic Premise

Utilitarian (teleological)

Provide the greatest good for the greatest number of people.

Rights based (deontological)

Individuals have basic inherent rights that should not be interfered with.

Duty based (deontological)

A duty to do something or to refrain from doing something

Intuitionist (deontological)

Each case is weighed on a case-by-case basis to determine relative goals, duties, and rights.

Ethical frameworks do not solve ethical problems, but they do assist decision makers in clarifying personal values and beliefs.

The teleological theory of ethics is also called utilitarianism or consequentialist theory. Using an ethical framework of utilitarianism encourages decision making based on what provides the greatest good for the greatest number of people. In doing so, the needs and wants of the individual are diminished. Utilitarianism also suggests that the end can justify the means. For example, a manager using a utilitarian approach might decide to use travel budget money to send many staff to local workshops rather than to fund one or two people to attend a national conference. Another example would be an insurance program that meets the needs of many but refuses coverage for expensive organ transplants. As illustrated in Learning Exercise 4.6, the organization uses utilitarianism to justify lying to employee applicants because their hiring would result in good for many employees by keeping several units in the hospital open.

Deontological ethical theory judges whether the action is right or wrong regardless of the consequences and is based on the philosophy of Immanuel Kant in the 18th century. Primarily, this theory uses both duty-based reasoning and rights-based reasoning as the basis for its philosophy. Duty-based reasoning is an ethical framework stating that some decisions must be made because there is a duty to do something or to refrain from doing something. In Learning Exercise 4.5, the supervisor feels a duty to hire the most qualified person for the job, even if the personal cost is high.

Rights-based reasoning is based on the belief that some things are a person’s just due (i.e., each individual has basic claims, or entitlements, with which there should be no interference). Rights are different from needs, wants, or desires. The supervisor in Learning Exercise 4.5 believes that both applicants have the right to fair and impartial consideration of their application. In Learning Exercise 4.6, Sam believes that all people have the right to truth and, in fact, that he has the duty to be truthful.

The intuitionist framework allows the decision maker to review each ethical problem or issue on a case-by-case basis, comparing the relative weights of goals, duties, and rights. This weighting is determined primarily by intuition—what the decision maker believes is right for that particular situation. Recently, some ethical theorists have begun questioning the appropriateness of intuitionism as an ethical decision-making framework because of the potential for subjectivity and bias. Yet, many of the cases solved in this chapter involve some degree of decision making by intuition.

Other more recent theories of ethical philosophy include ethical relativism and ethical universalism. Ethical relativism suggests that individuals make decisions based only on what seems right or reasonable according to their value system or culture. Conversely, universalism holds that ethical principles are universal and constant and that ethical decision making should not vary as a result of individual circumstances or cultural differences.

Principles of Ethical Reasoning Both teleological and deontological theorists have developed a group of moral principles that are used for ethical reasoning. These principles of ethical reasoning further explore and define what beliefs or values form the basis for decision making. Respect for people is the most basic and universal ethical principle. The major ethical principles stemming from this basic principle are discussed in Display 4.2.

DISPLAY 4.2 ETHICAL PRINCIPLES

Autonomy: Promotes self-determination and freedom of choice Beneficence: Actions are taken in an effort to promote good Nonmaleficence: Actions are taken in an effort to avoid harm Paternalism: One individual assumes the right to make decisions

for another Utility: The good of the many outweighs the wants or needs of

the individual Justice: Seeks fairness; treats “equals” equally and treats

“unequals” according to their differences Veracity: Obligation to tell the truth Fidelity: Need to keep promises Confidentiality: Keeps privileged information private

Autonomy (Self-Determination) A form of personal liberty, autonomy, is also called freedom of choice or accepting the responsibility for one’s choice. Rosenberg (2019) notes that autonomy means that patients are able to make independent decisions. This means that nurses should be sure patients have all the information they need to make a decision about their medical care. Examples of nurses fostering patient autonomy

include obtaining informed consent from the patient for treatment, accepting the situation when a patient refuses a medication, and maintaining confidentiality.

The legal right of self-determination supports autonomy. For example, progressive discipline recognizes the autonomy of the employee. The employee has the choice to meet organizational expectations or to be disciplined further. If the employee’s continued behavior warrants termination, the principle of autonomy says that the employee has made the choice to be terminated because of his or her actions, not by that of the manager. Therefore, nurse- managers must be cognizant of the ethical component present whenever an individual’s decisional capacity is in question. To take away a person’s right to self-determination is a serious but sometimes necessary action.

Beneficence (Doing Good) This principle states that the actions one takes should be done in an effort to promote good. The concept of nonmaleficence, which is associated with beneficence, says that if one cannot do good, then one should at least do no harm. For example, if a manager uses this ethical principle in planning performance appraisals, he or she is much more likely to view the performance appraisal as a means of promoting employee growth. Another example would be providing a standard of care that avoids risk or minimizes it, as it relates to medical competence (Rosenberg, 2019).

It is not always clear, however, if a nurse’s actions are beneficent or maleficent. For example, Ganz, Sharfi, Kaufman, and Einav (2018) point out that cardiopulmonary resuscitation is the default procedure during cardiopulmonary arrest. If a patient does not want cardiopulmonary resuscitation, then a “do-not-resuscitate” order must be documented. Sometimes, this order is not given, even if thought to be appropriate. This situation then can lead to a slow

code, defined as an ineffective resuscitation, where all resuscitation procedures are not performed or done slowly (Ganz et al., 2018). Some nurses perceive slow codes to be a beneficent ethical alternative, but this is in contrast with most legal and ethical opinions expressed in the literature (see Examining the Evidence 4.1).

EXAMINING THE EVIDENCE 4.1 Source: Ganz, F. D., Sharfi, R., Kaufman, N., & Einav, S. (2018). Perceptions of slow codes by nurses working on internal medicine wards. Nursing Ethics. Advance online publication. doi:10.1177/0969733018783222

Are “Slow Codes” Ethical? In some health-care institutions, slow codes (ineffective resuscitation) are used when a do- not-resuscitate order is not available and health-care providers perceive it to be more ethical to have limited intervention (lifesaving measures are not performed or done slowly) than to fully attempt to resuscitate the patient. This cross-sectional, descriptive study sought to describe the perceptions of nurses working on internal medicine wards that use slow codes, including the factors associated with their implementation.

Most nurses reported that resuscitations were conducted according to protocol (n = 90; 76.2%). Some took their time calling the code (n = 22; 18.3%) or waited by the bedside and did not perform cardiopulmonary resuscitation (n = 45; 37.5%). Factors most often associated with slow codes were poor patient prognosis (mean = 3.52/5) and a low chance of patient survival (mean = 3.37/5). Two thirds (n = 76; 66.8%) reported that slow codes were done on their unit, and the majority (n = 80; 69%) perceived slow codes as ethical. The researchers concluded that nurses should be

educated about the legal and ethical implications of slow codes, and qualitative and quantitative studies should be conducted to further investigate their implementation.

Paternalism This principle is related to beneficence in that one person assumes the authority to decide for another. In clinical nursing, care providers may become paternalistic when they believe the patient’s judgment is impaired or that they have knowledge the patient does not have. Because paternalism limits freedom of choice, however, most ethical theorists believe that paternalism is justified only to prevent a person from coming to harm.

Unfortunately, paternalism is present in nursing management as well as clinical decision making. For example, some managers use the principle of paternalism in subordinates’ career planning. In doing so, managers assume that they have greater knowledge of what an employee’s short- and long-term goals should be than the employee does.

The most fundamental universal principle is respect for people.

Utility This principle reflects a belief in utilitarianism—what is best for the common good outweighs what is best for the individual. Utility justifies paternalism as a means of restricting individual freedom. Managers who use the principle of utility need to be careful not to become so focused on desired group outcomes that they become less humanistic.

Justice (Treating People Fairly) This principle states that equals should be treated equally and that unequals should be treated according to their differences. For example, Haden (2017) suggests that if two people have the same relative position in an organization and the same level of responsibility, then justice is treating them the same in terms of resources, expectations, rewards, and other factors necessary for them to succeed. However, if one person has significantly different responsibilities than another—that is, they are unequal—then the just leader must treat them as unequals.

Haden (2017) also argues that justice is giving each person his or her due. From this perspective, justice is defined by the leader’s responsibility to give each follower what rightfully belongs to him or her; whether that right is determined by nature or by contract.

The principle of justice is frequently applied when there are scarcities or competition for resources or benefits. The manager who uses the principle of justice will work to see that pay raises reflect consistency in terms of performance and time in service. Nurses demonstrate this when making impartial medical decisions related to limited resources or new treatments regardless of economic status, ethnicity, sexual orientation, etc. (Rosenberg, 2019).

LEARNING EXERCISE 4.1

Are Some People More Equal Than Others?

Research suggests that individuals with health insurance in this country have better access to health-

care services and enjoy better health-care outcomes than those who do not. This does not mean, however, that all individuals with health insurance receive “equal treatment.” Medicaid recipients (people who are financially indigent) often complain that although they have public insurance, many private providers refuse to accept them as patients. Patients enrolled in managed care suggest that their treatment options are more limited than traditional private insurance because of the use of gatekeepers, required authorizations, and queuing. Some individuals, with lower cost insurance plans under the Patient Protection and Affordable Care Act, suggest that high out-of-pocket costs for copayments and deductibles continue to restrict their choice to access needed care.

ASSIGNMENT:

Using the ethical principle of justice, determine whether health care in this country should be a right or a privilege. Are the uninsured and the insured “unequals” that should be treated according to their differences? Does the type of health insurance that one has also create a system of unequals? If so, are the unequals being treated according to their differences?

Veracity (Truth Telling) This principle is used to explain how people feel about the need for truth telling or the acceptability of deception. A manager who believes that deception is morally acceptable if it is done with the objective of beneficence may tell all rejected job applicants that they were highly considered whether they had been or not.

Fidelity (Keeping Promises) Fidelity refers to the moral obligation that individuals should be faithful to their commitments and promises. Breaking a promise is believed by many ethicists to be wrong regardless of the consequences. In other words, even if there were no far-reaching negative results of the broken promise, it is still wrong because it would render the making of any promise meaningless. However, there are times when keeping a promise (fidelity) may not be in the best interest of the other party, as discussed under “Confidentiality (Respecting Privileged Information)” section. Although nurses have multiple fidelity duties (patient, physician, organization, profession, and self) that at times may be in conflict, the American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements is clear that the nurse’s primary commitment is to the patient (ANA, 2015).

Confidentiality (Respecting Privileged Information) The obligation to observe the privacy of another and to hold certain information in strict confidence is a basic ethical principle and a foundation of both medical and nursing ethics. However, as in deception, there are times when the presumption against disclosing information must be overridden. For example, health-care managers are required by law to report certain cases, such as drug abuse in employees, elder abuse, and child abuse.

LEARNING EXERCISE 4.2

Weighing Veracity and Nonmaleficence

You are a second-year nursing student. During the first year of the nursing program, you formed a close friendship with Susan, another nursing student, and the two of you spend many of your free evenings and weekends together doing fun things. The only thing that drives you a bit crazy about your friend is that she is incredibly messy. When you go to her home, you usually see dirty dishes piled in the sink, dog hair over all the furniture, clothing strewn all over the apartment, and uneaten pizza or other half spoiled food sitting on the floor. You attempt to limit your time at her apartment because it is so bothersome to you, so it has not been a factor in your friendship.

Today, when Susan and you are sitting at the dining table in your apartment, your current roommate tells you that she is unexpectedly vacating her lease at the end of the month. Susan becomes excited and shares that her lease will end at the end of this month as well and suggests how much fun it would be if the two of you could move in together. She immediately begins talking about when she could move in, where she would locate her furniture in the apartment, and where her dog might stay when the two of you are in clinical. Although you value Susan’s friendship and really enjoy the time you spend together, the idea of living with someone as untidy as Susan is not something you want to do. Unfortunately, your current lease does not preclude pets or subleases.

ASSIGNMENT:

Decide how you will respond to Susan. Will you tell her the truth? Are your values regarding veracity stronger or weaker than your desire to cause no harm to Susan’s feelings (nonmaleficence)?

LEARNING EXERCISE 4.3

Family Values

You are the evening shift charge nurse of the postanesthesia care unit (PACU). You have just admitted a 32-year-old woman who, 2 hours ago, was thrown from a Jeep in which she was a passenger. She was rushed to the emergency department and subsequently to surgery, where cranial burr holes were placed and an intracranial monitor was inserted. No further cranial exploration was attempted because the patient sustained extensive and massive neurologic damage. She will probably not survive your shift. The plan is to hold her in the PACU for 1 hour and, if she is still alive, transfer her to the intensive care unit.

Shortly after receiving the patient, you are approached by the evening house supervisor, who says that the patient’s sister is pleading to be allowed into the PACU. Normally, visitors are not allowed into the PACU when patients are being held there only temporarily, but occasionally, exceptions are made. Tonight, the PACU is empty except for this patient. You decide to bend the rules and allow the young woman’s sister to come in. The

visiting sister is near collapse; it is obvious that she had been the driver of the Jeep. As the visitor continues to speak to the comatose patient, her behavior and words make you begin to wonder if she is indeed the sister.

Within 15 minutes, the house supervisor returns and states, “I have made a terrible mistake. The patient’s family just arrived, and they say that the visitor we just allowed into the PACU is not a member of the family but is the patient’s girlfriend. They are very angry and demand that this woman not be allowed to see the patient.”

You approach the visitor and confront her in a kindly manner regarding the information that you have just received. She looks at you with tears streaming down her face and says, “Yes, it is true. Mary and I have been together for 6 years. Her family disowned her because of it, but we were everything to each other. She has been my life, and I have been hers. Please, please let me stay. I will never see her again. I know the family will not allow me to attend the funeral. I need to say my goodbyes. Please let me stay. It is not fair that they have the legal right to be family when I have been the one to love and care for Mary.”

ASSIGNMENT:

1. Review the ANA (2018) Position Statement— Nursing Advocacy for LGBTQ+ Populations available at https://www.nursingworld.org/~49866e/globalass ets/practiceandpolicy/ethics/nursing-advocacy- for-lgbtq-populations.pdf.

2. Decide what you will do. Recognize that your own value system will play a part in your decision. List several alternatives that are available to you. Identify which ethical frameworks or principles most affected your decision making.

Codes of Ethics and Professional Standards Professional ethics relates to the values held by a profession. A professional code of ethics then is a set of principles, established by a profession, to guide the individual practitioner. The first Code of Ethics for Nurses was adopted by the ANA in 1950 and has been revised 6 times since then, most recently in 2015. This code outlines the important general values, duties, and responsibilities that flow from the specific role of being a nurse. Although not legally binding, the code functions as a guide to the highest ethical practice standards for nurses and as an aid for moral thinking.

The ANA (2015) Code of Ethics for Nurses With Interpretive Statements has nine statements. The professional issues in the first three statements are concerned with protection of clients’ rights and safety; those in the next three pertain to promoting healthy work cultures and self-care. The social issues of the last three statements of the code relates to the nurse’s obligations to society and the profession (Display 4.3).

DISPLAY 4.3 AMERICAN NURSES ASSOCIATION (2015) CODE OF ETHICS FOR NURSES

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

2. The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

4. The nurse has the authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.

5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Source: American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

Regarding ethics, Provisions 5 and 6 focus on ethical issues related to boundaries of duty and loyalty. Lachman, Swanson, and Winland-Brown (2015) suggest that the language used in the revised code makes these provisions more precise and the interpretive statements supporting the provisions better organized, making them easier to understand. Lachman et al. also note that Provisions 7 to 9 concentrate on the nurse’s ethical duties beyond individual patient encounters and suggest that these provisions had the most significant changes because they focus on the nurse’s obligation to address social justice issues through direct action and involvement in health policy as well as a responsibility to contribute to nursing knowledge through scholarly inquiry and research.

Professional codes of ethics function as a guide to the highest standards of ethical practice for nurses. They are not legally binding.

Practitioners may also find ethical guidance in examining the International Council of Nurses (ICN) Code of Ethics for Nurses, which was revised most recently in 2012. It provides a guide for action based on social values and needs and has served as the standard for nurses worldwide since it was first adopted in 1953 (ICN, 2018).

Another document that may be helpful specifically to the nurse- manager in creating and maintaining an ethical work environment is Nursing Administration: Scope and Standards of Practice (ANA, 2016) published by the ANA. These standards specifically delineate professional standards in management ethics, and these appear in Display 4.4.

DISPLAY 4.4 STANDARDS OF PROFESSIONAL PERFORMANCE FOR NURSE ADMINISTRATORS

Standard 7. Ethics The nurse administrator practices ethically.

Competencies 1. Uses the Code of Ethics for Nurses With Interpretive

Statements (ANA, 2015) to guide leadership and practice 2. Advocates for compassionate systems of care delivery that

preserve and protect health-care consumer, family, and employee’s dignity, rights, values, belief, and autonomy

3. Provides guidance in situations where the rights of the individuals conflict with public health or health systems

4. Supports the primary commitment to the health-care consumer and family regardless of setting

5. Protects health-care consumers’ and others’ privacy, confidentiality, data, and information within ethical, legal, and regulatory parameters

6. Promotes health-care consumers’ self-determination and informed decision making through organizational culture values and institutional policies

7. Collaborates with nursing and other employees to maintain therapeutic and professional health-care consumer relationships within appropriate professional role boundaries

8. Assures protection of the rights, health, and safety of the health-care consumer, employees, and others

9. Promotes systems to address and resolve ethical issues involving health-care consumers, colleagues, community groups, systems, and other stakeholders

10. Collaborates with other health professionals and the public to protect human rights, promote health diplomacy, enhance

cultural sensitivity and congruence, and reduce health disparities

11. Holds nurses accountable and responsible for competent nursing practice

12. Institutes effective action to address illegal, unethical, discriminatory, or inappropriate behavior that can endanger or jeopardize the best interests of the health-care consumer, organization, or situation

13. Creates a safe environment for employees and others to discuss health-care practices, which do not appear to be in the best interests of the health-care consumer organization, community, or situation

14. Empowers nurses to participate in interprofessional teams to address ethical risks, benefits, and outcomes

15. Articulates nursing values to maintain individual nurses’ personal integrity and the integrity of the profession

16. Integrates principles of social justice into nursing and policy 17. Demonstrates commitment to self-reflection and self-care 18. Advocates for the establishment and maintenance of an

ethical environment that is conducive to safe, accessible, equitable, and quality health care

Source: American Nurses Association. (2016). Nursing administration: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.

Ethical Problem Solving and Decision Making Hooker (2018) suggests solving ethical dilemmas is increasingly difficult in a complex and fast-moving world. That’s because it “requires careful analysis, not gut feeling or simplistic platitudes” (Hooker, 2018, para. 3).

Some of the difficulty people have in making ethical decisions can be attributed to a lack of formal education about problem solving. Other individuals lack the thinking skills or risk taking needed to

solve complex ethical problems. Still, other nurses erroneously use decision-making outcomes as the sole basis for determining the quality of the decision making. Although decision makers should be able to identify desirable and undesirable outcomes, outcomes alone cannot be used to assess the quality of the problem solving.

Many variables affect outcome, and some of these are beyond the control or foresight of the problem solver. In fact, even the most ethical courses of action can have undesirable and unavoidable consequences. Indeed, Ramos (2015) notes that care professionals must recognize that many outcomes are the result of our practice circumstance and should not be considered personal or professional failures. In addition, Ramos argues that although caregivers can “own” their feelings, they should not take personal responsibility for the shortcomings of the systems they work in and the impossibilities of practice. “Care givers can no more control every outcome than anyone else working within the system” (Ramos, 2015, p. 1).

Thus, the quality of ethical problem solving should be evaluated in terms of both outcome and the process used to make the decision. The best possible decisions stem from structured problem solving, adequate data collection, and examination of multiple alternatives— even if outcomes are poor.

If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, even with a poor outcome, the nurse should accept that the best possible decision was made at that time with the information and resources available.

In addition, Mortell (2012) suggests that some decision making by nurses reflects a theory–practice–ethics gap despite the moral obligation, nurses have to ensure theory and practice are integrated. For example, Mortell notes that noncompliance exists in hand

hygiene among practitioners despite ongoing infection prevention education and training; easy access to facilities such as washbasins; antiseptic/alcohol hand gels that are convenient, effective, and skin- and user-friendly; and organizational recognition and support for clinicians in handwashing and hand gel practices. Thus, despite nurses having knowledge of best practices based on current research, they continue to fail to achieve the required and desired compliance in hand hygiene. Mortell concludes that more emphasis should be placed on clinicians’ moral and ethical obligations as part of training and orientation and that organizations must continue to emphasize the duty of care toward patients in nurses’ decision making.

LEARNING EXERCISE 4.4

A Nagging Uneasiness

You are a nurse on a pediatric unit. One of your patients is a 15-month-old girl with a diagnosis of failure to thrive. The mother says that the child is emotional, cries a lot, and does not like to be held. You have been taking care of the child for 2 days since her admission, and she has smiled and been receptive to being held by you. She has also eaten well. There is something about the child’s reaction to the mother’s boyfriend that bothers you. The child appears to draw away from him when he visits. The mother is very young and seems to be rather immature but appears to care for the child.

This is the second hospital admission for this child. Although you were not on duty for the first admission 6 weeks ago, you check the records and see that the child

was admitted with the same diagnosis. While you are on duty today, the child’s father calls and asks about her condition. He lives several hundred miles away and requests that the child be hospitalized until the weekend (it is Wednesday) so that he can “check things out.” He tells you that he believes the child is mistreated. He says he is also concerned about his ex-wife’s 4-year-old child from another marriage and is attempting to gain custody of that child in addition to his own child. From what little the father said, you are aware that the divorce was bitter and that the mother has full custody. Because of Health Insurance Portability and Accountability Act, you tell the father that you cannot provide any information about the child.

You talk with the physician at length. He says that after the last hospitalization, he requested that the community health agency and Child Protective Services call on the family. Their subsequent report to him was that the 4- year-old child appeared happy and well and that the 15- month-old child appeared clean, although somewhat underweight. There was no evidence to suggest child abuse. However, the community health agency plans to continue following the children. He says that the mother has been good about keeping doctor appointments and has kept the children’s immunizations up to date. The pediatrician proceeds to write an order for discharge. He says that although he also feels somewhat uneasy, continued hospitalization is not justified, and Medicaid will not pay for additional days. He also says that he will follow up once again with Child Protective Services to make another visit.

When the mother and her boyfriend come to take the baby home, the baby clings to you and refuses to go to

the boyfriend. She also seems reluctant to go to the mother. All during the discharge, you are extremely uneasy. When you see the car drive away, you feel very sad.

After returning to the unit, you talk with your supervisor, who listens carefully and questions you at length. Finally, she says, “It seems as if you have nothing concrete on which to act and are only experiencing feelings. I think you would be risking a lot of trouble for yourself and the hospital if you acted rashly at this time. Accusing people with no evidence and making them go through a traumatic experience is something I would hesitate to do.”

You leave the supervisor’s office still troubled. She did not tell you that you must do nothing, but you believe that she would disapprove of further action on your part. The doctor also felt strongly that there was no reason to do more than was already being done. The child will be followed by community health nurses. Perhaps, the ex- husband was just trying to make trouble for his ex-wife and her new boyfriend. You would certainly not want anyone to have reported you or created problems regarding your own children. You remember how often your 5-year-old bruised himself when he was that age. You go about your duties and try to shake off your feeling. What should you do?

ASSIGNMENT:

1. Solve the case in small groups by using the traditional problem-solving process. Identify the problem and several alternative solutions to solve this ethical dilemma. What should you do and why? What are the risks? How does your value system play a part in your decision? Justify your solution. After completing this assignment, solve the second part of this assignment below.

2. Assume that this was a real case. Twenty-four hours after the child’s discharge, she is readmitted with critical head trauma. Police reports indicate that the child suffered multiple skull fractures after being thrown up against the wall by her mother’s boyfriend. The child is not expected to live. Does knowing the outcome change how you would have solved the case? Does the outcome influence how you feel about the quality of your group’s problem solving?

Kearney and Penque (2012) provide another example of a theory– practice–ethics gap in their suggestion that although nurses recognize that checklists can reduce episodes of patient harm by ensuring that procedures are being carried out appropriately, some providers will indicate that an intervention has been undertaken when it has not. This occurs because of the mantra “If it wasn’t documented, it wasn’t done” and an increasing emphasis and reliance on documentation that demands that “all boxes must be ticked” to ensure complete care has been provided. Kearney and Penque suggest then that checklists present a context for ethical decision making in that when providers do not take ethics into account, checklists could perpetuate rather than prevent unsafe practices or errors.

The Traditional Problem-Solving Process Although not recognized specifically as an ethical problem-solving model, one of the oldest and most frequently used tools for problem solving is the traditional problem-solving process. This process, which is discussed in Chapter 1, consists of seven steps, with the actual decision being made at step 5 (review the seven steps under “Traditional Problem-Solving Process” section in Chapter 1). Although many individuals use at least some of these steps in their decision making, they frequently fail to generate an adequate number of alternatives or to evaluate the results—two essential steps in the process.

The Nursing Process Another problem-solving model not specifically designed for ethical analysis, but appropriate for it, is the nursing process. Most nurses are aware of the nursing process and the cyclic nature of its components of assessment, diagnosis, planning, implementation, and evaluation (see Fig. 1.2 ). However, most nurses do not recognize its use as a decision-making tool. The cyclic nature of the process allows for feedback to occur at any step. It also allows the cycle to repeat until adequate information is gathered to make a decision. It does not, however, require clear problem identification. Learning Exercise 4.5 shows how the nursing process might be used as an ethical decision-making tool.

LEARNING EXERCISE 4.5

One Applicant Too Many

The reorganization of the public health agency has resulted in the creation of a new position of community health liaison. A job description has been written, and the job opening has been posted. As the chief nursing executive of this agency, it will be your responsibility to select the best person for the position. Because you are aware that all hiring decisions have some subjectivity, you want to eliminate as much personal bias as possible. Two people have applied for the position; one of them is a close friend.

Analysis

Assess: As the chief nursing executive, you have a responsibility to make personnel decisions as objectively as you can. This means that the hiring decision should be based solely on which employee is best qualified for the position. You do recognize, however, that there may be a personal cost in terms of the friendship.

Diagnose: You diagnose this problem as a potential intrapersonal conflict between your obligation to your friend and your obligation to your employer.

Plan: You must plan how you are going to collect your data. The tools you have selected are applications, resumés, references, and personal interviews.

Implement: Both applicants are contacted and asked to submit resumés and three letters of reference from recent employers. In addition, both are scheduled for structured formal interviews with you and two of the board members of the agency. Although the board members will provide feedback, you have been reserved the right to make the final hiring decision.

Evaluate: As a result of your plan, you have discovered that both candidates meet the minimal job requirements. One candidate, however, clearly has higher level communication skills, and the other candidate (your friend) has more experience in public health and is more knowledgeable regarding the resources in your community. Both employees have complied with the request to submit resumés and letters of reference; they are of similar quality.

Assess: Your assessment of the situation is that you need more information to make the best possible decision. You must assess whether strong communication skills or public health experience and familiarity with the community would be more valuable in this position.

Plan: You plan how you can gather more information about what the employee will be doing in this newly created position.

Diagnose: If the job description is inadequate in providing this information, it may be necessary to gather information from other public health agencies with a similar job classification.

Evaluate: You now believe that excellent communication skills are essential for the job. The candidate who had these skills has an acceptable level of public health experience and seems motivated to learn more about the community and its resources. This means that your friend will not receive the job.

Assess: Now, you must assess whether a good decision has been made.

Plan: You plan to evaluate your decision in 6 months, basing your criteria on the established job description.

Implement: You are unable to implement your plan because this employee resigns unexpectedly 4 months after she takes the position. Your friend is now working in a similar capacity in another state. Although you correspond infrequently, the relationship has changed as a result of your decision.

Evaluate: Did you make a good decision? This decision was based on a carefully thought-out process, which included adequate data gathering and a weighing of alternatives. Variables beyond your control resulted in the employee’s resignation, and there was no apparent reason for you to suspect that this would happen. The decision to exclude or minimize personal bias was a conscious one, and you were aware of the possible ramifications of this choice. The decision making appears to have been appropriate.

The Moral Decision-Making Model Crisham (1985) developed a model for ethical decision making incorporating the nursing process and principles of biomedical ethics. This model is especially useful in clarifying ethical problems that result from conflicting obligations. This model is represented by the mnemonic MORAL as shown in Display 4.5.

DISPLAY 4.5 THE MORAL DECISION-MAKING MODEL

Massage the dilemma: Collect data about the ethical problem and who should be involved in the decision-making process.

Outline options: Identify alternatives and analyze the causes and consequences of each.

Review criteria and resolve: Weigh the options against the values of those involved in the decision. This may be done through a weighting or grid.

Affirm position and act: Develop the implementation strategy. Look back: Evaluate the decision making.

Source: Crisham, P. (1985). Moral: How can I do what’s right? Nursing Management, 16(3), 42A–42N.

Learning Exercise 4.6 demonstrates the MORAL modeling in solving an ethical issue.

LEARNING EXERCISE 4.6

Little White Lies

Sam is the nurse recruiter for a metropolitan hospital that is experiencing an acute nursing shortage. He has been told to do or say whatever is necessary to recruit professional nurses so that the hospital will not have to close several units. He also has been told that his position will be eliminated if he does not produce a substantial number of applicants in the nursing career days to be held the following week. Sam loves his job and is the sole provider for his family. Because many

organizations are experiencing severe personnel shortages, the competition for employees is keen. After his third career day without a single prospective applicant, he begins to feel desperate. On the fourth and final day, Sam begins making many promises to potential applicants regarding shift preference, unit preference, salary, and advancement that he is not sure he can keep. At the end of the day, Sam has a lengthy list of interested applicants but also feels a great deal of intrapersonal conflict.

Massage the Dilemma

In a desperate effort to save his job, Sam finds he has taken action that has resulted in high intrapersonal value conflict. Sam must choose between making promises he likely cannot keep and losing his job. This has far- reaching consequences for all involved. Sam has the ultimate responsibility for knowing his values and acting in a manner that is congruent with his value system. The organization is, however, involved in the value conflict in that its values and expectations conflict with those of Sam. Sam and the organization have some type of responsibility to these applicants, although the exact nature of this responsibility is one of the values in conflict. Because this is Sam’s problem and an intrapersonal conflict, he must decide the appropriate course of action. His primary role is to examine his values and act in accordance.

Outline Options

Option 1. Quit his job immediately. This would prevent future intrapersonal conflict, provided that Sam becomes aware of his value system and behaves in a manner consistent with that value system in the future. It does not, however, solve the immediate conflict about the action Sam has already taken. This action takes away Sam’s livelihood.

Option 2. Do nothing. Sam could choose not to be accountable for his own actions. This will require Sam to rationalize that the philosophy of the organization is in fact acceptable or that he has no choice regarding his actions. Thus, the responsibility for meeting the needs and wants of the new employees is shifted to the organization. Although Sam will have no credibility with the new employees, there will be only a negligible impact on his ability to recruit at least on a short-term basis. Sam will continue to have a job and be able to support his family.

Option 3. If after value clarification, Sam has determined that his values conflict with the organization’s directive to do or say whatever is needed to recruit employees, he could approach his superior and share these concerns. Sam should be very clear about what his values are and to what extent he is willing to compromise them. He also should include in this meeting what, if any, action should be taken to meet the needs of the new employees. Sam must be realistic about the time and effort usually required to change the values and beliefs of an organization. He also must be aware of his bottom line if the organization is not willing to provide a compromise resolution.

Option 4. Sam could contact each of the applicants and tell them that certain recruitment promises may not be possible. However, he will do what he can to see that the promises are fulfilled. This alternative is risky. The applicants will probably be justifiably suspicious of both the recruiter and the organization, and Sam has little formal power at this point to fulfill their requests. This alternative also requires a time and energy commitment by Sam and does not prevent the problem from recurring.

Review the Options

In value clarification, Sam discovered that he valued truth telling. Alternative 3 allows Sam to present a recruiting plan to his supervisor that includes a bottom line that this value will not be violated.

Affirm Position and Act

Sam approached his superior and was told that his beliefs were idealistic and inappropriate in an age of severe worker shortages. Sam was terminated. Sam did, however, believe that he made an appropriate decision. He did become self-aware regarding his values and attempted to communicate these values to the organization in an effort to work out a mutually agreeable plan.

Look Back

Although Sam was terminated, he knew that he could find some type of employment to meet his immediate fiscal needs. He did become self-aware regarding his

values and used what he had learned in this decision- making process, in that he planned to evaluate more carefully the recruitment philosophy of the organization in relation to his own value system before accepting another job.

Working Toward Ethical Behavior as the Norm The concerns about ethical conduct in American institutions are documented by many news articles in the national press. Many individuals believe that organizational and institutional ethical failure has become the norm. Governmental agencies, both branches of Congress, the stock exchange, oil companies, and savings and loan institutions have all experienced problems with unethical conduct. Many members of society wonder what has gone wrong.

Gallagher and Jago (2018) argue that at times, individual ethical misconduct is excused because of aggravating factors in the organization. They suggest, however, that the role of individual responsibility in unethical actions and omissions should not be downplayed. Nursing practice is challenging, but the privilege of licensure should compel nurses to behave in an ethical manner. Nurse-managers, then, have a responsibility to create a climate in their organizations in which ethical behavior is not only the expectation but also the norm.

In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by nurse-managers will involve some ethical component. Indeed, the following forces ensure that ethics will become an even greater dimension in management decision making in the future: increasing technology, regulatory pressures, and competitiveness among health-care providers; workforce shortages; an imperative to provide better care at less cost; spiraling costs of supplies and salaries; and the public’s increasing distrust of the health-care delivery system and its

institutions. The following actions, as shown in Display 4.6, can help the manager in ethical problem solving.

DISPLAY 4.6 STRATEGIES LEADER-MANAGERS CAN USE TO PROMOTE ETHICAL BEHAVIOR AS THE NORM

1. Separate legal and ethical issues. 2. Collaborate through ethics committees. 3. Use institutional review boards appropriately. 4. Foster an ethical work environment.

Separate Legal and Ethical Issues Although they are not the same, separating legal and ethical issues is sometimes difficult. Legal controls are generally clear and philosophically impartial; ethical controls are much less clear and individualized. In many ethical issues, courts have made a decision that may guide managers in their decision making. Often, however, these guidelines are not comprehensive, or they differ from the manager’s own philosophy. Managers must be aware of established legal standards and cognizant of possible liabilities and consequences for actions that go against the legal precedent.

In general, legal controls are clearer and philosophically impartial; ethical controls are much less clear and individualized.

Legal precedents are frequently overturned later and often do not keep pace with the changing needs of society. In addition, certain circumstances may favor an illegal course of action as the “right” thing to do. If a man were transporting his severely ill wife to the

hospital, it might be morally correct for him to disobey traffic laws. Therefore, the manager should think of the law as a basic standard of conduct, whereas ethical behavior requires a greater examination of the issues involved.

The manager may confront several particularly sensitive legal– ethical issues, including termination or refusal of treatment, durable power of attorney, abortion, sterilization, child abuse, and human experimentation. Most health-care organizations have legal counsel to assist managers in making decisions in such sensitive areas. Because legal aspects of management decision making are so important, Chapter 5 is devoted exclusively to this topic.

Collaborate Through Interprofessional Ethics Committees The new manager must consult with others when solving sensitive legal–ethical questions because a person’s own value system may preclude examining all possible alternatives. Many institutions have ethics committees to assist with problem solving in ethical issues. These ethics committees typically are interprofessional and are organized to consciously and reflectively consider significant and often difficult or ambiguous value issues related to patient care or organizational activities. Ethics committees are a core element of collaborative ethical decision making and should include representatives of all stakeholders, including patients when they are involved in the ethical issue.

Use Institutional Review Boards Appropriately IRBs are primarily formed to protect the rights and welfare of research subjects. They provide oversight to ensure that individuals conducting research adhere to ethical principles that were articulated by the National Commission for the Protection of Human Subjects of

Biomedical and Behavioral Research. The primary role of the manager regarding IRBs is to make sure that such a board is in place in the organization where the manager works and that any research performed within his or her sphere of responsibility has been approved by such a board.

Foster an Ethical Work Environment Perhaps the most important thing a leader-manager can do to foster an ethical work environment, however, is to role model ethical behavior. Likewise, working as a team with a standard for behavior can promote a positive ethical climate. Other important interventions include encouraging staff to openly discuss ethical issues that they face daily in their practice. This allows subordinates to gain greater perspective on complex issues and provides a mechanism for peer support.

Integrating Leadership Roles and Management Functions in Ethics Leadership roles in ethics focus on the human element involved in ethical decision making. Leaders are self-aware regarding their values and basic beliefs about the rights, duties, and goals of human beings. As self-aware and ethical people, they role model confidence in their decision making to subordinates. They also are realists and recognize that some ambiguity and uncertainty must be a part of all ethical decision making. Leaders are willing to take risks in their decision making despite the fact that negative outcomes can occur even with quality decision making.

In ethical issues, the manager is often the decision maker. Because ethical decisions are so complex, and the cost of a poor decision may be high, management functions focus on increasing the chances that the best possible decision will be made at the least

possible cost in terms of fiscal and human resources. This usually requires that the manager becomes expert at using systematic approaches to problem solving or decision making, such as theoretical models, ethical frameworks, and ethical principles. By developing expertise, the manager can identify universal outcomes that should be sought or avoided.

The integrated leader-manager recognizes that ethical issues pervade every aspect of leadership and management. Rather than being paralyzed by the complexity and ambiguity of these issues, the leader-manager seeks counsel as needed, accepts his or her limitations, and makes the best possible decision at that time with the information and resources available.

Edmonson (2015) concludes that organizations and health-care systems today need moral leadership and that the influence of morally courageous nurses, regardless of position, will be critically needed to transform health-care and care systems to safeguard patients. “As nurse leaders in the healthcare system and in specific facilities, we need to demonstrate moral courage and create environments that promote morally courageous acts so as to keep us centered on the very thing that drew us into healthcare, namely the patient, the families, and the communities we serve” (Edmonson, 2015, Conclusion section, para. 1). Barlem and Ramos (2015) concur, arguing that “instead of questioning the reason nurses experience moral distress according to certain situations and contexts, it is more important to question the reasons why nursing professionals allow themselves to accept certain contexts as unchangeable or natural, renouncing the possibility to ethically resist situations that bring about moral distress” (p. 613).

Key Concepts

■ Ethics is the systematic study of what a person’s conduct and actions should be with regard to self, other human beings, and the environment; it is the justification of what is right or good and the study of what a person’s life and relationships should be—not necessarily what they are.

■ In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by nurse-managers involves some ethical component. Multiple advocacy roles and accountability to the profession further increase the likelihood that managers will be faced with ethical dilemmas in their practice.

■ Many systematic approaches to ethical problem solving are appropriate. These include the use of theoretical problem- solving and decision-making models, ethical frameworks, and ethical principles.

■ Outcomes should never be used as the sole criterion for assessing the quality of ethical problem solving because many variables affect outcomes that have no reflection on whether the problem solving was appropriate. Quality, instead, should be evaluated both by the outcome and by the process used to make the decision.

■ If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, regardless of the outcome, the manager should feel comfortable that the best possible decision was made at that time with the information and resources available.

■ Four of the most commonly used ethical frameworks for decision making are utilitarianism, duty-based reasoning, rights-based reasoning, and intuitionism. These frameworks do not solve the ethical problem but assist individuals

involved in the problem solving to clarify their values and beliefs.

■ Principles of ethical reasoning explore and define what beliefs or values form the basis for our decision making. These principles include autonomy, beneficence, nonmaleficence, paternalism, utility, justice, fidelity, veracity, and confidentiality.

■ Professional codes of ethics and standards for practice are guides to the highest standards of ethical practice for nurses.

■ Sometimes, it is very difficult to separate legal and ethical issues, although they are not the same. Legal controls are generally clear and philosophically impartial. Ethical controls are much more unclear and individualized.

Additional Learning Exercises and Applications

LEARNING EXERCISE 4.7

Everything Is Not What It Seems

You are a perinatal unit coordinator at a large teaching hospital. In addition to your management responsibilities, you have been asked to fill in as a member of the hospital promotion committee, which reviews petitions from clinicians for a step-level promotion on the clinical specialist ladder. You believe that you could learn a great deal on this committee and could be an objective and contributing member.

The committee has been convened to select the annual winner of the Outstanding Clinical Specialist Award. In reviewing the applicant files, you find that one file from a perinatal clinical specialist contains many overstatements and several misrepresentations. You know for a fact that this clinician did not accomplish all that she has listed because she is a friend and close colleague. She did not, however, know that you would be a member of this committee and thus would be aware of this deception.

When the entire committee met, several members commented on this clinician’s impressive file. Although you were able to dissuade them covertly from further considering her nomination, you are left with many uneasy feelings and some anger and sadness. You recognize that she did not receive the nomination, and thus, there is little real danger regarding the deceptions in the file being used inappropriately at this time. However, you will not be on this committee next year, and if she were to submit an erroneous file again, she could be highly considered for the award. You also recognize that even with the best of intentions and the most therapeutic of communication techniques, confronting your friend with her deception will cause her to lose face and will probably result in an unsalvageable friendship. Even if you do confront her, there is little you can do to stop her from doing the same in future nomination processes other than formally reporting her conduct.

ASSIGNMENT:

Determine what you will do. Do the potential costs outweigh the potential benefits? Be realistic about your actions.

LEARNING EXERCISE 4.8

The Valuable Employee

Gina has been the supervisor of a 16-bed intensive care unit (ICU)/critical care unit (CCU) in a 200-bed urban hospital for 8 years. She is respected and well liked by her staff. Her unit’s staff retention level and productivity are higher than any other unit in the hospital. For the last 6 years, Gina has relied heavily on Mark, her permanent charge nurse on the day shift. He is bright and motivated and has excellent clinical and managerial skills. Mark seems satisfied and challenged in his current position, although Gina has not had any formal career planning meetings with him to discuss his long-term career goals. It would be fair to say that Mark’s work has greatly increased Gina’s scope of power and has enhanced the reputation of the unit.

Recently, one of the physicians approached Gina about a plan to open an outpatient cardiac rehabilitation program. The program will require a strong leader and manager who is self-motivated. It will not only be a lot of work but will also provide many opportunities for advancement. The physician suggests that Mark would

be an excellent choice for the job, although the physician has given Gina full authority to make the final decision.

Gina is aware that Lynn, a bright and dynamic staff nurse from the open-heart surgery floor, also would be very interested in the job. Lynn has been employed at the hospital for only 1 year but has a proven track record and would probably be very successful in the job. In addition, there is a staffing surplus right now on the open-heart surgery floor because two of the surgeons have recently retired. It would be difficult and time-consuming to replace Mark as charge nurse in the ICU/CCU.

ASSIGNMENT:

What process should this supervisor pursue to determine who should be hired for the position? Should the position be posted? When does the benefit of using transfers/promotions as a means of reward outweigh the cost of reduced productivity?

LEARNING EXERCISE 4.9

To See or Not to See

For the last few days, you have been taking care of Mr. Cole, a 28-year-old patient with end-stage cystic fibrosis. You have developed a caring relationship with Mr. Cole and his wife. They are both aware of the prognosis of his

disease and realize that he has only a short time left to live.

When Dr. Jones made rounds with you this morning, she told the Coles that Mr. Cole could be discharged today if his condition remains stable. They were both excited about the news because they had been urging the doctor to let him go home to enjoy his remaining time surrounded by the people he loves.

When you bring in Mr. Cole’s discharge orders to his room to review his medications and other treatments, you find Mrs. Cole assisting Mr. Cole as he coughs up bright red blood. When you confront them, they both beg you not to tell the doctor or chart the incident because they do not want their discharge to be delayed. They believe that it is their right to go home and let Mr. Cole die surrounded by his family. They said that they know that they can leave against their physician’s wishes and go home against medical advice, but if they do, their insurance will not pay for home care.

ASSIGNMENT:

What is your duty in this case? What are Mr. Cole’s rights? Is it ever justified to withhold information from the physician? Will you chart the incident, and will you report it to anyone? Solve this case, justifying your decision by using ethical principles.

LEARNING EXERCISE 4.10

The Untruthful Employee (Marquis & Huston, 2012)

You are the registered nurse on duty at a skilled nursing facility. Judy, a 35-year-old, full-time nurse’s aide on the day shift, has been with the skilled nursing facility for 10 years. You have worked with Judy on numerous occasions and have found her work to be marginal at best. She tries to be extra friendly with the staff and occasionally brings them small treats that she bakes. She also makes a point of telling everyone how much she needs this job to support her family and how she loves working here. She has a disabled daughter who relies on her hospital-provided health insurance to have her health-care needs met.

Most of the other staff seem willing to put up with Judy’s poor work habits, but lately, you have felt that her work has shown many serious errors. Things are not reported to you that should have been—intake and output

volumes that are in error, strange recordings for vital signs, and so on. She has tried to cover up such errors, with what you suspect are outright lies. She claims to have bathed patients when this does not appear to be the case, and has said some patients have refused to eat when you have found that they were willing to eat for you. Although the chief nursing officer acknowledges that Judy is only a marginally adequate employee, she has been unable to observe directly any of the behaviors that would require disciplinary action and has told you that you must have real evidence of her wrongdoing in order to for her to take action.

During morning report, you made a specific request to Judy that a confused patient, Mr. Brown, assigned to her, be assisted to the bathroom, and you told her that someone must remain in the room to assist him when he is up, as he fell last evening. You also told Judy that when in bed, Mr. Brown’s side rails were always to be up. Later in the morning, you take Mr. Brown his medication and notice that his side rails are down and after pulling them up and giving him his medicine, you find Judy and talk with her. She denies leaving the side rails down and insisted someone else must have done it. You caution her again about Mr. Brown’s needs. Thirty minutes later, you go by Mr. Brown’s room and find his bed empty and discover he is in the bathroom unattended. As you are assisting Mr. Brown back to bed, Judy bursts into the room and pales when she sees you with her patient. At first, she denies that she had gotten Mr. Brown up, but when you express your disbelief, she tearfully admits that she left him unattended but stated that this was an isolated incident and asked you to forget it. When you said that it was her lying about the incident that most

disturbed you, she promised never to lie about anything again. She begged you not to report her to the chief nursing officer and said she needed her job.

You are torn between wanting to report Judy for her lying because of concerns about patient safety and also not wanting to be responsible for getting her fired. To reduce the emotionalism of the event and to give yourself time to think, you decide to take a break and think over the possible actions you should take.

ASSIGNMENT:

Evaluate this problem. Is this just a simple leadership–management problem that requires some problem solving and a decision or does the problem have ethical dimensions? Using one of the problem-solving models in this chapter, solve this problem. Compare your solution with others in your class.

LEARNING EXERCISE 4.11

Sometimes Things Go Wrong (Marquis & Huston, 2012)

You have been working as a registered nurse on an orthopedic unit since your graduation from your nursing program 2 years ago. Both the doctors and supervisor respect your work, and you have found it exciting to work

with the home health nurses as many of your patients need home health follow-up for physical therapy and other needs following their surgeries.

Mrs. George is an elderly widow who has recently had bilateral hip replacement. Although she has made good progress, she continues to need quite a bit of assistance with ambulation. Normally, if family members cannot assist them at home, patients with bilateral hip replacements are sent from the hospital to an assisted living facility for several weeks. Mrs. George does not have any immediate family to help her, but she has pleaded with her doctor, you, and the home health nurse to let her go back to her home, which she refers to as a cabin in the “piney woods” to complete her recuperation. The doctor tells you and the home health nurse to work on a plan to see if it is feasible.

The home health nurse reports after her home assessment that with some assistance every day, she could probably manage at home, and although her cabin is not near any neighbor, she does have a telephone. Mrs. George is insistent that she will not go to what she calls “a nursing home” and her insurance will no longer pay for her to stay at the hospital. Eventually, it is decided that Meals on Wheels will deliver her meals and that a home health nurse will call on her every other day and a physical therapist will visit every other day so that she will have at least two people in her home each day.

Although you and the home health nurse and the doctor are a bit uneasy, you feel that you have solved this ethical dilemma (a choice between two negative solutions) and have selected the one that is the least damaging to Mrs. George’s quality of life.

Seven days after Mrs. George is discharged, there is a severe storm, which disables most phone lines including Mrs. George’s. The storm also causes the flue in her wood stove to overheat in the middle of the night causing a fire. Mrs. George is unable to use her walker fast enough to get outside before the fire consumes the small cabin. Mrs. George dies in the fire.

ASSIGNMENT:

Would you have solved this problem as described? Does knowing the outcome change the way you would solve the problem? Having a negative outcome may or may not mean that the ethical problem solving was faulty. Do you feel the people in this story made a faulty decision? If so, what would you have done differently?

LEARNING EXERCISE 4.12

Shortcuts (Marquis & Huston, 2012)

Gina is the charge nurse of the 3:00 PM to 11:00 PM

shift on the acute care unit where you have worked for 18 months since your graduation. Your supervisor has asked you if you would like to learn the duties of the relief charge nurse. You were thrilled that she approached you for this position. Because it was a relief position, it was

permissible for your supervisor to appoint you and not necessary for you to formally apply for the position.

One day each week, for the last 2 weeks, you have been working with Gina about the responsibilities of the position. There are several things Gina does that bother you, and you are not sure what you should do. For example, if used supplies were inadvertently not charged to patients at the time of service, Gina admitted she would just charge them to whoever patients she thought were likely to have used them. When you questioned Gina about this, she said, “Well, at the end of the day, the unit needs to make sure that all supplies have been charged for, or the CFO will be after all of us. It is one of the charge nurses’ responsibilities, and I don’t have time to chase everyone down to find the correct patient to charge and besides everyone has insurance and so it does not come out of the patient’s pocket. Most importantly, we must make sure the hospital gets reimbursed or we won’t have our jobs.”

In addition, when Gina does the staffing correlation for the upcoming shift, you notice that she fudges a bit and makes sure the night shift is given credit for needing more staff than they need. When questioned, she said, “Oh, we have to take care of each other, better too much staff than not enough.”

You think Gina’s actions are unethical, but you do not know what to do about it. It does not directly harm a patient, but you feel uncomfortable about what she is doing and feel it is not the ethical thing to do.

ASSIGNMENT:

You have many options here including doing nothing. Using the MORAL ethical problem-solving model, solve this case and compare your solution with others in your class.

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5

Legal and Legislative Issues . . . It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.—Florence Nightingale

. . . Laws or ordinances unobserved, or partially attended to, had better never have been made.— George Washington, letter to James Madison, March 31, 1787

. . . The best way to get a bad law repealed is to enforce it strictly.—Abraham Lincoln

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential V: Health-care policy, finance, and regulatory environments

BSN Essential VIII: Professionalism and professional values MSN Essential II: Organizational and systems leadership MSN Essential VI: Health policy and advocacy AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency V: Business skills

ANA Standard of Professional Performance 10: Collaboration

ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 14: Quality of practice

ANA Standard of Professional Performance 15: Professional practice evaluation

ANA Standard of Professional Performance 17: Environmental health

QSEN Competency: Safety

LEARNING OBJECTIVES

The learner will:

identify the primary sources of law and how each affects nursing practice

describe the types (criminal, civil, and administrative) of legal cases nurses may be involved in and differentiate between the burden of proof and the potential consequences for rule breaking in each

identify specific doctrines used by the courts to define legal boundaries for nursing practice

correlate the legal authority of nursing practice and the nursing process

assess his or her personal need for malpractice insurance as a nurse, weighing the potential risks versus benefits

describe the five elements that must be present for a professional to be held liable for malpractice

identify strategies nurses can use to reduce their likelihood of being sued for malpractice

describe the liability nurses, other care providers, and employers share under the concept of joint liability

identify types of intentional torts as well as strategies nurses can use to reduce their likelihood

describe appropriate nursing actions to ensure informed consent describe the need for patient and family education regarding treatment and end-of-life issues as part of the Patient Self- Determination Act

describe conditions that must exist to receive liability protection under Good Samaritan laws

recognize his or her legal imperative to protect patient confidentiality in accordance with the Health Insurance Portability and Accountability Act of 1996

identify the role State Boards of Nursing play in professional licensure and discipline

explain how increased consumer awareness of patient rights has affected the actions of the health-care team

select appropriate legal nursing actions in sensitive clinical situations

differentiate between legal and ethical accountability

Introduction Chapter 4 presented ethics as an internal control of human behavior and nursing practice. Therefore, ethics has to do with actions that people should take, not necessarily actions that they are legally required to take. On the other hand, ethical behavior written into law is no longer just desired, it is mandated. This chapter focuses on the external controls of legislation and law. Since the first mandatory Nurse Practice Act was passed in North Carolina in 1903, nursing has been legislated, directed, and controlled to some extent.

The primary purpose of law and legislation is to protect the patient and the nurse. Laws and legislation define the scope of acceptable practice and protect individual rights. Nurses who are aware of their

rights and duties in legal matters are better able to protect themselves against liability or loss of professional licensure.

This chapter has five sections. The first section presents the primary sources of law and how each affects nursing practice. The nurse’s responsibility to be proactive in establishing and revising laws affecting nursing practice is emphasized. The second section presents the types of legal cases in which nurses may be involved and differentiates between the burden of proof and the consequences for each if the nurse is found to have broken the law. The third section identifies specific doctrines used by the courts to define legal boundaries for nursing practice. The role of state boards in professional licensure and discipline is examined. The fourth section deals with the components of malpractice for the individual practitioner and the manager or supervisor. Legal terms are defined. The fifth and final section discusses issues such as informed consent, medical records, intentional torts, the Patient Self- Determination Act (PSDA), the Good Samaritan Act, and the Health Insurance Portability and Accountability Act (HIPAA).

This chapter is not meant to be a complete legal guide to nursing practice. There are many excellent legal textbooks and handbooks that accomplish that function. The primary function of this chapter is to emphasize the widely varying and rapidly changing nature of laws and the responsibility that each manager has to keep abreast of legislation and laws affecting both nursing and management practice. Leadership roles and management functions associated with legal and legislative issues are shown in Display 5.1.

DISPLAY 5.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN LEGAL AND LEGISLATIVE ISSUES

Leadership Roles 1. Serves as a role model by providing nursing care that meets

or exceeds accepted standards of care 2. Practices within the scope of the Nurse Practice Act 3. Creates a work environment where each person understands

he or she has some liability for his or her own conduct 4. Updates knowledge and skills in the field of practice and

seeks professional certification to increase expertise in a specific field

5. Reports substandard nursing care to appropriate authorities following the established chain of command

6. Fosters nurse–patient relationships that are respectful, caring, and honest, thus reducing the possibility of future lawsuits

7. Creates an environment that encourages and supports diversity and sensitivity

8. Prioritizes patient rights and patient welfare in decision making

9. Ensures that patients receive informed consent for treatment 10. Demonstrates vision, risk taking, and energy in applying

appropriate legal boundaries for nursing practice

Management Functions 1. Increases knowledge regarding sources of law and legal

doctrines that affect nursing practice 2. Ensures that organizational guidelines regarding scope of

practice are consistent with the state Nurse Practice Act 3. Delegates to subordinates wisely, looking at the manager’s

scope of practice and that of the individuals he or she supervises

4. Understands and adheres to institutional policies and procedures

5. Minimizes the risk of product liability by assuring that all staff are appropriately oriented to the appropriate use of equipment and products

6. Monitors subordinates to ensure they have a valid, current, and appropriate license to practice nursing

7. Uses foreseeability of harm in delegation and staffing decisions

8. Increases staff awareness of intentional torts and assists them in developing strategies to reduce their liability in these areas

9. Provides education for staff and patients on issues concerning treatment and end-of-life issues under the Patient Self-Determination Act

10. Protects all patients’ rights to confidentiality under the Health Insurance Portability and Accountability Act

11. Ensures patients have reasonable access to information in the medical record, following established organizational processes

12. Secures appropriate background checks for new employees to reduce managerial liability

13. Provides educational and training opportunities for staff on legal issues affecting nursing practice

Sources of Law The US legal system can be somewhat confusing because there are not only four sources of the law but also parallel systems at the state and federal levels. The sources of law include constitutions, statutes, administrative agencies, and court decisions. A comparison is shown in Table 5.1.

TABLE 5.1 SOURCES OF LAW

Origin of Law Use

Impact on Nursing Practice

The Constitution

The highest law in the United States; interpreted by the U.S. Supreme Court; gives authority to other three sources of the law

Constitutional law has little direct involvement in the area of malpractice.

Statutes Also called statutory law or legislative law; laws that are passed by the state or federal legislators and that must be signed by the president or governor

Before 1970s, very few state or federal laws dealt with malpractice. Since the malpractice crisis, many statutes affect malpractice.

Administrative agencies

The rules and regulations established by appointed agencies of the executive branch of the government (governor or president)

State Boards of Nursing and agencies, such as the National Labor Relations Board and health and safety boards significantly impact nursing practice.

Court decisions

Also called tort law; this is court mode law, and the courts interpret the statutes and set precedents; in the United States, there are two levels of court: trial court and appellate court

Most malpractice laws are addressed by the courts.

A constitution is a system of fundamental laws or principles that govern a nation, society, corporation, or other aggregate of individuals. The purpose of a constitution is to establish the basis of a governing system for the future and the present. The U.S. Constitution establishes the general organization of the federal government and grants and limits its specific powers. Each state also has a constitution that establishes the general organization of the state government and grants and limits its powers.

The second source of law is statutes—laws that govern. Legislative bodies, such as the U.S. Congress, state legislatures, and city councils, make these laws. Statutes are officially enacted (voted on and passed) by the legislative body and are compiled into codes, collections of statutes, and ordinances. The 51 Nurse Practice Acts representing the 50 states and the District of Columbia are examples of statutes. These Nurse Practice Acts define and limit the practice of nursing, thereby stating what constitutes authorized practice as well as what exceeds the scope of authority. Although Nurse Practice Acts may vary among states, all must be consistent with provisions or statutes established at the federal level.

The 51 Nurse Practice Acts (one for each state and the District of Columbia) define and limit the practice of nursing, thereby stating what constitutes authorized practice as well as what exceeds the scope of authority.

Administrative agencies, the third source of law, are given authority to act by the legislative bodies and create rules and regulations that enforce statutory laws. For example, State Boards of Nursing are administrative agencies set up to implement and enforce the state Nurse Practice Act by writing rules and regulations and by conducting investigations and hearings to ensure the law’s enforcement. Administrative laws are valid only to the extent that

they are within the scope of the authority granted to them by the legislative body.

The fourth source of law is court decisions. Judicial or decisional laws are made by the courts to interpret legal issues that are in dispute. Depending on the type of court involved, judicial or decisional law may be made by a single justice, with or without a jury, or by a panel of justices. Generally, initial trial courts have a single judge or magistrate, intermediary appeal courts have three justices, and the highest appeal courts have nine justices.

Types of Laws and Courts Although most nurses worry primarily about being sued for malpractice, they may actually be involved in three different types of court cases: criminal, civil, and administrative (Table 5.2). The court in which each is tried, the burden of proof required for conviction, and the resulting punishment associated with each is different.

TABLE 5.2 TYPES OF LAWS AND COURTS

Type

Burden of Proof Required for Guilty Verdict

Likely Consequences of a Guilty Verdict

Criminal Beyond a reasonable doubt

Incarceration, probation, and fines

Civil Based on a preponderance of the evidence

Monetary damages

Administrative Clear and convincing standard

Suspension or loss of licensure

In criminal cases, the individual faces charges generally filed by the state or federal attorney general for crimes committed against an

individual or society. In criminal cases, the individual is always presumed to be innocent unless the state can prove his or her guilt beyond a reasonable doubt. Incarceration and even death are possible consequences for being found guilty in criminal matters. Nurses found guilty of intentionally administering fatal doses of drugs to patients would be charged in a criminal court.

In civil cases, one individual sues another for money to compensate for a perceived loss. The burden of proof required to be found guilty in a civil case is described as a preponderance of the evidence. In other words, the judge or jury must believe that it was more likely than not that the accused individual was responsible for the injuries of the complainant. Consequences of being found guilty in a civil suit are monetary. Most malpractice cases are tried in civil court.

In administrative cases, an individual is sued by a state or federal governmental agency assigned the responsibility of implementing governmental programs. State Boards of Nursing are one such governmental agency. When an individual violates the state Nurse Practice Act, the Boards of Nursing may seek to revoke licensure or institute some form of discipline. The burden of proof in these cases varies from state to state. When the clear and convincing standard is not used, the preponderance of the evidence standard may be used. Clear and convincing involves higher burdens of proof than preponderance of evidence but a significantly lower burden of proof than beyond a reasonable doubt.

The burden of proof required for conviction as well as the type of punishment given differs in criminal, civil, and administrative cases.

LEARNING EXERCISE 5.1

Both Guilty and Not Guilty

Think of celebrated cases where defendants have been tried in both civil and criminal courts. What were the verdicts in both cases? If the verdicts were not the same, analyze why this happened. Do you agree that taking away an individual’s personal liberty by incarceration should require a higher burden of proof than assessing for monetary damages?

ASSIGNMENT:

Also complete a literature search to see if you can find cases where a nurse faced both civil and administrative charges. Were you able to find cases where the nurse was found guilty in a civil court but did not lose his or her license? Did you find the opposite?

Legal Doctrines and the Practice of Nursing Two important legal doctrines frequently guide all three courts in their decision making. The first of these, stare decisis, means to let the decision stand. Stare decisis uses precedents as a guide for decision making. This doctrine gives nurses insight into ways that the court has previously fixed liability in given situations. However, the nurse must avoid two pitfalls in determining if stare decisis should apply to a given situation.

Precedent is often used as a guide for legal decision making.

The first is that the previous case must be within the jurisdiction of the court hearing the current case. For example, a previous Florida case decided by a state court does not set precedent for a Texas appellate court. Although the Texas court may model its decision after the Florida case, it is not compelled to do so. The lower courts in Texas, however, would rely on Texas appellate decisions.

The other pitfall is that the court hearing the current case can depart from the precedent and set a landmark decision. Landmark decisions generally occur because societal needs have changed, technology has become more advanced, or following the precedent would further harm an already injured person. Roe v. Wade, the 1973 landmark decision to allow a woman to seek and receive a legal abortion during the first two trimesters of pregnancy, is an example. Given the influence of politics and varying societal views about abortion, this precedent could change again at some point in the future.

The second doctrine that guides courts in their decision making is res judicata, which means a “thing or matter settled by judgment.” It applies only when a competent court has decided a legal dispute and when no further appeals are possible. This doctrine keeps the same parties in the original lawsuit from retrying the same issues that were involved in the first lawsuit.

When using doctrines as a guide for nursing practice, the nurse must remember that all laws are fluid and subject to change. An example of changing law regarding professional nursing occurred in an Illinois Supreme Court more than a decade ago when the law finally recognized nursing as an independent profession with its own unique body of knowledge. In this case (Sullivan v. Edward Hospital, 2004), the Illinois Supreme Court decided that physicians could not

serve as expert witnesses regarding nursing standards (FindLaw for Legal Professionals, 2019). This demonstrates how the law is ever- evolving. Laws cannot be static; they must change to reflect the growing autonomy and responsibility desired by nurses. It is critical that all nurses be aware of and sensitive to rapidly changing laws and legislation that affect their practice. Nurses must also recognize that state laws may differ from federal laws and that legal guidelines for nursing practice in the organization may differ from state or federal guidelines.

Boundaries for practice are defined in the Nurse Practice Act of each state. These acts are general in most states to allow for some flexibility in the broad roles and varied situations in which nurses practice. Because this allows for some interpretation, many employers have established guidelines for nursing practice in their own organization. These guidelines regarding scope of practice cannot, however, exceed the requirements of the state Nursing Practice Acts. Managers need to be aware of their organization’s specific practice interpretations and ensure that subordinates are aware of the same and follow established practices. All nurses must understand the legal controls for nursing practice in their state.

Professional Negligence (Malpractice) Elements of Malpractice All liability suits involve a plaintiff and a defendant. In malpractice cases, the plaintiff is the injured party and the defendant is the professional who is alleged to have caused the injury. Negligence is the omission to do something that a reasonable person, guided by the considerations that ordinarily regulate human affairs, would do— or as doing something that a reasonable and prudent person would not do. Reasonable and prudent generally means the average judgment, foresight, intelligence, and skill that would be expected of a person with similar training and experience. Malpractice—the

failure of a person with professional training to act in a reasonable and prudent manner—also is called professional negligence. Five elements must be present for a professional to be held liable for malpractice (Table 5.3).

TABLE 5.3 COMPONENTS OF PROFESSIONAL NEGLIGENCE

Elements of Liability Explanation

Example: Giving Medications

1. Duty to use due care (defined by the standard of care)

The care that should be given under the circumstances reflects what a reasonably prudent nurse would have done.

A nurse should give medications accurately, completely, and on time.

2. Failure to meet standard of care (breach of duty)

The care that should have been given, was not.

A nurse fails to give medications accurately, completely, or on time.

3. Foreseeability of harm

The nurse must have reasonable access to information about whether the possibility of harm exists.

The drug handbook specifies that the wrong dosage or route may cause injury.

4. A direct relationship between failure to meet the standard of care (breach) and injury can be proved.

Patient is harmed because proper care is not given.

Wrong dosage causes the patient to have a convulsion.

5. Injury Actual harm results to the patient.

Convulsion or other serious complication

occurs.

“Medical malpractice is a lawsuit rooted in professional negligence. It often requires an act or omission by a healthcare provider in which the conduct (usually the treatment provided or withheld) falls below the accepted standard of practice in the community. The remaining component is damage—some injury or harm to the patient” (Silberman, 2015, p. 312).

First, a standard of care must have been established that outlines the level or degree of quality considered adequate by a given profession. Standards of care outline the duties a defendant has to a plaintiff or a nurse to a client. These standards represent the skills and learning commonly possessed by members of the profession and generally are the minimal requirements that define an acceptable level of care. Standards of care, which guarantee clients safe nursing care, include organizational policy and procedure statements, job descriptions, and student guidelines.

Second, after the standard of care has been established, it must be shown that the standard was violated—there must have been a breach of duty. This breach is shown by calling other nurses who practice in the same specialty area as the defendant to testify as expert witnesses.

Third, the nurse must have had the knowledge or availability of information that not meeting the standard of care could result in harm. This is called foreseeability of harm. If the average, reasonable person in the defendant’s position could have anticipated the plaintiff’s injury as a result of his or her actions, then the plaintiff’s injury was foreseeable. Ignorance is not an excuse, but lack of information may have an effect on the ability to foresee harm.

Being ignorant is not a justifiable excuse for malpractice, but not having all the information in a situation may impede one’s ability to foresee harm.

For example, a charge nurse assigns another registered nurse (RN) to care for a critically ill patient. The assigned RN makes a medication error that injures the patient in some way. If the charge nurse had reason to believe that the RN was incapable of adequately caring for the patient or failed to provide adequate supervision, foreseeability of harm is apparent, and the charge nurse also could be held liable. If the charge nurse was available as needed and had good reason to believe that the RN was fully capable, he or she would be less likely to be held liable.

Many malpractice cases have hinged on whether the nurse was persistent enough in attempting to notify health-care providers of changes in a patient’s conditions or to convince the providers of the seriousness of a patient’s condition. Because the nurse has foreseeability of harm in these situations, the nurse who is not persistent can be held liable for failure to intervene because the intervention was below what was expected of him or her as a patient advocate.

The fourth element is that failure to meet the standard of care must have the potential to injure the patient. There must be a provable correlation between improper care and injury to the patient.

The final element is that actual patient injury must occur. This injury must be more than transitory. The plaintiff must show that the action of the defendant directly caused the injury and that the injury would not have occurred without the defendant’s actions. It is important to remember here, however, that not taking action is an action.

Being Sued for Malpractice

Historically, physicians were the health-care providers most likely to be held liable for nursing care. As nurses have gained authority, autonomy, and accountability, they have assumed responsibility, accountability, and liability for their own practice. As roles have expanded, nurses have begun performing duties traditionally reserved for medical practice.

LEARNING EXERCISE 5.2

Who Is Responsible for Harm to This Patient? You Decide

You are a surgical nurse at Memorial Hospital. At 4:00 PM, you receive a patient from the recovery room who has had a total hip replacement. You note that the hip dressings are saturated with blood but are aware that total hip replacements frequently have some postoperative oozing from the wound. There is an order on the chart to reinforce the dressing as needed, and you do so. When you next check the dressing at 6:00 PM, you find the reinforcements saturated and drainage on the bed linen. You call the physician and tell her that you believe the patient is bleeding too heavily. The physician reassures you that the amount of bleeding you have described is not excessive but encourages you to continue to monitor the patient closely. You recheck the patient’s dressings at 7:00 and 8:00 PM. You again call the physician and tell her that the bleeding still looks too heavy. She again reassures you and tells you to continue

to watch the patient closely. At 10:00 PM, the patient’s blood pressure becomes nonpalpable, and she goes into shock. You summon the doctor, and she comes immediately.

ASSIGNMENT:

What are the legal ramifications of this case? Using the components of professional negligence outlined in Table 5.3, determine who in this case is guilty of malpractice. Justify your answer. At what point in the scenario should each character have altered his or her actions to reduce the probability of a negative outcome?

Because of an increased scope of practice, many nurses now carry individual malpractice insurance. This is a double-edged sword. Nurses need malpractice insurance in basic practice as well as in expanded practice roles. They do incur a greater likelihood of being sued, however, if they have malpractice insurance because injured parties will always seek damages from as many individuals with financial resources as possible. In fact, a recent study by the Nurses Service Organization found that $90 million was paid out in nursing malpractice claims over a recent 5-year period (Injury Trial Lawyers, 2018).

In addition, some nurses count on their employer-provided professional liability policies to protect them from malpractice claims, but such policies often have limitations. For example, employers may not provide coverage once an employee has terminated his or her employment, even if the situation that led to the complaint occurred while the nurse was employed there, and some employer-provided

policies have inadequate limits of liability for the individual employee. Nurses then are advised to obtain their own personal liability policy.

In addition, Neil (2015) notes that without personal nursing malpractice insurance, nurses are dependent on the attorney representing the facility and their first priority is to defend the facility. During a lawsuit, the nurse needs an attorney dedicated solely to his or her own interests. Unfortunately, both the enhanced role of nurses and the increase in the number of insured nurses have led to a great increase in the number of liability suits seeking damages from nurses as individuals over the past few decades.

In particular, malpractice has become a greater concern to advanced practice nurses such as nurse practitioners (NPs) and nurse midwives. An analysis of 67 malpractice claims filed against NPs that closed over a 6-year period (January 2011 to December 2016) is shown in Examining the Evidence 5.1. As a result of their increased risk for litigation, NPs pay high costs for their insurance premiums and are subject to strict professional liability (malpractice) insurance requirements.

EXAMINING THE EVIDENCE 5.1 Source: Troxel, D. B. (2018). In primary care, who gets sued and why? Retrieved July 19, 2018, from https://thedoctorweighsin.com/primary-care-who- gets-sued-and-why/

Malpractice Claims for Nurse Practitioners Working in Primary Care The Doctors Company analyzed 67 malpractice claims against nurse practitioners (NPs) that closed over a 6-year period from January 2011 to December 2016. These claims arose in family medicine (FM) and internal medicine (IM) practices.

Study findings revealed that the three most common claim allegations against NPs working in FM and IM accounted for 88% of their total claim allegations. The most common claim (48%) was diagnosis related (failure, delay, wrong diagnosis). The second most common was medication related (24%), and the third was medical treatment related (16%).

An allegation of failure or delay in obtaining a specialty consultation or referral often occurred when an NP managed a complication that was beyond his or her expertise or scope of practice (SOP). Failure to perform an adequate patient assessment often occurred when an NP relied on the medical history or diagnosis in a previous medical record rather than performing a new, comprehensive exam.

In addition, many NP malpractice claims could be traced to clinical and administrative

factors including failure to adhere to the SOP, inadequate physician supervision, the absence of written protocols, deviation from written protocols, and failure or delay in seeking physician collaboration or referral.

Avoiding Malpractice Claims Interactions between nurses and clients that are less businesslike and more personal are more satisfying to both. It has been shown that despite technical competence, nurses who have difficulty establishing positive interpersonal relationships with patients and their families are at greater risk for being sued. Communication that proceeds in a caring and professional manner has been shown repeatedly to be a major reason that people do not sue despite adequate grounds for a successful lawsuit.

In addition, many experts have suggested a need to create safer environments for care so that less patients are injured during their care. This has especially been true since the release of To Err Is Human by the Institute of Medicine (IOM, 1999), a congressionally chartered independent organization. The IOM report indicated that errors are simply a part of the human condition and that the health- care system itself needs to be redesigned so that fewer errors can occur. For example, even though there are unit-dose systems in play, nurse-leaders often look the other way when staff pour all the medications into a soufflé cup and hand them to patients, thus increasing the possibility of medication errors.

Strategies recommended by The Joint Commission, in its 2005 seminal report, Health care in the Crossroads (Joint Commission on Accreditation of Healthcare Organizations, 2005), can be viewed in Display 5.2. The three major areas of focus in the call to action are to

prevent injuries, improve communication, and examine mechanisms for injury compensation.

DISPLAY 5.2 SUMMARY OF RECOMMENDATIONS FROM THE EXECUTIVE SUMMARY OF HEALTH CARE IN THE CROSSROADS: STRATEGIES FOR IMPROVING THE MEDICAL LIABILITY SYSTEM AND PREVENTING PATIENT INJURY

1. Pursue patient safety initiatives that prevent medical injury by Strengthening oversight and accountability mechanisms to

better ensure the competencies of physicians and nurses Encouraging appropriate adherence to clinical guidelines to

improve quality and reduce liability risk Supporting team development through team training Continuing to leverage patient safety initiatives through

regulatory and oversight bodies Building an evidence-based information and technology

system that impacts patient safety and pursue proposals to offset implementation costs

Promoting the creation of cultures of patient safety in health- care organizations

Establishing a federal leadership locus for advocacy of patient safety and health-care quality

Pursuing “pay-for-performance” strategies that provide incentives to improve patient safety and health-care quality

2. Promote open communication between patients and practitioners by Involving health-care consumers as active members of the

health-care team Encouraging open communication between practitioners and

patients when adverse events occur Pursuing legislation that protects disclosure and apology

from being used as evidence against practitioners in litigation

Encouraging nonpunitive reporting of errors to third parties that promote information and data analysis as a basis for developing safety improvement

Enacting federal safety legislation that provides legal protection for when information is reported to patient safety organizations

3. Create an injury compensation system that is patient centered and serves the common good by Conducting demonstration projects of alternatives to medical

liability that promote patient safety and transparency and provide swift compensation for injured patients

Encouraging continued development of mediation and early- offer initiatives

Prohibiting confidential settlements that prevent learning from events

Redesigning the National Practitioner Data Bank Advocating for court-appointed, independent expert

witnesses to mitigate bias in expert witness testimony

Source: Joint Commission on Accreditation of Healthcare Organizations. (2005). Health care in the crossroads: Strategies for improving the medical liability system and preventing patient injury. Oakbrook Terrace, IL: Author.

Nurses then can reduce the risk of malpractice claims by taking the following actions:

Practice within the scope of the Nurse Practice Act. Observe agency policies and procedures. Model practice after established standards by using evidence-

based practice. Always put patient rights and welfare first. Be aware of relevant law and legal doctrines and combine such

with the biological, psychological, and social sciences that form the basis of all rational nursing decisions.

Practice within the area of individual competence. Upgrade technical skills consistently by attending continuing

education programs and seeking specialty certification.

Nurses should also purchase their own liability insurance and understand the limits of their policies. Although this will not prevent a malpractice suit, it should help protect a nurse from financial ruin should there be a malpractice claim.

Extending the Liability In recent years, the concept of joint liability, in which the nurse, physician, and employing organization are all held liable, has become the current position of the legal system. This probably more accurately reflects the higher level of accountability now present in the nursing profession. Before 1965, nurses were rarely held accountable for their own acts, and hospitals were usually exempt due to charitable immunity. However, following precedent-setting cases in the 1960s, employers are now held liable for the nurse’s acts under a concept known as vicarious liability.

One form of vicarious liability is called respondeat superior, which means “the master is responsible for the acts of his servants.” Respondeat superior applies when an employee causes damages or injuries while working on behalf of his or her employer (Hale Law Firm, 2018). In such a scenario, the employer would also be liable for the injuries. The theory behind the doctrine is that an employer should be held legally liable for the conduct of employees whose actions he or she has a right to direct or control.

The difficulty in interpreting respondeat superior is that many exceptions exist. The first and most important exception is related to the state in which the nurse practices. In some states, the doctrine of charitable immunity applies, which holds that a charitable (nonprofit) hospital cannot be sued by a person who has been injured because

of a hospital employee’s negligence. Thus, liability is limited to the employee.

LEARNING EXERCISE 5.3

Understanding Limitations and Rules

Have you ever been directed in your nursing practice to do something that you believed might be unsafe or that you felt inadequately trained or prepared to do? What did you do? Would you act differently if the situation occurred now? What risks are inherent in refusing to follow the direct orders of a physician or superior? What are the risks of performing a task that you believe may be unsafe?

Another exception to respondeat superior occurs when the state or federal government employs the nurse. The common law rule of governmental immunity provides that governments cannot be held liable for the negligent acts of their employees while carrying out government activities. Some states have changed this rule by statute, however, and in these particular jurisdictions, respondeat superior continues to apply to the acts of nurses employed by the state government.

The purpose of respondeat superior is not to shift the burden of blame from the employee to the organization but rather to share the blame, increasing the possibility of larger financial compensation to the injured party.

Some nurses erroneously assume that they do not need to carry malpractice insurance because their employer will probably be sued as well and thus will be responsible for financial damages. Under the doctrine of respondeat superior, any employer required to pay damages to an injured person because of an employee’s negligence may have the legal right to recover or be reimbursed that amount from the negligent employee.

One rule that all nurses must know and understand is that of personal liability, which says that every person is liable for his or her own conduct. The law does not permit a wrongdoer to avoid legal liability for his or her own wrongdoing, even though someone else also may be sued and held legally liable. For example, if a manager directs a subordinate to do something that both know to be improper, the injured party can recover damages against the subordinate even if the supervisor agreed to accept full responsibility for the delegation at the time. In the end, each nurse is always held liable for his or her own negligent practice.

Managers are not automatically held liable for all acts of negligence on the part of those they supervise, but they may be held liable if they were negligent in the supervision of those employees at the time that they committed the negligent acts. Liability for negligence is generally based on the manager’s failure to determine which of the patient needs can be assigned safely to a subordinate or the failure to supervise a subordinate adequately for the assigned task (Huston, 2020c). Both the abilities of the staff member and the complexity of the task assigned must be considered when determining the type and amount of direction and supervision warranted.

Hospitals have also been found liable for assigning personnel who were unqualified to perform duties as shown by their evaluation reports. Managers, therefore, need to be cognizant of their responsibilities in assigning and appointing personnel because they could be found liable for ignoring organizational policies or for

assigning employees duties that they are not capable of performing. In such cases, though, the employee must provide the supervisor with the information that he or she is not qualified for the assignment. The manager does have the right to reassign employees as long as they are capable of discharging the anticipated duties of the assignment.

In addition, there has been a push to have more in-depth background checks when health-care employees are hired, with some states already mandating such checks. For example, California, as of 2009, determined that it would no longer issue temporary or permanent licenses to nurses without a criminal background check. Indeed, many states are now requiring a criminal background check on all license renewals, and federal legislation has recently been introduced along these lines.

At present, except in a few states, personnel directors in hospitals (those making hiring decisions) are required to request information from the National Practitioner Data Bank for those individuals who seek clinical privileges, and many states now require nursing students to be fingerprinted before they can work with vulnerable populations. In the future, hiring someone without an adequate background check, who later commits a crime involving a patient, could be another area of liability for the manager. This is an example of the type of pending legislation with which a manager must keep abreast so that if it becomes law, its impact on future management practices will be minimized.

Incident Reports and Adverse Event Forms Incident reports or adverse event forms are records of unusual or unexpected incidents that occur during a client’s treatment. Because attorneys use incident reports to defend the health agency against lawsuits brought by clients, the reports are generally considered confidential communications and cannot be subpoenaed by clients

or used as evidence in their lawsuits in most states. (Be sure, however, that you know the law for the state in which you live, as this does vary.) However, incident reports that are inadvertently disclosed to the plaintiff are no longer considered confidential and can be subpoenaed in court. Thus, a copy of an incident report should not be left in the chart. In addition, no entry should be made in the patient’s record about the existence of an incident report. The chart should, however, provide enough information about the incident or occurrence so that appropriate treatment can be given.

Intentional Torts Torts are legal wrongs committed against a person or property, independent of a contract, that render the person who commits them liable for damages in a civil action. Whereas professional negligence is considered to be an unintentional tort, assault, battery, false imprisonment, invasion of privacy, defamation, and slander are intentional torts. Intentional torts are a direct invasion of someone’s legal rights. Managers are responsible for seeing that staff members are aware of and adhere to laws governing intentional torts. In addition, the manager must clearly delineate policies and procedures about these issues in the work environment.

Nurses can be sued for assault and battery. Assault is conduct that makes a person fearful and produces a reasonable apprehension of harm, and battery is an intentional and wrongful physical contact with a person that entails an injury or offensive touching. Thompson Defense Firm (2019) notes that actual battery is not necessary to be charged with either first- or second-degree assault and battery. It is only necessary that body injury could have resulted.

Unit managers must be alert to patient complaints of being handled in a rough manner or complaints of excessive force in restraining patients. In fact, performing any treatment without

patient’s permission or without receiving an informed consent might constitute both assault and battery. In addition, many battery suits have been won based on the use of restraints when dealing with confused patients.

LEARNING EXERCISE 5.4

Discussing Lawsuits and Liability

In small groups, discuss the following questions:

1. Do you believe that there are unnecessary lawsuits in the health-care industry? What criteria can be used to distinguish between appropriate and unnecessary lawsuits?

2. Have you ever advised a friend or family member to sue to recover damages that you believed they suffered because of poor-quality health care? What motivated you to encourage them to do so?

3. Do you think that you will make clinical errors in judgment as a nurse? If so, what types of errors should be considered acceptable (if any) and what types are not acceptable?

4. Do you believe that the recent national spotlight on medical error identification and prevention will encourage the reporting of medical errors when they do occur?

The use of physical restraints also has led to claims of false imprisonment. False imprisonment occurs when a person (who

doesn’t have legal authority or justification) intentionally restrains another person’s ability to move freely (FindLaw, 2019). Practitioners are liable for false imprisonment when they unlawfully restrain the movement of their patients.

Unfortunately, the use of restraints continues to be common practice in many health-care institutions (especially skilled nursing facilities) despite a growing body of evidence that supports the implementation of alternative strategies to promote resident safety. Physical restraints should be applied only with a physician’s direct order. Likewise, the patient who wishes to sign out against medical advice should not be held against his or her will. This tort also is frequently applicable to involuntary commitments to mental health facilities. Managers in mental health settings must be careful to institutionalize patients in accordance with all laws governing commitment.

Another intentional tort is defamation. Defamation is communicating to a third-party false information that injures a person’s reputation. When defamation is written, printed, or broadcasted, it is called libel. When it is spoken, it is called slander. The damages for defamation can be enhanced by how widespread the publication of the defamatory information was. “Each additional disclosure has the potential of increasing the damages for the aggrieved party and thus the exposure for the improper actor (person acting improperly)” (Silberman, 2015, p. 313).

Other Legal Responsibilities of the Manager Managers also have some legal responsibility for the quality control of nursing practice at the unit level, including such duties as reporting dangerous understaffing, checking staff credentials and qualifications, and carrying out appropriate discipline. Health-care facilities may also be held responsible for seeing that staff know how

to operate equipment safely. Sources of liability for managers vary from facility to facility and from position to position.

For example, standards of care as depicted in policies and procedures may pose a liability for the nurse if such policies and procedures are not followed. The chain of command in reporting inadequate care by a physician is another area in which management liability may occur if employees are not taught proper protocols. Managers have a responsibility to see that written protocols, policies, and procedures are followed to reduce liability. In addition, the manager, like all professional nurses, is responsible for reporting improper or substandard medical care, child and elder abuse, and communicable diseases, as specified by the Centers for Disease Control and Prevention.

Individual nurses also may be held liable for product liability. Historically, a contractual relationship known as privity of contract had to exist for a product liability claim to be filed. This meant that the injured party had to have purchased a product directly from the manufacturer to sue the manufacturer for injury caused by the product (Mascaranhas, 2018). By the 1950s and 1960s, the courts moved away from privity of contract because more wholesalers and retailers were selling products directly to the consumer. In 1963, California became the first state to adopt strict product liability, and in 1986, many other states followed (Mascaranhas, 2018).

Essentially, strict liability holds that a product may be held to a higher level of liability than a person. In other words, if it can be proved that the equipment or product had a defect that caused an injury, then it would be debated in court by using all the elements essential for negligence, such as duty and breach. Therefore, equipment and other products fall within the scope of nursing responsibility. In general, if they are aware that equipment is faulty, nurses have a duty to refuse to use the equipment. If the fault in the equipment is not readily apparent, risks are low that the nurse will be found liable for the results of its use.

Neil (2015) concurs, noting that to avoid product liability, nurses should not use equipment they are unfamiliar with. In addition, nurses should make sure they have documented competency in using equipment and know how to detect and document equipment failures.

Informed Consent Many nurses erroneously believe that they have obtained informed consent when they witness a patient’s signature on a consent form for surgery or procedure. Strictly speaking, informed consent (Display 5.3) can be given only after the patient has received a complete explanation of the surgery, procedure, or treatment and indicates that he or she understands the risks and benefits related to it.

DISPLAY 5.3 GUIDELINES FOR INFORMED CONSENT

The person(s) giving consent must fully comprehend 1. The procedure to be performed 2. The risks involved 3. Expected or desired outcomes 4. Expected complications or side effects that may occur as a

result of treatment 5. Alternative treatments that are available

Consent may be given by 1. A competent adult 2. A legal guardian or an individual holding durable power of

attorney 3. An emancipated or married minor 4. A mature minor (varies by state) 5. A parent of a minor child 6. A court order

The information must be in a language that the patient can understand and should be conveyed by the individual who will be performing the procedure. Patients must be invited to ask questions and have a clear understanding of the options as well.

Informed consent is obtained only after the patient receives full disclosure of all pertinent information regarding the surgery or procedure and only if the patient understands the potential benefits and risks associated with doing so.

Only a competent adult can legally sign the form that shows informed consent. To be considered competent, patients must be

capable of understanding the nature and consequences of the decision and of communicating their decision. Spouses or other family members cannot legally sign unless there is an approved guardianship or conservatorship or unless they hold a durable power of attorney for health care. If the patient is younger than 16 years (18 years in some states), a parent or guardian must generally give consent.

In an emergency, the physician can invoke implied consent, in which the physician states in the progress notes of the medical record that the patient is unable to sign but that treatment is immediately needed and is in the patient’s best interest. Usually, this type of implied consent must be validated by another physician.

Nurses frequently seek express consent from patients by witnessing patients sign a standard consent form. In express consent, the role of the nurse is to be sure that the patient has received informed consent and to seek remedy if he or she has not.

LEARNING EXERCISE 5.5

Is It Really Informed Consent?

You are a staff nurse in a surgical unit. Shortly after reporting for duty, you make rounds on all your patients. Mrs. Jones is a 36-year-old woman scheduled for a bilateral salpingo-oophorectomy and hysterectomy. In the course of conversation, Mrs. Jones comments that she is glad she will not be undergoing menopause as a result of this surgery. She elaborates by stating that one of her friends had surgery that resulted in “surgical menopause” and that it was devastating to her. You return to the chart

and check the surgical permit and doctor’s progress notes. The operating room permit reads “bilateral salpingo-oophorectomy and hysterectomy,” and it is signed by Mrs. Jones. The physician has noted “discussed surgery with patient” in the progress notes.

You return to Mrs. Jones’s room and ask her what type of surgery she is having. She states, “I’m having my uterus removed.” You phone the physician and relate your information to the surgeon who says, “Mrs. Jones knows that I will take out her ovaries if necessary; I’ve discussed it with her. She signed the permit. Now, please get her ready for surgery—she is the next case.”

ASSIGNMENT:

Discuss what you should do at this point. Why did you select this course of action? What issues are involved here? Be able to discuss legal ramifications of this case.

Informed consent does pose ethical issues for nurses. Although nurses are obligated to provide teaching and to clarify information given to patients by their physicians, nurses must be careful not to give new information that contradicts information given by the physician, thus interfering in the physician–patient relationship. The nurse is not responsible for explaining the procedure to be performed. The role, rather, is to be a patient advocate by determining their level of understanding and seeing that the appropriate person answers their questions. At times, this can be a cloudy issue both legally and ethically.

Informed Consent for Clinical Research The intent of informed consent in clinical research is to give patients adequate information, through a full explanation of a proposed treatment, including any possible harms, so they can make an informed decision. Studies, however, repeatedly suggest that participants often have incomplete understanding of various features of clinical trials and issues associated with written informed consent are common.

Medical Records One source of information that people seek to help them make decisions about their health care is their medical record. Nurses have a legal responsibility for accurately recording appropriate information in the client’s medical record. The alteration of medical records can result in license suspension or revocation.

Although the patient owns the information in that medical record, the actual record belongs to the facility that originally made the record and is storing it. Although patients must have “reasonable access” to their records, the method for retrieving the record varies greatly from one institution to another. Generally, a patient who wishes to inspect his or her records must make a written request and

pay reasonable clerical costs to make such records available. The health-care provider generally permits such inspection during business hours within several working days of the inspection request. Nurses should be aware of the procedure for procuring medical records for patients at the facilities where they work. Often, a patient’s attempt to procure medical records results from a lack of trust or a need for additional teaching and education. Nurses can do a great deal to reduce this confusion and foster an open, trusting relationship between the patient and his or her health-care providers. Collaboration between health-care providers and patients, and documentation thereof, is a good indication of well-provided clinical care.

If it is not documented in the health-care record . . . it did not happen.

The Patient Self-Determination Act The PSDA, enacted in 1991, required health-care organizations that received federal funding (Medicare and Medicaid) to provide education for staff and patients on issues concerning treatment and end-of-life issues. This education included the use of advance directives (ADs), written instructions regarding desired end-of-life care. Most ADs address the use of dialysis and respirators; if you want to be resuscitated if breathing or heartbeat stops; tube feeding; and organ or tissue donation (MedlinePlus, 2019). They also likely include a durable power of attorney for health care, which names your health-care proxy, someone you trust to make health decisions if you are unable to do so (MedlinePlus, 2019).

The PSDA requires acute care facilities to document on the medical record whether a patient has an AD and to provide written information to patients who do not. However, despite mechanisms

within most health-care institutions to provide this information, the AD completion rate remains low and many patients do not understand what is included in the AD or whether this is something important they should have.

The reality is that many people do not express their wishes about end-of-life treatment before a crisis exists and then they may be unable to do so. This problem prompted Cooper, Chidwick, Cybulski, and Sibbald (2015) to develop a five-question checklist to elicit an incapable patient’s perspective on treatment based on the wishes and values he or she expressed while capable. The goal was to ensure that basic legal obligations were met for patients who were no longer able to advocate for themselves. Findings from a 2-year pilot project suggested that the use of such a checklist gave nurses a way to fulfill their professional roles as patient advocates in end-of- life care, when many patients and families were most vulnerable.

LEARNING EXERCISE 5.6

Mrs. Brown’s Chart

You are a nurse in a multiphysician office that treats oncology patients. Mrs. Brown, a patient seen by Dr. Watson in your office, was recently diagnosed with invasive cancer. She started radiation treatments last week. Her husband attends her radiation treatments and office visits with her and seems to be very devoted. They both are very interested in her progress.

Although they have asked many questions during the last two office visits and you have given truthful answers, Dr. Watson’s interactions have sometimes been a bit

short and you felt that Mr. and Mrs. Brown may have left with unanswered questions. In addition, Dr. Watson has not shared much with them yet about Mrs. Brown’s prognosis as he continues to refine his differential diagnosis.

Today, when you walk into Mrs. Brown’s exam room, you find Mr. Brown reading her electronic record on the computer tablet that was inadvertently left on the counter in her room. The look on his face is one of feeling overwhelmed and confused.

ASSIGNMENT:

Identify several alternatives for action that you have. Discuss what you would do and why. Is there a problem here? What follow-up is indicated? Attempt to solve this learning exercise on your own before reading the sample analysis that follows.

Analysis The nurse needs to determine the most important goal in this situation. Possible goals include (a) eliminating Mr. Brown’s access to the medical record as soon as possible, (b) protecting the privacy of Mrs. Brown, (c) gathering more information, or (d) becoming an advocate for the Browns.

In solving the case, it is apparent that not enough information has been gathered. Mr. Brown has already viewed at least a portion of his wife’s electronic medical record. Usually, the danger in patients’ families reading a patient’s record lies in the direction of their not understanding the information contained within or the patient’s privacy being invaded because the patient has

not consented to family members’ access to their records.

Using this as the basis for rationale, the nurse could use the following approach:

1. Clarify that Mr. Brown has Mrs. Brown’s permission to read her records by asking her directly.

2. Ask Mr. Brown if there is anything in the electronic health record that he did not understand or anything that he questions. You may even ask him to summarize what he has read. Clarify the things that are appropriate for the nurse to address, such as terminology, procedures, and nursing care.

3. Refer questions that are inappropriate for the nurse to answer to the physician and let Mr. Brown know that you will help him in talking with the physician regarding the medical plan and prognosis.

4. When finished talking with Mr. Brown, the nurse should secure the electronic health record.

5. The nurse should notify Dr. Watson about the incident and Mr. Brown’s concerns and assist the Browns in obtaining the information they have requested.

Conclusion The nurse first gathered more information before becoming the adversary or advocate. It is possible that the Browns had only simple questions to ask and that the problem was a lack of communication between staff and their patients rather than a physician–patient communication deficit. Legally, patients have a right to understand what is happening to them, and that should be the basis for the decisions in this case.

Good Samaritan Laws Nurses are not required to stop and provide emergency services as a matter of law, although most health-care workers feel ethically compelled to stop if they believe they can help. Good Samaritan laws suggest that health-care providers are typically protected from potential liability if they volunteer their nursing skills away from the workplace (generally limited to emergencies), if actions taken are not grossly negligent, and if the health-care worker does not exceed his or her training or scope of practice in performing the emergency services.

Hermosillo (2019) suggests that an example of gross negligence that would negate Good Samaritan protection would be to pull an injured victim from the scene of a car accident without imminent danger such as fire, drowning, or other harm. Due to the high risk of spinal cord injury, it is expected that even those without medical training would know better than to move an injured person in the absence of further threat of injury or death. Also, there will likely be no protection for those who are deemed to have caused or contributed to the accident.

Good Samaritan laws apply only if the health-care worker does not exceed his or her training or scope of practice in performing the emergency services.

In addition, protections under Good Samaritan laws vary from state to state. Some states’ protections only apply to those with some medical training or background. Fortunately, many courts in these states have been willing to extend those protections to untrained passersby as well (Hermosillo, 2019). In some states, the law grants immunity to RNs but does not protect licensed vocational nurses (LVNs) or licensed professional nurses. Other states offer protection to anyone who offers assistance, even if they do not have

a health-care background. Nurses should be familiar with the Good Samaritan laws in their state.

Health Insurance Portability and Accountability Act of 1996 Another area of the law that nurses must understand is the right to confidentiality. Efforts to preserve patient confidentiality increased tremendously with the passage of the HIPAA of 1996 (also known as the Kassebaum–Kennedy Act). Unauthorized release of information or photographs in medical records may make the person who discloses the information civilly liable for invasion of privacy, defamation, or slander. Written authorization by the patient to release information is needed to allow such disclosure.

Many nurses have been caught unaware by the telephone call requesting information about a patient’s condition. It is extremely important that the nurse does not give out unauthorized information, regardless of the urgency of the person making the request. In addition, nurses must be careful not to discuss patient information in venues where it can be inadvertently overheard, read, transmitted, or otherwise unintentionally disclosed. For example, nurses talking in elevators, the hospital gift shop, or in a restaurant for lunch need to be aware of their surroundings and remain alert about not revealing any patient information in a public place.

HIPAA essentially represents two areas for implementation. The first is the Administrative Simplification plan, and the second area includes the Privacy Rule. The Administrative Simplification plan is directed at restructuring the coding of health information to simplify the digital exchange of information among health-care providers and to improve the efficiency of health-care delivery. The privacy rules are directed at ensuring strong privacy protections for patient without threatening access to care.

The Privacy Rule applies to health plans, health-care clearinghouses, and health-care providers. It also covers all patient records and other individually identifiable health information. Although there are many components to HIPAA, key components of the Privacy Rule are that direct treatment providers must make a good faith effort to obtain written acknowledgment of the notice of privacy rights and practices from patients. In addition, health-care providers must disclose protected health information to patients requesting their own information or when oversight agencies request the data. Reasonable efforts must be taken, however, to limit the disclosure of personal health information to the minimum information necessary to complete the transaction. There are situations, however, when limiting the information is not required. For example, a minimum of information is not required for treatment purposes because it is clearly better to have too much information than too little. The HIPAA Privacy Rule and Common Rule also require that individuals participating in research studies should be assured privacy, particularly regarding personal health information.

The Privacy Rule attempts to balance the need for the protection of personal health information with the need to disclose that information for patient care.

Because of the complexity of the HIPAA regulations, it is not expected that a nurse-manager would be responsible for compliance alone. Instead, it is most important that the manager work with the administrative team to develop compliance procedures. For example, managers must ensure that unauthorized people do not have access to patient charts or medical records and that unauthorized people are not allowed to observe procedures.

It is equally important that managers remain cognizant of ongoing changes to the guidelines and are aware of how rules governing

these issues may differ in the state in which they are employed. Some provisions of the Privacy Rules mention “reasonable efforts” toward achieving compliance, but being reasonable is provision specific. The American Recovery and Reinvestment Act applies several of HIPAA’s security and privacy requirements to business associates and changes data restrictions, disclosure, and reporting requirements.

Legal Considerations of Managing a Diverse Workforce Diversity has been defined as the differences among groups or between individuals and comes in many forms, including age, gender, religion, customs, sexual orientation, physical size, physical and mental capabilities, beliefs, culture, ethnicity, and skin color (Huston, 2020b). Demographic data from the United States Census Bureau continue to show increased diversification of the US population, a trend that began almost 40 years ago.

As discussed in later chapters, a primary area of diversity is language, including word meanings, accents, and dialects. Problems arising from this could be misunderstanding or reluctance to ask questions. Staff from cultures in which assertiveness is not promoted may find it difficult to disagree with or question others. How the manager handles these manifestations of cultural diversity is of major importance. If the manager’s response is seen as discriminatory, the employee may file a complaint with one of the state or federal agencies that oversee civil rights or equal opportunity enforcement. Such things as overt or subtle discrimination are prohibited by Title VII (Civil Rights Act of 1964). Managers have a responsibility to be fair and just. Lack of promotions and unfair assignments may occur with minority employees just because they are different and this is illegal.

In addition, English-only rules in the workplace may be viewed as discriminatory under Title VII. Such rules may not violate Title VII if employers require English only during certain periods of time. Even in these circumstances, the employees must be notified of the rules and how they are to be enforced.

Clearly, managers should be taught how to deal sensitively and appropriately with an increasingly diverse workforce. Enhancing self- awareness and staff awareness of personal cultural biases, developing a comprehensive cultural diversity program, and role modeling cultural sensitivity are some of the ways that managers can effectively avoid many legal problems associated with discriminatory issues. However, it is hoped that future goals for the manager would go beyond compliance with Title VII and move toward understanding of and respect for other cultures.

Professional Versus Institutional Licensure In general, a license is a legal document that permits a person to offer special skills and knowledge to the public in a particular jurisdiction when such practice would otherwise be unlawful. Licensure establishes standards for entry into practice, defines a scope of practice, and allows for disciplinary action. Currently, licensing for nurses is a responsibility of State Boards of Nursing or State Boards of Nurse Examiners, which also provide discipline as necessary. The manager, however, is responsible for monitoring that all licensed subordinates have a valid, appropriate, and current license to practice.

Professional licensure is a privilege and not a right.

All nurses must safeguard the privilege of licensure by knowing the standards of care applicable to their work setting. Deviation from that standard should be undertaken only when nurses are prepared

to accept the consequences of their actions, in terms of both liability and loss of licensure.

Nurses who violate specific norms of conduct, such as securing a license by fraud, performing specific actions prohibited by the Nurse Practice Act, exhibiting unprofessional or illegal conduct, performing malpractice, and abusing alcohol or drugs, may have their licenses suspended or revoked by the licensing boards in all states. Frequent causes of license revocation are shown in Display 5.4.

DISPLAY 5.4 COMMON CAUSES OF PROFESSIONAL NURSING LICENSE SUSPENSION OR REVOCATION

Professional negligence Practicing medicine or nursing without a license Obtaining a nursing license by fraud or allowing others to use

your license Felony conviction for any offense substantially related to the

function or duties of a registered nurse Participating professionally in criminal abortions Failing to follow accepted standards of care Not reporting substandard medical or nursing care Providing patient care while under the influence of drugs or

alcohol Giving narcotic drugs without an order Falsely holding oneself out to the public or to any health-care

practitioner as a “nurse practitioner” Failing to use equipment safely and responsibly

Typically, suspension and revocation proceedings are administrative. Following a complaint, the Board of Nursing completes an investigation. Most of these investigations reveal no grounds for discipline; however, there are things a nurse should do if

he or she becomes aware they are being investigated by the board. These are shown in Display 5.5.

DISPLAY 5.5 ACTIONS A NURSE SHOULD TAKE WHEN BEING INVESTIGATED BY THE BOARD OF NURSING

1. Do not ignore the Board’s notification. It won’t go away. 2. Do not unnecessarily share news of the complaint with friends

and colleagues as it may undermine your credibility. 3. Read employee handbooks/contracts/policy and procedures

to determine if must report the investigation to your employer. 4. Consider contacting an attorney. 5. If a lawyer is needed, hire an experienced one. 6. Carefully consider anything you put in writing. 7. Contact your malpractice insurance provider. 8. If the investigation involves a patient, do not violate HIPAA by

copying the patient’s medical record. 9. Do not alter the patient’s medical record. 10. Be prepared for a lengthy process of investigation.

Source: Extracted from Mackay, T. R. (2018). What do you mean there’s a complaint?! Texas Nursing, 92(1), 20–22.

If the investigation supports the need for discipline, nurses are notified of the charges and can prepare a defense. At the hearing, which is very similar to a trial, the nurse can present evidence. Based on the evidence, an administrative law judge makes a recommendation to the State Board of Nursing, which makes the final decision. The entire process, from complaint to final decision, may take up to 2 years or longer.

Some professionals have advocated shifting the burden of licensure, and thus accountability, from individual practitioners to an institution or agency. Proponents for this move believe that

institutional licensure would provide more effective use of personnel and greater flexibility. Most professional nursing organizations oppose this move strongly because they believe that it has the potential for diluting the quality of nursing care.

An alternative to institutional licensure has been the development of certification programs by the American Nurses Association (ANA). By passing specifically prepared written examinations, nurses are able to qualify for certification in most nurse practice areas. This voluntary testing program represents professional organizational certification. In addition to ANA certification, other specialties, such as cardiac care, offer their own certification examinations. Many nursing leaders today strongly advocate professional certification as a means of enhancing the profession. However, certification is really only helpful in determining a nurse’s continued competence if that nurse is functioning in the areas of his or her certified competence (Huston, 2020a).

Integrating Leadership Roles and Management Functions in Legal and Legislative Issues Legislative and legal controls for nursing practice have been established to clarify the boundaries of nursing practice and to protect clients. The leader uses established legal guidelines to role model nursing practice that meets or exceeds accepted standards of care. Leaders also are role models in their efforts to expand expertise in their field and to achieve specialty certification. Perhaps the most important leadership roles in law and legislation are those of vision, risk taking, and energy. The leader is active in professional organizations and groups that define what nursing is and what it should be in the future. This is an internalized responsibility that must be adopted by many more nurses if the profession is to be a recognized and vital force in the political arena.

Management functions in legal and legislative issues are more directive. Managers are responsible for seeing that their practice and the practice of their subordinates are in accord with current legal guidelines. This requires that managers have a working knowledge of current laws and legal doctrines that affect nursing practice. Because laws are not static, this is an active and ongoing function. The manager has a legal obligation to uphold the laws, rules, and regulations affecting the organization, the patient, and nursing practice.

Managers have a responsibility to be fair and nondiscriminatory in dealing with all members of the workforce, including those whose culture differs from their own. The effective leader goes beyond merely preventing discriminatory charges and instead strives to develop sensitivity to the needs of a culturally diverse staff.

The integrated leader-manager reduces the personal risk of legal liability by creating an environment that prioritizes patient needs and welfare. In addition, caring, respect, and honesty as part of nurse– patient relationships are emphasized. If these functions and roles are truly integrated, the risks of patient harm and nursing liability are greatly reduced.

Key Concepts

■ Sources of law include constitutions, statutes, administrative agencies, and court decisions.

■ The burden of proof required to be found guilty and the punishment for the crime varies significantly between criminal, civil, and administrative courts.

■ Nurse Practice Acts define and limit the practice of nursing in each state.

■ Professional organizations generally espouse standards of care that are higher than those required by law. These voluntary controls often are forerunners of legal controls.

■ Legal doctrines such as stare decisis and res judicata frequently guide courts in their decision making.

■ Currently, licensing for nurses is a responsibility of State Boards of Nursing or State Boards of Nurse Examiners. These state boards also provide discipline as necessary.

■ Some professionals have advocated shifting the burden of licensure, and thus accountability, from individual practitioners to an institution or agency. Many professional nursing organizations oppose this move.

■ Malpractice or professional negligence is the failure of a person with professional training to act in a reasonable and prudent manner. Five components must be present for an individual to be found guilty of malpractice.

■ Employers of nurses can now be held liable for an employee’s acts under the concept of vicarious liability.

■ Each person, however, is liable for his or her own tortuous conduct.

■ Managers are not automatically held liable for all acts of negligence on the part of those they supervise, but they may be held liable if they were negligent in supervising those employees at the time that they committed the negligent acts.

■ Although professional negligence is considered to be an unintentional tort, assault, battery, false imprisonment, invasion of privacy, defamation, and slander are intentional torts.

■ Consent can be informed, implied, or expressed. Nurses need to understand the differences between these types of consents and use the appropriate one.

■ Although the patient owns the information in a medical record, the actual record belongs to the facility that originally

made it and is storing it. ■ It has been shown that despite good technical competence,

nurses who have difficulty establishing positive interpersonal relationships with clients and their families are at greater risk for being sued for malpractice.

■ Each nurse should be aware of how laws such as Good Samaritan immunity or legal access to incident reports are implemented in the state in which they live.

■ New legislation pertaining to confidentiality (HIPAA) and patient rights (e.g., PSDA) continues to shape nurse–client interactions in the health-care system.

Additional Learning Exercises and Applications

LEARNING EXERCISE 5.7

Where Does Your Responsibility Lie?

Mrs. Shin is a 68-year-old patient with liver cancer. She has been admitted to the oncology unit at Memorial Hospital. Her admitting physician has advised chemotherapy, even though she believes that there is little chance of it working. The patient asks her doctor, in your presence, if there is an alternative treatment to chemotherapy. She replies, “Nothing else has proved to be effective. Everything else is quackery, and you would be wasting your money.” After the doctor leaves, the patient and her family ask you if you know anything about alternative treatments. When you indicate that you do

have some current literature available, they beg you to share your information with them.

ASSIGNMENT:

What do you do? What is your legal responsibility to your patient, the doctor, and the hospital? Using your knowledge of the legal process, the Nurse Practice Act, patients’ rights, and legal precedents (look for the case Tuma v. Board of Nursing, 1979; The Climate Change and Public Health Law Site, n.d.), explain what you would do and defend your decision.

LEARNING EXERCISE 5.8

Legal Ramifications for Exceeding One’s Duties

You have been the evening charge nurse in the emergency department at Memorial Hospital for the last 2 years. Besides yourself, you have two licensed vocational nurses (LVNs) and four registered nurses (RNs) working in your department. Your normal staffing is to have two RNs and one LVN on duty Monday to Thursday and one LVN and three RNs on duty during the weekend.

It has become apparent that one of the LVNs, Maggie, resents the recently imposed limitations of LVN duties

because she has had 10 years of experience in nursing, including a tour of duty as a medic in the first Gulf War. The emergency department physicians admire her and are always asking her to assist them with any minor wound repair. Occasionally, she has exceeded her job description as an LVN in the hospital, although she has done nothing illegal of which you are aware. You have given her satisfactory performance evaluations in the past, even though everyone is aware that she sometimes pretends to be a “junior physician.” You also suspect that the physicians sometimes allow her to perform duties outside her licensure, but you have not investigated this or seen it yourself.

Tonight, you come back from supper and find Maggie suturing a deep laceration while the physician looks on. They both realize that you are upset, and the physician takes over the suturing. Later, the doctor comes to you and says, “Don’t worry! She does a great job, and I’ll take the responsibility for her actions.” You are not sure what you should do. Maggie is a good employee, and taking any action will result in unit conflict.

ASSIGNMENT:

What are the legal ramifications of this case? Discuss what you should do, if anything. What responsibility and liability exist for the physician, Maggie, and yourself? Use appropriate rationale to support your decision.

LEARNING EXERCISE 5.9

To Float or Not to Float

You have been an obstetrical staff nurse at Memorial Hospital for 25 years. The obstetrical unit census has been abnormally low lately, although the patient census in other areas of the hospital has been extremely high. When you arrive at work today, you are told to float to the thoracic surgery unit. This is a specialized unit, and you feel ill prepared to work with the equipment on the unit and the type of patients who are there. You call the staffing office and ask to be reassigned to a different area. You are told that the entire hospital is critically short staffed, that the thoracic surgery unit is four nurses short, and that you are at least as well equipped to handle that unit as the other three staff who also are being floated. Now, your anxiety level is even higher. You will be expected to handle a full registered nurse patient load. You also are aware that more than half of the staff on the unit today will have no experience in thoracic surgery. You consider whether to refuse to float. You do not want to place your nursing license in jeopardy, yet you feel conflicting obligations.

ASSIGNMENT:

To whom do you have conflicting obligations? You have little time to make this decision. Outline the steps that you use to reach your final decision. Identify the legal and ethical ramifications that may result from your decision. Are they in conflict?

LEARNING EXERCISE 5.10

Is It Your Responsibility to Force the Surgeon to See the Patient? (Marquis & Huston, 2012)

Jimmy Smith is a 19-year-old male who had a severe compound fracture of his tibia today in football practice. He returned from the surgery to set and cast the leg at 4:00 PM today. The evening shift reported that he was having quite a bit of swelling from the severe trauma that accompanied the fracture, but that the toes on the effected leg were warm and he had good pedal pulses.

By the time you received report tonight at 11:00 PM and went to check on Jimmy, you felt that his pedal pulses were slightly diminished and that his foot was slightly cool to touch. By 2:00 AM, you felt the swelling had increased slightly and his toes were quite cool, although they were not blue.

You phoned his physician, and he was quite upset to be awakened in the middle of the night. He instructed you to put ice on the cast and to elevate Jimmy’s leg higher to reduce the swelling. He promised you that he would see Jimmy first thing in the morning. As the night wears on, you become increasingly alarmed. By the time the night supervisor arrived at 4:00 AM, you were so concerned that you asked her to check the casted leg. The supervisor rushed out of the room and said, “The circulation in this boy’s leg is severely compromised, why haven’t you gotten the doctor here to cut the cast?”

ASSIGNMENT:

Have you committed malpractice? Has the doctor? What is the nurse’s responsibility in reporting a patient’s condition to their physician? Examine the elements of malpractice. If there is permanent damage to Jimmy’s leg, who will be liable for the failure to act soon enough to prevent injury?

R E F E R E N C E S Cooper, A. B., Chidwick, P., Cybulski, P., & Sibbald, R. (2015).

Checklist to meet Ethical and Legal Obligations in the consent pathway for critically ill patients (ChELO): A quality improvement project and case studies. Canadian Journal of Critical Care Nursing, 26(3), 16–24.

FindLaw. (2019). False imprisonment. Retrieved June 8, 2019, from https://injury.findlaw.com/torts-and-personal-injuries/false- imprisonment.html

FindLaw for Legal Professionals. (2019). JUANITA SULLIVAN, indiv. and as special adm’r of the estate of Burns Sullivan, deceased, appellant, v. EDWARD HOSPITAL et al., appellees. No. 95409. Retrieved June 8, 2019, from http://caselaw.findlaw.com/il- supreme-court/1367447.html

Hale Law Firm. (2018). What is respondeat superior? Retrieved July 16, 2018, from https://www.halelawfirm.com/blog/2018/02/what- is-respondeat-superior.shtml

Hermosillo, A. (2019). Good Samaritan laws reduce the risk of helping strangers. Retrieved June 8, 2019, from http://www.workingnurse.com/articles/Good-Samaritan-Laws- Reduce-the-Risk-of-Helping-Strangers

Huston, C. J. (2020a). Assuring provider competence through licensure, continuing education, and certification. In C. J. Huston

(Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 287–300). Philadelphia, PA: Wolters Kluwer.

Huston, C. J. (2020b). Diversity in the nursing workforce. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 124–138). Philadelphia, PA: Wolters Kluwer.

Huston, C. J. (2020c). Unlicensed assistive personnel and the registered nurse. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 112–123). Philadelphia, PA: Wolters Kluwer.

Injury Trial Lawyers. (2018). Can nurses be sued for medical malpractice? Retrieved July 19, 2018, from https://getinjuryanswers.com/can-nurses-sued-medical- malpractice/

Institute of Medicine. (1999). To err is human: Building a safer health system. Retrieved July 17, 2018, from http://www.nationalacademies.org/hmd/~/media/Files/Report%20 Files/1999/To-Err-is- Human/To%20Err%20is%20Human%201999%20%20report%20 brief.pdf

Joint Commission on Accreditation of Healthcare Organizations. (2005). Health care in the crossroads: Strategies for improving the medical liability system and preventing patient injury. Oakbrook Terrace, IL: Author.

Marquis, B., & Huston, C. (2012). Leadership and management tools for the new nurse. Philadelphia, PA: Lippincott Williams & Wilkins.

Mascaranhas, C. (2018). The legal nurse consultant’s primer on product liability. Journal of Legal Nurse Consulting, 29(1), 18–21.

MedlinePlus. (2019). Advance directives. Retrieved June 8, 2019, from http://www.nlm.nih.gov/medlineplus/advancedirectives.html

Neil, H. P. (2015). Legally: What is quality care? Understanding nursing standards. Medsurg Nursing, 24(1),14–15.

Silberman, M. J. (2015). Back to basics: The importance of patient respect. AANA Journal, 83(5), 312–315.

The Climate Change and Public Health Law Site. (n.d.). Nurse disciplined for telling patient about alternative treatments (court reverses)—Tuma v. Board of Nursing, 100 Idaho 74, 593 P.2d 711 (Idaho Apr 17, 1979). Retrieved July 16, 2018, from http://biotech.law.lsu.edu/cases/pro_lic/Tuma_v_Board_of_Nursin g.htm

Thompson Defense Firm. (2019). Assault and battery. Retrieved June 8, 2019, from https://www.grandstrandlaw.com/assault-and- battery.html

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6

Patient, Subordinate, Workplace, and Professional Advocacy

. . . to see what is right, and not do it, is want of courage, or of principles.—Confucius

. . . in our imperfect state of conscience and enlightenment, publicity and the collision resulting from publicity are the best guardians of the interest in the sick.—Florence Nightingale

. . . No voice is too soft when that voice speaks for others.—Janna Cachola

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential V: Health-care policy, finance, and regulatory environments

BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

BSN Essential VIII: Professionalism and professional values

MSN Essential II: Organizational and systems leadership MSN Essential VI: Health policy and advocacy AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency III: Leadership AONL Nurse Executive Competency IV: Professionalism ANA Standard of Professional Performance 7: Ethics ANA Standard of Professional Performance 8: Culturally congruent practice

ANA Standard of Professional Performance 9: Communication

ANA Standard of Professional Performance 10: Collaboration

ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 14: Quality of practice

ANA Standard of Professional Performance 16: Resource utilization

ANA Standard of Professional Performance 17: Environmental health

QSEN Competency: Patient-centered care QSEN Competency: Teamwork and collaboration

LEARNING OBJECTIVES

The learner will:

differentiate between the manager’s responsibility to advocate for patients, for subordinates, for the organization, for the profession, and for self

identify values central to advocacy differentiate between controlling patient choices and assisting patients to choose

select an appropriate response that exemplifies advocacy in given situations

identify entry points for user engagement in the health-care system as well as strategies for patient and family engagement in health care

describe the core concepts of person- and family-centered care identify how the Patient’s Bill of Rights protects patients describe ways a manager can advocate for subordinates identify ways individual nurses can become advocates for the profession

identify both the risks and potential benefits of becoming a whistleblower

specify both direct and indirect strategies to influence legislation that promotes advocacy

describe strategies nurses can use to successfully interact with the media

Introduction Advocacy—helping others to grow and self-actualize—is a critically important leadership role. Many of the leadership skills that are described in the following chapters, such as risk taking, vision, self- confidence, ability to articulate needs, and assertiveness, are used in the advocacy role.

Managers, by their many roles, must be advocates for the profession, subordinates, workplace, and patients. The actions of an advocate are to inform others of their rights and to be sure they have adequate information on which to base their decisions. The term advocacy can be stated in its simplest form as protecting and defending what one believes in for both self and others (The Free Dictionary, 2003–2019).

Nurses often are expected to advocate for patients when they are unable to speak for themselves. Indeed, advocacy has been recognized as one of the most vital and basic roles of the nursing profession since the time of Florence Nightingale. Nurses, as the frontline care providers, often have comprehensive knowledge and a well-rounded perspective about patient care issues, both those of direct care and system issues. When patients in the system are without insurance, are denied care, or do not know how to access appropriate care, nurses should have the knowledge competencies to provide informational guidance regarding these or similar issues.

For example, one vulnerable population is the incarcerated, and this is particularly true for the incarcerated with opioid addictions. Indeed, only a small percentage of incarcerated people with opioid addictions in the United States have access to what leading medical organizations consider to be the standard of care: medication- assisted treatment (MAT) (Linden, Marullo, Bone, Barry, & Bell, 2018). Of the nation’s 5,100 jails and prisons, fewer than 30 administer methadone or buprenorphine—the most proven method of recovery. This forces inmates to suffer withdrawal and puts them at risk of life-altering diseases, only to release them back into a world with reduced tolerance, primed for unintentional overdose (Linden et al., 2018).

Linden et al. (2018) suggest that denying access to MAT for patients who medically require it violates the Eighth Amendment’s prohibition of cruel and unusual punishment because it is deliberately indifferent to the serious medical needs that opioid dependency presents. Failure to provide MAT may also violate other laws such as the Americans with Disabilities Act of 1990. It is nurses who may be in the best position to advocate for compassionate medical care in this vulnerable population (see Examining the Evidence 6.1).

EXAMINING THE EVIDENCE 6.1 Source: Linden, M., Marullo, S., Bone, C., Barry, D. T., & Bell, K. (2018). Prisoners as patients: The opioid epidemic, medication-assisted treatment, and the eighth amendment. Journal of Law, Medicine & Ethics, 46(2), 252–267.

A Case Study in Advocacy: Prisoners as Patients The United States has the highest rate of incarceration of any nation in the world. The prevalence of opioid use disorder is extremely high in this population, putting the lives and well-being of incarcerated people at risk. Yet in the face of such great need, only a small percentage of incarcerated people with opioid addictions have access to what leading medical organizations take to be the standard of care: medication-assisted treatment (MAT). MAT typically uses medications that are opioid agonists, such as methadone and buprenorphine-naloxone. Both allow patients to pursue normal activities of daily living without debilitating drug cravings.

In 2016, a Rhode Island government– appointed task force advocated for a comprehensive corrections-based MAT for about 2,200 prisoners in that state. That program was implemented in 2017.

Preliminary results, published in 2018, compared results from the first 6 months of the program to the period 1 year prior. As expected, the number of inmates receiving

MAT in a given month grew significantly, from 80 inmates preimplementation to over 300 inmates afterward. The number of individuals dying of overdose within 6 months of release fell by 61%, from 26 deaths to 9 deaths, a statistically significant result. Although these results are preliminary and did not take place in the context of a randomized controlled trial, the reduction in deaths is remarkable and points to both the impact of advocacy on the health of a vulnerable population and the impact of MAT programs themselves.

Nurses may act as advocates by helping others make informed decisions, by acting as an intermediary in the environment, or by directly intervening on behalf of others.

This chapter examines the processes through which advocacy is learned as well as the ways in which leader-managers can advocate for their patients, subordinates, and the profession. The role of “whistleblower” as an advocacy role is discussed. Specific suggestions for interacting with legislators and the media to influence health policy are also included. Leadership roles and management functions essential for advocacy are shown in Display 6.1.

DISPLAY 6.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH ADVOCACY

Leadership Roles 1. Creates a climate where advocacy and its associated risk

taking are valued 2. Seeks fairness and justice for individuals who are unable to

advocate for themselves 3. Seeks to strengthen patient and subordinate support systems

to encourage autonomous, well-informed decision making 4. Role models the use of patient and family engagement

strategies 5. Influences others by providing information necessary to

empower them to act autonomously 6. Assertively advocates on behalf of patients and subordinates

when an intermediary is necessary 7. Participates in professional nursing organizations and other

groups that seek to advance the profession of nursing 8. Role models proactive involvement in health-care policy

through both formal and informal interactions with the media and legislative representatives

9. Works to establish the creation of a national, legally binding Patient’s Bill of Rights

10. Speaks up when appropriate to advocate for health-care practices necessary for safety and quality improvement

11. Supports workers who report perceived wrongdoings through whistleblowing

12. Advocates for social justice in addition to individual patient advocacy

13. Appropriately differentiates between controlling patient choices (domination and dependence) and in assisting patient choices (allowing freedom)

Management Functions 1. Assures that subordinates and patients have adequate

information to make informed decisions 2. Establishes a work climate that prioritizes the rights and

values of patients in health-care decision making 3. Seeks appropriate consultation when advocacy results in

intrapersonal or interpersonal conflict 4. Promotes and protects the workplace safety and health of

subordinates and patients 5. Encourages subordinates to bring forth concerns about the

employment setting and seeks impunity for whistleblowers 6. Demonstrates the skills needed to interact appropriately with

the media and legislators regarding nursing and health-care issues

7. Is aware of current legislative efforts affecting nursing practice and organizational and unit management

8. Assures that the work environment is both safe and conducive to professional and personal growth for subordinates

9. Creates work environments that promote subordinate empowerment so that workers have the courage to speak up for patients, themselves, and their profession

10. Takes immediate action when illegal, unethical, or inappropriate behavior occurs that can endanger or jeopardize the best interests of the patient, the employee, or the organization

Becoming an Advocate Although advocacy is present in all clinical practice settings, the nursing literature contains only limited descriptions of how nurses learn the advocacy role, and some experts have even questioned

whether advocacy can be taught at all. Some students learn about the advocacy role as part of ethics or policy content in their nursing education, and although most undergraduate and graduate programs likely include some type of advocacy instruction, the extent or impact of this education is largely unknown.

Regardless of how or when advocacy is learned, or the extent to which it is used, there are nursing values central to advocacy. These values emphasize caring, autonomy, respect, and empowerment (Display 6.2).

DISPLAY 6.2 NURSING VALUES CENTRAL TO ADVOCACY

1. Every individual has a right to autonomy in deciding what course of action is most appropriate to meet his or her health- care goals.

2. Every individual has a right to hold personal values and to use those values in making health-care decisions.

3. All individuals should have access to the information they need to make informed decisions and choices.

4. The nurse must act on behalf of patients who are unable to advocate for themselves.

5. Empowerment of patients and subordinates to make decisions and act on their own is the essence of advocacy.

The nursing values central to advocacy emphasize caring, autonomy, respect, and empowerment.

Patient Advocacy Standard VII of the American Nurses Association (ANA, 2015b) Scope and Standards of Practice states that the registered nurse practices ethically. As such, the registered nurse is expected to take

appropriate action regarding instances of illegal, unethical, and inappropriate behaviors that can endanger or jeopardize the best interests of the health-care consumer or situation; speak up when appropriate to question health-care practice when necessary for safety and quality improvement; and advocate for equitable health- care consumer care.

LEARNING EXERCISE 6.1

Values and Advocacy

How important a role do you believe advocacy to be in nursing? Do you believe that your willingness to assume this role is a learned value? Were the values of caring and service emphasized in your family and/or community when you were growing up? Have you identified any role models in nursing who actively advocate for patients, subordinates, or the profession? What strategies might you use as a new nurse to impart the need for advocacy to your peers and to the student nurses who work with you?

This patient advocacy is necessary because disease almost always results in decreased independence, loss of freedom, and interference with the ability to make choices autonomously. In addition, aging, as well as physical, mental, or social disability, may make individuals more vulnerable and in need of advocacy. Thus, advocacy becomes the foundation and essence of nursing, and nurses have a responsibility to promote human advocacy.

These ideas are also reinforced in the ANA (2015a) Code of Ethics for Nurses With Interpretive Statements. Provision 2 of the Code suggests that the nurse’s primary commitment is to the patient, whether an individual, family, group, community or population. Provision 3 suggests that the nurse promotes, advocates for, and protects the rights, health and safety of the patient.

Patient and Family Engagement In addition, in 2013, the American Hospital Association (AHA) Committee on Research released a report entitled Engaging Health Care Users: A Framework for Healthy Individuals and Communities, suggesting that health-care user engagement is a key ingredient in reaching the triple aim of better population health, enhanced patient experience, and lower costs (AHA, 2019). The report suggested that hospitals must become more “activist” in their efforts to engage patients and that a continuum for engagement from information sharing to partnerships must exist. The report went on to recommend entry points for user engagement at four different levels of the health-care system as shown in Display 6.3.

DISPLAY 6.3 ENTRY POINTS FOR USER ENGAGEMENT IN THE HEALTH-CARE SYSTEM

Individual: The aim is to increase the skills, knowledge, and understanding of patients and families about what to expect when receiving care.

Health-care team: The focus is to promote shared understanding of expectations among patients and providers when seeking care.

Organization: The objective is to encourage partnerships and integrate the patient and family perspective into all aspects of hospital operations.

Community: The emphasis is to expand the focus beyond the hospital setting and find opportunities to improve overall community health.

Source: American Hospital Association. (2019). Engaging health care users: A framework for healthy individuals and communities. Retrieved June 8, 2019, from http://www.aha.org/research/cor/engaging/index.shtml

In addition, the Agency for Healthcare Research and Quality (AHRQ, 2017) developed the Guide to Patient and Family Engagement in Hospital Quality and Safety to help patients, families, and health professionals work together as partners to promote improvements in care. The Guide (AHRQ, 2017) outlines four strategies hospitals can use to connect with patients and families, including the following:

Encourage patients and family members to participate as advisors.

Promote better communication among patients, family members, and health-care professionals from the point of admission.

Implement safe continuity of care by keeping the patient and family informed through nurse bedside change-of-shift reports.

Engage patients and families in discharge planning throughout the hospital stay.

Managers also must advocate for patients regarding distribution of resources and the use of technology. The advances in science and limits of financial resources have created new problems and ethical dilemmas. For example, although diagnosis-related groupings may have eased the strain on government fiscal resources, they have created ethical problems, such as patient dumping, premature patient discharge, and inequality of care.

Common areas in which nurses must advocate for patients are shown in Display 6.4.

DISPLAY 6.4 COMMON AREAS REQUIRING NURSE– PATIENT ADVOCACY

1. End-of-life decisions 2. Technological advances 3. Health-care reimbursement 4. Access to health care 5. Transitions in health care 6. Provider–patient conflicts regarding expectations and desired

outcomes 7. Withholding of information or blatant lying to patients 8. Insurance authorizations, denials, and delays in coverage 9. Medical errors 10. Patient information disclosure (privacy and confidentiality) 11. Patient grievance and appeals processes 12. Cultural and ethnic diversity and sensitivity 13. Respect for patient dignity 14. Inadequate consents 15. Incompetent health-care providers 16. Complex social problems including AIDS, teenage pregnancy,

violence, and poverty 17. Aging population

LEARNING EXERCISE 6.2

Culture and Decisions

You are a staff nurse on a medical unit. One of your patients, Mr. Dau, is a 56-year-old Hmong immigrant to

the United States. He has lived in the United States for 4 years and became a citizen 2 years ago. His English is marginal, although he understands more than he can verbalize. He was admitted to the hospital with sepsis resulting from urinary tract infection. His condition is now stable.

Today, Mr. Dau’s physician informed him that his computed tomography scan shows a large tumor in his prostate. The physician wants to do immediate follow-up testing and surgical resection of the tumor to relieve his symptoms of hesitancy and urinary retention. Although the tumor is probably cancerous, the physician believes that it will respond well to traditional oncology treatments. The expectation is that Mr. Dau should recover fully.

One hour later, when you go in to check on Mr. Dau, you find him sitting on his bed with his suitcase packed, waiting for a ride home. He informs you that he is checking out of the hospital. He states that he believes he can make himself better at home with herbs and through prayers by the Hmong shaman. He concludes by telling you, “If I am meant to die, there is little anyone can do.” When you reaffirm the hopeful prognosis reported by his physician that morning, Mr. Dau says, “The doctor is just trying to give me false hope. I need to go home and prepare for my death.”

ASSIGNMENT:

What should you do? How can you best advocate for this patient? Is the problem a lack of information? How does culture play a role in the patient’s decision? Does a lack of understanding on this patient’s part justify paternalism?

Person- and Family-Centered Care The Institute for Healthcare Improvement (2019) notes that patient- and family-centered care (also known as patient-centered care) is an innovative approach to the planning, delivery, and evaluation of health care that emphasizes partnerships between clinicians and individuals where the values, needs, and preferences of the individual are honored; the best evidence is applied; and the shared goal is optimal functional health and quality of life. Thus, it

humanizes, personalizes, and demystifies the patient experience (Planetree, 2018).

Planetree argues that patient-centered care is the “right thing to do” (Planetree, 2018). The Institute for Patient- and Family-Centered Care (IPFCC, 2019) agrees, suggesting that patient- and family- centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health-care providers, patients, and families, thus redefining the relationships in health care. Core concepts of patient- and family-centered care are shown in Display 6.5.

DISPLAY 6.5 CORE CONCEPTS OF PATIENT- AND FAMILY- CENTERED CARE

Patient care is organized first and foremost around the needs of patients.

Patient and family perspectives are sought out, and their choices are honored.

Patient and family knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of care.

Health-care providers communicate openly and honestly with patients and families to empower them to be effective partners in their health-care decision making.

Patients and families are encouraged and supported in participating in care and decision making at the level they choose.

Patients, families, and health-care providers collaborate in policy and program development, implementation, and evaluation; in research; in facility design; and in professional education as well as in the delivery of care.

The voice of the patient and family is represented at both the organizational and policy levels as well as at the health system’s strategic planning.

Sources: Planetree. (2018). History of Planetree. Retrieved June 8, 2019, from https://www.planetree.org/certification/about-planetree; and Institute for Patient- and Family-Centered Care. (2019). Patient- and family-centered care. Retrieved June 8, 2019, from http://www.ipfcc.org/about/pfcc.html

Planetree and the IPFCC have been two of the most prominent pioneers in developing and promoting patient- and family-centered care. Planetree is a mission-based, not-for-profit organization that partners with health-care organizations around the world and across the care continuum to transform how care is delivered (Planetree,

2018). Guided by a foundation in 10 components of patient-centered care, Planetree informs policy at a national level, aligns strategies at a system level, guides implementation of care delivery practices at an organizational level, and facilitates compassionate human interactions at a deeply personal level. Their philosophical conviction that patient-centered care is the right thing to do is supported by a structured process that enables sustainable change (Planetree, 2018).

Founded in 1992, the IPFCC is a not-for-profit organization offering health-care providers and institutions information and core guiding concepts related to patient- and family-centered care. These concepts include open visitation; family presence during all procedures; patient, family, and staff communication and collaboration in care plan development, multidisciplinary rounds, and bedside handoffs between nurses; information availability in patient and family resource centers; and the use of patient and family advisors in performance and safety improvement efforts (IPFCC, 2019). In addition, the model encourages the use of soft colors, lighting, homelike fabrics, and music for patient rooms and common areas as well as opportunities for patients and families to learn about their illness to foster participation in their care.

LEARNING EXERCISE 6.3

Changing Organization Cultures to Be Patient and Family Centered

Adoption of patient- and family-centered care often requires changing an organization culture so that patients and families are truly recognized as partners in care,

whether at the bedside or at the institutional level in strategic planning. It also requires a reconsideration of many of the rules and barriers often in place that pose obstacles for patients and families to be active participants in care decisions.

ASSIGNMENT:

Select any one of the following rules/procedures/situations common to many hospitals and write a one-page essay outlining why it would not be consistent with a patient- and family- centered care approach. Include in the discussion how the rule/procedure/situation could be changed to better reflect the core concepts shown in Display 6.5. 1. Visiting hours end at 9:00 PM unless someone is

willing to “bend the rules.” 2. Only one visitor is allowed at a time in the critical

care units and then for only 20 minutes every hour.

3. Flat, comfortable sleeping surfaces are not readily available for family members who wish to spend the night in patient rooms.

4. Physicians typically make patient care rounds between 7:00 AM and 8:00 PM before family members have arrived.

5. Handoff report occurs behind closed doors, and family members do not participate.

6. Family lounges are too small to accommodate all visitors during peak visiting hours.

7. Staff complain in handoff report that patients are unwilling to follow the plan of care rather than asking if the patients themselves were involved in determining the plan of care.

8. Dining halls are open only to staff in the middle of the night.

Patient Rights

Until the 1960s, patients had few rights; in fact, patients often were denied basic human rights during a time when they were most vulnerable. This changed with the adoption of the Consumer Bill of Rights and Responsibilities, also known as the Patient’s Bill of Rights in 1998. This document had three key goals: (a) to help patients feel more confident in the US health-care system, (b) to stress the importance of a strong relationship between patients and their health-care providers, and (c) to stress the key role patients play in staying healthy by laying out rights and responsibilities for all patients and health-care providers (American Cancer Society, 2019).

Since that time, the National League for Nursing, the AHA, and many other organizations have created documents outlining the rights of patients. Although not legally binding, these documents do guide health-care organizations and practitioners in terms of professional expectations for patient advocacy. Some federal laws do exist, though, in terms of patient rights such as the right to get a copy of one’s medical records and the right to keep them private (MedlinePlus, 2019).

In addition, with the passage of the Patient Protection and Affordable Care Act in 2010, a new Patient’s Bill of Rights was established to give new patient protections in dealing with insurance companies (American Cancer Society, 2019). These protections, which phased in between 2010 and 2014, included the elimination of annual and lifetime coverage limits, provided for choice of physician from a plan’s network, allowed children to get health insurance in spite of existing medical conditions, allowed children to stay on a parent’s policy until age 26 years if they met other requirements, and restricted health insurance companies from being able to rescind (take back) health coverage because of honest mistakes on insurance applications.

The government, in its role as the single largest insurer of health care, has also influenced the protection of patient rights by linking reimbursement with patient right provisions. For example, in 2011,

the U.S. Department of Health and Human Services mandated that all hospitals that receive Medicare and Medicaid funding must protect the visitation rights of lesbian, gay, bisexual, and transgender (LGBT) patients (The Human Rights Campaign, 2019). Learning Exercise 6.4 addresses the rights of LGBT patients.

LEARNING EXERCISE 6.4

Advocating for a Transgender Patient

You are the charge nurse on a medical unit. Today, during walking rounds, a male-to-female transgender patient tells you that she hears the staff whispering and making fun of her in the hallway outside her room. She says this is hurtful and that although the staff may lack clarity about her gender identity, she does not, and that becoming a woman is all she ever wanted. She said that friends who have come to visit her have also been made to feel uncomfortable.

ASSIGNMENT:

1. How best can you advocate for this patient? 2. What leadership roles could you employ to

address the lack of compassion and advocacy for this patient with the staff?

3. What policies should be created to assure compliance with the U.S. Department of Health and Human Services mandate to protect the visitation rights of this patient’s friends and significant others?

There has also been significant progress in patient rights related to the privacy of health-care information, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In addition, legislation—the American Recovery and Reinvestment Act of 2009— maintains and expands HIPAA guidelines as they are related to patient health information privacy and security protections.

States have also created bills of rights. In 1994, the Illinois General Assembly (n.d.) established a Medical Patient Rights Act that established certain rights for medical patients and provided a penalty for violations of these rights. California has adopted a similar patient guide pertaining to health-care rights and remedies (Display 6.6). These guidelines, however, are not legally binding, although they may influence federal or state funding and certainly should be considered professionally binding.

DISPLAY 6.6 LIST OF PATIENT RIGHTS IN CALIFORNIA

In accordance with Section 70707 of the California Administrative Code, the hospital and medical staff have adopted the following list of patient rights to 1. Exercise these rights without regard to sex; cultural,

economic, educational, or religious background; or the source of payment for care

2. Considerate and respectful care 3. Knowledge of the name of the physician who has primary

responsibility for coordinating care and the names and professional relationships of other physicians who will see the patient

4. Receive information from the physician about illness, course of treatment, and prospects for recovery in terms the patient can understand.

5. Receive as much information about any proposed treatment or procedure as the patient may need to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, alternate course of treatment or nontreatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment.

6. Participate actively in decisions regarding medical care. To the extent permitted by law, this includes the right to refuse treatment.

7. Full consideration of privacy concerning medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be advised of the reason for the presence of any individual.

8. Confidential treatment of all communications and records pertaining to the patient’s care and stay in the hospital. Written permission shall be obtained before medical records are made available to anyone not directly concerned with the patient’s care.

9. Reasonable responses to any reasonable requests for service

10. Ability to leave the hospital even against the advice of the physician

11. Reasonable continuity of care and to know in advance the time and location of appointment and the physician providing care

12. Be advised if hospital/personal physician proposes to engage in or perform human experimentation affecting care or treatment. The patient has the right to refuse to participate in such research projects.

13. Be informed by the physician or a delegate of the physician of continuing health-care requirements following discharge from the hospital

14. Examine and receive an explanation of the bill, regardless of source of payment.

15. Know which hospital rules and policies apply to the patient’s conduct.

16. Have all patient’s rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.

Source: Consumer Watchdog. (n.d.). The California patient’s guide. Your health care rights and remedies. Retrieved August 2, 2018, from http://www.calpatientguide.org/index.html

Some legally binding legislation has been passed, however, to safeguard vulnerable populations. One such legislation, the Genetic

Information Nondiscrimination Act, is a federal law passed in 2008, making it illegal for health insurers or employers to discriminate against individuals based on their genetic information (Genetics Home Reference, 2019).

Genetics Home Reference (2019) notes that

the law has two parts: Title I, which prohibits genetic discrimination in health insurance, and Title II, which prohibits genetic discrimination in employment. Title I makes it illegal for health insurance providers to use or require genetic information to make decisions about a person’s insurance eligibility or coverage. This part of the law went into effect on May 21, 2009. Title II makes it illegal for employers to use a person’s genetic information when making decisions about hiring, promotion, and several other terms of employment. This part of the law went into effect on November 21, 2009. (para. 2–3)

Other countries have passed legally binding legislation as well. The Deprivation of Liberty Safeguards, an amendment to the United Kingdom’s 2005 Mental Capacity Act, provides some protection for residents in care homes from unneeded use of physical restraints and other loss of liberties. Similarly, mental health patients who are involuntarily admitted to hospitals in Alberta, Canada, are afforded some legal protections, including the Mental Health Act of Alberta. This act provides the authority, protocols, and timelines for admitting, detaining, and treating persons with serious mental disorders.

The Right to Die Movement and Physician- Assisted Suicide At times, individual rights must be superseded to ensure the safety of all parties involved. It is important, however, for the patient advocate to know the difference between controlling patient choices and assisting patients to choose. Health-care professionals often

have knowledge that patients do not have but must be careful not to use paternalism at the cost of patient autonomy.

It is important for the patient advocate to be able to differentiate between controlling patient choices (domination and dependence) and assisting patient choices (allowing freedom).

For example, the right to die movement has gained momentum in the past decade. In 1997, Oregon became the first state to allow terminally ill people to receive lethal doses of medication from their doctors. By mid-2019, seven other states had followed suit (Washington, Vermont, California, Colorado, Hawaii, New Jersey, and District of Columbia), and Montana allowed it by court decision (Death with Dignity, 2019). Multiple other states are considering legislation for physician-assisted suicide (PAS) as well.

Typically, right to die laws apply only to patients who are at least 18 years old, with the capacity to make medical decisions, with a terminal disease expected to result in death within 6 months. The California End of Life Option Act requires the patient to make two verbal requests at least 15 days apart and one written request that is signed, dated, and witnessed by two adults (McGreevy, 2016). The patient may rescind the request for an aid-in-dying drug at any time and in any manner, and a request for a prescription cannot be made on behalf of a patient through an agent under a power of attorney, an advance health-care directive, a conservator, or any other person (McGreevy, 2016). Once the prescription is filled, the patient must complete a “Final Attestation for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner” form within 48 hours before self- administering the drug. Although the law is silent as to what cause of death should be identified on the death certificate, it does say taking an aid-in-dying drug “shall not constitute suicide” (McGreevy, 2016).

Debates, however, around the impetus for and ethics of PAS continue to rage. Although many proponents characterize the action as a liberation from suffering, opponents suggest that advances in pain control and hospice care could address many of the issues driving terminally ill patients to seek PAS (McGreevy, 2016).

Physicians do have the legal right to choose whether they will participate in PAS. “A healthcare provider who refuses to participate in activities under the act on the basis of conscience, morality or ethics cannot be subject to censure, discipline . . . or other penalty by a healthcare provider, professional association or organization” (McGreevy, 2016, para. 19). Physicians who do participate are protected from criminal, civil, and administrative liability if they follow the requirements.

Gallagher (2016) notes, however, that helping patients make decisions about PAS, and supporting them in their choices, is difficult even when impending death is a certainty. “All anyone can do is guarantee each individual the freedom of decision and to determine what he or she deems best for his or her own body or mental well- being” (Gallagher, 2016, para. 5).

The bottom line is that patients are increasingly aware that they have rights, and as a result, they are more assertive and involved in their health care. They want to know and understand their treatment options and to be participants in decisions about their health care. Leader-managers have a responsibility to see that all patient rights are met, including the right to privacy and personal liberty, which are guaranteed by the Constitution.

Subordinate and Workplace Advocacy Subordinate advocacy is a neglected concept in management theory but is an essential part of the leadership role. Standard 7 of the ANA (2016) Nursing Administration: Scope and Standards of Practice suggests that nurse administrators should advocate for other health-

care providers (including subordinates) as well as patients, especially when this is related to health and safety.

For example, workplace advocacy is a critical role that managers assume to promote subordinate advocacy. In this type of advocacy, the manager assures the work environment is both safe and conducive to professional and personal growth for subordinates. For example, managers should assure that Occupational Safety and Health Administration (OSHA) guidelines for worker safety are followed. Educating staff about proper body mechanics and assuring that staffing is adequate for safely ambulating and turning patients can reduce the incidence of back injuries in health-care workers. In addition, occupational health and safety must be assured by interventions such as reducing worker exposure to workplace violence, needle sticks, or blood and body fluids. When these working conditions do not exist, managers must advocate to higher levels of the administrative hierarchy to correct the problems.

In addition, workplace advocacy is needed to address workplace violence, an ever-increasing problem in contemporary society but particularly in the health-care system. OSHA reported that from 2002 to 2013, incidents of serious workplace violence were 4 times more common in health-care settings than in private industry, leading Durkin (2017) to suggest that workplace violence occurs so often in the hospital that some health-care workers consider it part of the job.

Clearly, no health-care worker is immune to workplace violence, but nurses are at particularly high risk. Durkin (2017) noted that among participants in a Minnesota Nurses’ Study, the yearly incidence of verbal and physical assaults was 39% and 13%, respectively. Yet, only 30% of nurses and 26% of physicians report workplace violence that has occurred.

In addition, the AHA reported in 2017 that beyond the human toll, hospitals spent an estimated $1.1 billion in security and training costs to prevent violence within their facilities, plus $429 million in medical care, staffing, indemnity, and other costs resulting from

violence against hospital workers (Durkin, 2017). “Hospitals and clinicians must increasingly recognize workplace violence as a problem and employ strategies to deal with it, or better yet, stop it before it happens” (Durkin, 2017, para. 1).

Subordinates should also be able to have the expectation that their work hours and schedules will be reasonable, that staffing ratios will be adequate to support safe patient care, that wages will be fair and equitable, and that nurses will be allowed participation in organizational decision making. When the health-care industry has faced the crisis of inadequate human resources and nursing shortages, many organizations have made quick, poorly thought-out decisions to find short-term solutions to a long-term and severe problem. New workers have been recruited at a phenomenally high cost; yet, the problems that caused high worker attrition were not solved. Upper level managers must advocate for subordinates in solving problems and making decisions about how best to use limited resources. These decisions must be made carefully, following a thorough examination of the political, social, economic, and ethical costs.

Another way leaders advocate for subordinates is in creating a work environment that promotes risk taking and leadership. For example, administrators should foster work environments that promote subordinate empowerment so that workers have the courage to speak up for patients, themselves, and their profession. In addition, managers must help members of their health-care team resolve ethical problems and work effectively with solutions at the unit level.

Gerber (2018) agrees, noting that the organization’s commitment to promoting nurse–patient advocacy is of utmost importance. Health-care administrators must maintain an effective and efficient chain of command so that clinical nurses know where to report concerns and how to access the chain of command.

The following are suggestions for creating an environment that promotes subordinate advocacy:

Invite collaborative decision making. Listen to staff needs. Get to know staff personally. Take time to understand the challenges faced by the staff in

delivering care. Face challenges and solve problems together. Support staff as needed. Promote shared governance. Empower staff. Promote nurse autonomy. Provide staff with workable systems.

Managers must recognize what subordinates are striving for and the goals and values that subordinates consider appropriate. The leader-manager should be able to guide subordinates toward actualization while defending their right to autonomy. To help nurses deal with ethical dilemmas in their practice, nurse-managers should establish and utilize appropriate support groups, ethics committees, and channels for dealing with ethical problems.

LEARNING EXERCISE 6.5

How Can You Best Advocate?

You are a unit supervisor in a skilled nursing facility. One of your aides, Martha Greenwald, recently reported that she suffered a “back strain” several weeks ago when she was lifting an elderly patient. She did not report the

injury at the time because she did not think it was serious. Indeed, she finished the remainder of her shift and has performed all her normal work duties since that time.

Today, Martha reports that she has just left her physician’s office and that he has advised her to take 4 to 6 weeks off from work to fully recover from her injury. He has also prescribed physical therapy and electrical nerve stimulation for the chronic pain. Martha is a relatively new employee, so she has not yet accrued enough sick leave to cover her absence. She asks you to complete the paperwork for her absence and the cost of her treatments to be covered as a work-related injury.

When you contact the workers’ compensation case manager for your facility, she states that the claim will be investigated; however, with no written or verbal report of the injury at the time it occurred, there is great likelihood that the claim will be rejected.

ASSIGNMENT:

How best can you advocate for this subordinate?

Whistleblowing as Advocacy The public has become much more aware of ethical malfeasance within its institutions and corporate organizations because of various scandals that have occurred in the last 50 years. From Watergate to Morgan Stanley to Bernard Madoff’s Ponzi scheme, the American public has been fed a diet of wrongdoing that has led to an increase in moral awareness.

Wrongdoing does not stop at large corporations or political activity, it also occurs within health-care organizations. Huston (2020c) suggests that in an era of managed care, declining reimbursements, and the ongoing pressure to remain fiscally solvent, the risk of fraud, misrepresentation, and ethical malfeasance in health-care organizations has never been higher. As a result, the need for whistleblowing has also likely never been greater.

Huston (2020c) also suggests that there are basically two types of whistleblowing. Internal whistleblowing occurs within an organization, reporting up the chain of command. External whistleblowing involves reporting outside the organization such as the media and an elected official. An example of whistleblowing by a health-care provider might be to report inflated practices of documentation and coding that result in elevated cost reimbursement.

Huston (2020c) notes that nurses as health-care professionals have a responsibility to uncover, openly discuss, and condemn shortcuts, which threaten the clients they serve. It is important, however, to remember that whistleblowing should never be considered the first solution to ethically troubling behavior. Indeed, it should be considered only after other prescribed avenues of solving

problems have been attempted. This is true, however, only if patients’ lives are not at stake. In those cases, immediate action must be taken.

In addition, the employee should typically go up the chain of command in reporting his or her concerns. This process, however, must be modified when the immediate supervisor is the source of the problem. In such a case, the employee might need to skip that level to see that the problem is addressed. Indeed, most whistleblowers would rather raise the issue internally to their manager than take it outside. Thus, companies generally get the opportunity to resolve issues internally—the question is whether they will take this opportunity or miss it.

There are other general guidelines for blowing the whistle that should also be followed, including carefully documenting all attempts to address the problem and being sure to report facts and not personal interpretations. These guidelines, as well as others, are presented in Display 6.7.

DISPLAY 6.7 GUIDELINES FOR BLOWING THE WHISTLE

Stay calm and think about the risks and outcomes before you act.

Know your legal rights because laws protecting whistleblowers vary by state.

First, make sure that there really is a problem. Check resources such as the medical library, the Internet, and institutional policy manuals to be sure.

Seek validation from colleagues that there is a problem, but do not get swayed by groupthink into not doing anything if you should.

Follow the chain of command in reporting your concerns whenever possible.

Confront those accused of the wrongdoing as a group whenever possible.

Present just the evidence; leave the interpretation of facts to others. Remember that there may be an innocent or good explanation for what is occurring.

Use internal mechanisms within your organization. If internal mechanisms do not work, use external mechanisms. Private groups, such as The Joint Commission or the National

Committee for Quality Assurance, do not confer protection. You must report to a state or national regulator.

Although it is not required by every regulatory agency, it is a good rule of thumb to put your complaint in writing.

Document carefully the problem that you have seen and the steps that you have taken to see that it is addressed.

Do not lose your temper, even if those who learn of your actions attempt to provoke you.

Do not expect thanks for your efforts.

Source: Adapted from American Nurses Association. (n.d.). Things to know about whistle blowing. Retrieved July 19, 2018, from https://www.nursingworld.org/practice-policy/workforce/things-to-know-about- whistle-blowing/

It is interesting to note that although much of the public wants wrongdoing or corruption to be reported, such behavior is often looked on with distrust, and whistleblowers may be considered disloyal or experience repercussions for their actions, even if the whistleblowing was done with the best of intentions. The whistleblower cannot even trust that other health-care professionals, with similar belief systems about advocacy, will value their efforts because the public’s feelings about whistleblowers are so mixed (Huston, 2020c).

Ahern (2018) agrees, noting that despite health-care codes of conduct, retaliation against nurses who report misconduct is common, as are outcomes of sadness, anxiety, and a pervasive loss of sense of worth in the whistleblower. Whistleblowers often feel traumatized by the emotional manipulation many employers routinely use to discredit and punish employees who report misconduct. This creates a situation where the whistleblower doubts his or her perceptions, competence, and mental state, and over time, these strategies can trap the whistleblower in a maze of enforced helplessness (Ahern, 2018).

Speaking out as a whistleblower is often honored more in theory than in fact.

Leader-managers then must be willing to advocate for whistleblowers so that they feel assured, that if they are acting within the scope of their expertise, and that remedy can be sought through appropriate channels without fear of retaliation. Unfortunately, there has been a collective silence in many cases of ethical malfeasance.

The reality is that whistleblowing offers no guarantee that the situation will change or the problem will improve, and the literature is replete with horror stories regarding negative consequences endured by whistleblowers. For all these reasons, it takes tremendous courage to come forward as a whistleblower. It also takes a tremendous sense of what is right and what is wrong as well as a commitment to follow a problem through until an acceptable level of resolution is reached (Huston, 2020c).

Leader-managers must be willing to advocate for whistleblowers who speak out about organizational practices that they believe may be harmful or inappropriate.

Although whistleblower protection has been advocated at the federal level and has passed in some states, many employees are reluctant to report unsafe conditions for fear of retaliation. Nurses should check with their state association to assess the status of whistleblower protection in their state. At present, there is no universal legal protection for whistleblowers in the United States.

Professional Advocacy Leader-managers also must be advocates for the nursing profession. This type of advocacy has a long history in nursing. It was nurses who pushed for accountability through state Nurse Practice Acts and state licensing, although this was not accomplished until 1903. Advocating for professional nursing is a leadership role.

Joining a profession requires making a personal decision to involve oneself in a system of socially defined roles. Thus, entry into a profession involves a personal and public promise to serve others with the special expertise that a profession can provide and that society legitimately expects it to provide.

LEARNING EXERCISE 6.6

Write It Down. How Can You Advocate? ASSIGNMENT:

Write a two-page essay about one of the following topics: 1. List five things that you would like to change

about nursing or the health-care system. Prioritize the changes that you have identified. Identify the strategies that you could use individually and collectively as a profession to make the change happen. Be sure that you are realistic about the time, energy, and fiscal resources you have to implement your plan.

2. Do you belong to your state nursing organization or student nursing organization? Why or why not? Make a list of six other things that you could do to advocate for the profession. Be specific and realistic in terms of your energy and commitment to nursing as a profession.

Professional issues are always ethical issues. When nurses find a discrepancy between their perceived role and society’s expectations, they have a responsibility to advocate for the profession. At times, individual nurses believe that the problems of the profession are too big for them to make a difference; however, their commitment to their profession obligates them to ask questions and think about problems that affect the profession. They cannot afford to become powerless or helpless or claim that one person cannot make a difference.

Often, one voice is all it takes to raise the consciousness of colleagues within a profession. Accepting the challenge to be an advocate for the profession is a choice.

A professional commitment means that people cannot shrink from their duty to question and contemplate problems that face the profession.

Nursing’s Advocacy Role in Legislation and Public Policy A distinctive feature of American society is how citizens can participate in the political process. People have the right to express their opinions about issues and candidates by voting. People also have relatively easy access to lawmakers and policy makers and can make their individual needs and wants known. Theoretically, then, any one person can influence those in policy-making positions. This rarely happens, however; policy decisions are generally focused on group needs or wants.

Much attention has recently been paid to nurses and the importance of the nursing profession and how nurses impact health- care delivery. This has been especially true in the areas of patient safety, staff shortages, and full practice authority.

In addition to active participation in national nursing organizations, nurses can influence legislation and health policy in many other ways. Nurses who want to be directly involved can lobby legislators either in person or by letter. This process may seem intimidating to the new nurse; however, there are many books and workshops available that deal with the subject, and a common format is used. Nurses can also influence legislators through social media.

In addition to nurse-leaders and individual nurses, there is a need for collective influence to impact health-care policy. The need for

organized group efforts by nurses to influence legislative policy has long been recognized in this country. In fact, the first state associations were organized expressly for unifying nurses to influence the passage of state licensure laws.

Nurses must exert their collective influence and make their concerns known to policy makers before they can have a major impact on political and legislative outcomes.

Political action committees (PACs) attempt to persuade legislators to vote in a particular way. Lobbyists of the PAC may be members of a group interested in a specific law or paid agents of the group that wants a specific bill passed or defeated. Nursing must become more actively involved with PACs to influence health-care legislation, and PACs provide one opportunity for small donors to feel like they are making a difference.

In addition, professional organizations generally espouse standards of care that are higher than those required by law. Voluntary controls often are forerunners of legal controls. What nursing is and should be depends on nurses taking an active part in their professional organizations. Currently, nursing lobbyists in our nation’s capital are influencing legislation on quality of care, access to care issues, patient and health worker safety, health-care restructuring, direct reimbursement for advanced practice nurses, and funding for nursing education. Representatives of the ANA regularly participate in meetings of the U.S. Department of Health and Human Services, the National Institutes of Health, OSHA, and the White House to be sure that the “nursing perspective” is heard in health policy issues (Huston, 2020a).

Collectively, the nursing profession has not yet recognized the full potential of collective political activity. Nurses must exert their

collective influence and make their concerns known to policy makers before they can have a major impact on political and legislative outcomes. Because they have been reluctant to become politically involved, nurses have failed to have a strong legislative voice in the past. Legislators and policy makers are more willing to deal with nurses as a group rather than as individuals; thus, joining and supporting professional organizations allow nurses to become active in lobbying for a stronger nurse practice act or for the creation or expansion of advanced nursing roles.

Personal letters are more influential than form letters, and the tone should be formal but polite. The letter should also be concise (not more than one page). Be sure to address the legislator properly by title. Establish your credibility early in the letter as both a constituent and a health-care expert. State your reason for writing the letter in the first paragraph and refer to the specific bill that you are writing about. Then, state your position on the issue and give personal examples as necessary to support your position. Offer your assistance as a resource person for additional information. Sign the letter, including your name and contact information. Remember to be persistent and write to legislators repeatedly who are undecided on an issue. Display 6.8 presents a format common to letters written to legislators.

DISPLAY 6.8 SAMPLE: A LETTER TO A LEGISLATOR

March 15, 2019 The Honorable John Doe Member of the Senate State Capitol, Room _______ City, State, Zip Code

Dear Senator Doe, I am a registered nurse and member of the American Nurses

Association (ANA). I am also a constituent in your district. I am writing in support of SB XXX, which requires the establishment of minimum RN staffing ratios in acute care facilities. As a staff nurse on an oncology unit in our local hospital, I see firsthand the problems that occur when staffing is inadequate to meet the complex needs of acutely ill patients: medical errors, patient and nurse dissatisfaction, workplace injuries, and perhaps most important, the inability to spend adequate time with and comfort patients who are dying.

I have enclosed a copy of a recent study conducted by John Smith that was published in the January 2019 edition of Nurses Today. This article details the positive impact of legislative staffing ratio implementation on patient outcomes as measured by medication errors, patient falls, and nosocomial infection rates.

I strongly encourage you to vote for SB XXX when it is heard by the Senate Business and Professions Committee next week. Thank you for your ongoing concern with nursing and health-care issues and for your past support of legislation to improve health- care staffing. Please feel free to contact me if you have any questions or would like additional information.

Respectfully, Nancy Thompson, RN, BSN Street

City, State, Zip Code Phone number including area code E-mail address

Other nurses may choose to monitor the progress of legislation, count congressional votes, and track a specific legislator’s voting intents as well as past voting records. Still, other nurses may choose to join network groups, where colleagues meet to discuss professional issues and pending legislation.

For nurses interested in a more indirect approach to professional advocacy, their role may be to influence and educate the public about nursing and the nursing agenda to reform health care. This may be done by speaking with professional and community groups about health-care and nursing issues and by interacting directly with the media. Never underestimate the influence that a single nurse may have even in writing letters to the editor of local newspapers or by talking about nursing and health-care issues with friends, family, neighbors, teachers, clergy, and civic leaders.

Nursing and the Media Although registered nurses are among the most knowledgeable, frontline health-care providers in the country, their interactions with mainstream media are often limited. This is because too few nurses are willing to interact with the media about vital nursing and health- care issues. Often, this is because they believe that they lack the expertise to do so or because they lack self-confidence. This is especially unfortunate because both the media and the public place a high trust in nurses and want to hear about health-care issues from a nursing perspective.

The reality is that the responsibility for nursing’s image as perceived by the public lies solely on the shoulders of those who claim nursing as their profession. Until nurses are able to agree on

the desired collective image and are willing to do what is necessary to both tell and show the public what that image is, little will change (Huston, 2020b). Nurses should take every opportunity to appear in the media—in newspapers, radio, and television. Nurses should also complete special training programs to increase their self-confidence in working with journalists and other media representatives. Bendure (2018) suggests that everyone can benefit from media training because the key to becoming good at interviewing (and speaking in general) is through repetition and practice.

Regardless, the first few media interactions will likely be stressful, just like any new task or learning. The following tips may be helpful to nurses learning to navigate media waters:

Dress professionally for the interview. Remember that reporters often have short deadlines. A delay in

responding to a reporter’s request for an interview usually results in the reporter looking elsewhere for a source.

Do not be unduly paranoid that the reporter “is out to get you” by inaccurately representing what you have to say. The reporter has a job to do, and most reporters do their best to be fair and accurate in their reporting.

Come to the interview prepared with any statistics, important dates and times, anecdotes, or other information you want to share.

Limit your key points to two or three and frame them as bullet points to reduce the likelihood that you will be misheard or misinterpreted. Brief but concise sound bites are much more quotable than rambling arguments.

Avoid technical or academic jargon.

Speak with credibility and confidence but do not be afraid to say that you do not know if asked a question beyond your expertise or which would be better answered by someone else. If you choose not to answer a question, give a brief reason for not wanting to do so rather than simply saying “no comment.”

Avoid being pulled into inflammatory arguments or blame setting. If you feel that you have been baited or that you are being pulled off on tangents, simply repeat the key points you intended to make and refocus the conversation if possible. Remember that you cannot control the questions you are asked, but you can control your responses.

Be prepared to respond to follow-up media inquiries via e-mail. Provide contact information so that the reporter can reach you if additional information or clarifications are needed. Be aware, however, that most reporters will not allow you to preview their story prior to publication.

These strategies are summarized in Display 6.9.

DISPLAY 6.9 TIPS FOR INTERACTING WITH THE MEDIA

1. Establish proactive, routine communication with local, regional, and national media to promote cooperation and transparency.

2. Attend media training and/or practice speaking in front of a camera with a microphone.

3. Dress professionally for interviews. 4. Respect and meet the reporter’s deadlines. 5. Assume, until proven otherwise, that the reporter will be fair

and accurate in his or her reporting. 6. Have key facts and figures ready for the interview. 7. Limit your key points to two or three and frame them as bullet

points. 8. Avoid technical or academic jargon. 9. Speak confidently but do not be afraid to say when you do not

have the expertise to answer a question or when a question is better directed to someone else.

10. Avoid being pulled into inflammatory arguments or blame setting and repeat key points if you are pulled off into tangents.

11. Provide the reporter with contact information for follow-up and needed clarifications.

LEARNING EXERCISE 6.7

Preparing for a Media Interview

You are the staffing coordinator for a medium-sized community hospital in California. Minimum staffing ratios were implemented in January 2004. Although this has represented an even greater challenge in terms of meeting your organization’s daily staffing needs, you believe that the impetus behind the legislative mandate was sound. You also are a member of the state nursing association that sponsored this legislation and wrote letters of support for its passage. The hospital that employs you and the state hospital association fought unsuccessfully against the passage of minimum staffing ratios.

The local newspaper contacted you this morning and wants to interview you about staffing ratios in general as well as how these ratios are impacting the local hospital. You approach your chief nursing officer, and she tells you to go ahead and do the interview if you want but to remember that you are a representative of the hospital.

ASSIGNMENT:

Assume that you have agreed to participate in the interview. 1. How might you go about preparing for the

interview? 2. Identify three factual points that you can state

during the interview as your sound bites. What would be your primary points of emphasis?

3. Is there a way to reconcile the conflict between your personal feelings about staffing ratios and those of your employer? How would you respond

if asked directly by the reporter to comment about whether staffing ratios are a good idea?

Integrating Leadership Roles and Management Functions in Advocacy Nursing leaders and managers recognize that they have an obligation not only to advocate for the needs of their patients, subordinates, and themselves but also to be active in furthering the goals of the profession. To accomplish these types of advocacy, nurses must value autonomy and empowerment.

However, the leadership roles and management functions to achieve advocacy with patients and subordinates and for the profession differ greatly. Advocating for patients requires that the manager create a work environment that recognizes patient’s needs and goals as paramount. This means creating a work culture where patients are respected, well informed, and empowered. The leadership role required to advocate for patients is often one of risk taking, particularly when advocating for a client may be in direct conflict with a provider or institutional goal. Leaders must also be willing to accept and support patient choices that may be different from their own.

Advocating for subordinates requires that the manager create a safe and equitable work environment where employees feel valued and appreciated. When working conditions are less than favorable, the manager is responsible for relaying these concerns to higher levels of management and advocating for needed changes.

The same risk taking that is required in patient advocacy is a leadership role in subordinate advocacy because subordinate needs and wants may conflict with the organization. There is always a risk that the organization will view the advocate as a troublemaker, but this does not provide an excuse for managers to be complacent in

this role. Managers also must advocate for subordinates in creating an environment where ethical concerns, needs, and dilemmas can be openly discussed and resolved.

Advocating for the profession requires that the nurse-manager be informed and involved in all legislation affecting the unit, organization, and the profession. The manager must also be an astute handler of public relations and demonstrate skill in working with the media. It is the leader, however, who proactively steps forth to be a role model and an active participant in educating the public and improving health care through the political process.

Key Concepts

■ Advocacy is helping others to grow and self-actualize and is a leadership role.

■ Managers, by virtue of their many roles, must be advocates for patients, subordinates, and the profession.

■ It is important for the patient advocate to be able to differentiate between controlling patient choices (domination and dependence) and assisting patient choices (allowing freedom).

■ Since the 1960s, some advocacy groups, professional associations, and states have passed bills of rights for patients. Although these are not legally binding, they can be used to guide professional practice.

■ The philosophy of person- and family-centered care suggests that care should be organized first and foremost around the needs of patients and family members.

■ In workplace advocacy, the manager works to see that the work environment is both safe and conducive to professional and personal growth for subordinates.

■ Although much of the public wants wrongdoing or corruption to be reported, such behavior is often looked on with distrust, and whistleblowers are often considered disloyal and experience negative repercussions for their actions.

■ Leader-managers must be willing to advocate for whistleblowers who speak out about organizational practices that they believe may be harmful or inappropriate.

■ Professional issues are ethical issues. When nurses find a discrepancy between their perceived role and society’s expectations, they have a responsibility to advocate for the profession.

■ If nursing is to advance as a profession, practitioners and managers must broaden their sociopolitical knowledge base to better understand the bureaucracies in which they live.

■ Because legislators and policy makers are more willing to deal with nurses as a group rather than as individuals, joining and actively supporting professional organizations allow nurses to have a greater voice in health-care and professional issues.

■ Nurses need to exert their collective influence and make their concerns known to policy makers before they can have a major impact on political and legislative outcomes.

■ Nurses have great potential to educate the public and influence policy through the media as a result of the public’s high trust in nurses and because the public wants to hear about health-care issues from a nursing perspective.

Additional Learning Exercises and Applications

LEARNING EXERCISE 6.8

Ethics and Advocacy

You are a new graduate staff nurse in a home health agency. One of your clients is a 23-year-old man with acute schizophrenia who was just released from the local county, acute care, behavioral health-care facility, following a 72-hour hold. He has no insurance. His family no longer has contact with him, and he is unable to hold a permanent job. He is noncompliant in taking his prescription drugs for schizophrenia. He is homeless and has been sleeping and eating intermittently at the local homeless shelter; however, he was recently asked not to return because he is increasingly agitated and, at times, violent. He calls you today and asks you “to help him with the voices in his head.”

You approach the senior registered nurse (RN) case manager in the facility for help in identifying options for this individual to get the behavioral health-care services that he needs. She suggests that you tell the patient to go to Maxwell’s Mini Mart, a local convenience store, at 3:00 PM today and wait by the counter. Then she tells you that you should contact the police at 2:55 PM and tell them that Maxwell’s Mini Mart is being robbed by your patient so that he will be arrested. She states, “I do this with all of my uninsured mental health patients, since the state Medicaid program offers only limited mental health services and the state penal system provides full mental health services for the incarcerated.” She goes on to say that the store owner and the police are aware of what she is doing and support the idea because it is the only way “patients really have a chance of getting better.” She

ends the conversation by saying, “I know you are a new nurse and don’t understand how the ‘real world’ works, but the reality is that this is the only way I can advocate for patients like this, and you need to do the same for your patients.”

ASSIGNMENT:

1. Will you follow the advice of the senior RN case manager?

2. If not, how else can you advocate for this patient?

LEARNING EXERCISE 6.9

Determining Nursing’s Entry Level

Grandfathering is the term used to grant certain people working within the profession for a given time period or prior to a deadline date the privilege of applying for a license without having to take the licensing examination. Grandfathering clauses have been used to allow licensure for wartime nurses—those with on-the-job training and expertise—even though they did not graduate from an approved school of nursing.

Some professional nursing organizations are once again proposing that the Bachelor of Science in Nursing (BSN) become the entry-level requirement for professional nursing. Some have suggested that as a

concession to current associate degree in nursing and diploma-prepared nurses, all nurses who have passed the registered nursing licensure examination before the new legislation, regardless of educational preparation or experience, would retain the title of professional nurse. Nonbaccalaureate-educated nurses after that time would be unable to use the title of professional nurse.

ASSIGNMENT:

Do you believe that the “BSN as entry level” proposal advocates the advancement of the nursing profession? Is grandfathering conducive to meeting this goal? Would you personally support both proposals? Does the long-standing internal dissension about making the BSN the entry level into professional nursing reduce nursing’s status as a profession? Do lawmakers or the public understand this dilemma or care about it?

LEARNING EXERCISE 6.10

How Would You Proceed?

You are a registered nurse case manager for a large insurance company. Sheila Johannsen is a 34-year-old mother of two small children. She was diagnosed with advanced metastatic breast cancer 6 months ago. Traditional chemotherapy and radiation seem to have

slowed the spread of the cancer, but the prognosis is not good.

Sheila contacted you this morning to report that she has been in contact with a physician at one of the most innovative medical centers in the country. He told her that she might benefit from an experimental gene therapy treatment; however, she is ineligible for participation in the free clinical trials because her cancer is so advanced. The cost for the treatment is approximately $250,000. Sheila states that she does not have the financial resources to pay for the treatment and begs you “to do whatever you can to get the insurance company to pay; otherwise, I’ll die.”

You know that the cost of experimental treatments is almost always disallowed by Sheila’s insurance company. You also know that even with the experimental treatment, Sheila’s probability of a cure is very small.

ASSIGNMENT:

Decide how you will proceed. How can you best advocate for this patient?

LEARNING EXERCISE 6.11

Conflict of Values

You are a case manager in an outpatient disease management program assigned to coordinate the care

needs of Sam, a 72-year-old man with multiple chronic health problems. His medical history includes myocardial infarctions, implantation of a pacemaker, open-heart surgery, an inoperable abdominal aneurysm, and repeated episodes of congestive heart failure. Because of his poor health, he cannot operate the small business he owns or work for any length of time at his gardening or other hobbies.

Although Sam has told you that death would be a relief to his nearly constant discomfort and depression, his wife dismisses such talk as “nonsense” and tells Sam that “she still needs him and will always do everything in her power to keep him here with her.” In deference to his wife’s wishes, Sam has not completed any of the legal paperwork necessary to create a durable power of attorney or a living will should he become unable to make his own health-care decisions. Today, Sam takes you aside and suggests that he “wants to fill out this paperwork so that no extraordinary means of life support are used,” and he “wants you to witness it so that his wife will not know.”

ASSIGNMENT:

Decide what you will do. What is your obligation to Sam? To his wife? To yourself? Whose needs are paramount? How do the ethical principles of autonomy, duty, and veracity intersect or compete in this case?

LEARNING EXERCISE 6.12

Peer Advocacy

You are a nursing student. Like many of the students in your nursing program, sometimes you feel you study too much and therefore miss out on partying with friends,

something many of your college friends do on a regular basis. Today, after a particularly grueling exam, three of your nursing school peers approach you and ask you to go out with them to a party tonight, off campus, which is being cohosted by Matt, another nursing student. Alcohol will be readily available, although not everyone at the party is of legal drinking age, including you and one of your nursing peers (Jenny). Because you really do not want to drink anyway, you agree to be the designated driver.

Almost immediately after you arrive at the party, all three of your nursing peers begin drinking. At first, it seems pretty harmless, but after several hours, you decide the tenor of the party is changing and becoming less controlled and that it is time to take your friends home. Two of your peers agree, but you cannot find Jenny. As you begin searching for her, several partygoers tell you that she has been drinking “kamikazes” all night and that she “looked pretty wasted” the last time they saw her. They suggest that you check the bathroom because Jenny said she was not feeling very well.

When you enter the bathroom, you see Jenny slumped in the corner by the toilet. She has vomited all over the floor as well as her clothing and she reeks of alcohol. When you attempt to rouse her, her eyelids flutter but she is unable to wake up or answer any questions. Her breathing seems regular and unlabored, but she is continuing to vomit in her “blacked-out” state. Her skin feels somewhat clammy to the touch and she cannot stand or walk on her own. You are not sure how much Jenny actually had to drink or how long it has been since she “passed out.”

You are worried that Jenny is experiencing acute alcohol poisoning but are not very experienced with this sort of thing. The other two nursing students you brought to the party feel you are overreacting, although they agree that Jenny has had too much to drink and needs to be watched. One of your peers suggests calling the new young, clinical instructor in the nursing program, who offered just the other day to provide rides to students who have been drinking. You think she might be able to provide some guidance. Another one tells you that she feels Jenny just needs to “sleep it off” and that she will stay with Jenny tonight to make sure she is OK, although she has had a fair amount to drink herself.

You think Jenny should be seen in the local emergency department (ED) for treatment and are contemplating calling for an ambulance. One partygoer agrees with you that Jenny should be seen at the hospital but suggests you drop Jenny off anonymously at the front door of the ED so “you won’t get in any trouble.” Matt encourages you not to take her to the ED at all because he is afraid the incident will be reported to the local police because Jenny is a minor and that he could be in “real trouble” for furnishing alcohol to a minor. He argues that this could threaten both his progression and Jenny’s in the nursing program. He says that she can just stay at the house tonight and that he will check in on her on a regular basis.

To complicate things, you, Jenny, and the other two students you brought to the party live in the college dormitories and they lock down for the evening in another 30 minutes. It will take you at least 20 minutes to gather the manpower you need to get Jenny down to your car and up to her dormitory room by lockdown, if that is what you decide to do. If you are not inside the dormitories by

lockdown, you will need to find another place to spend the evening. In addition, there will likely be someone at the door to the dormitory assigned to turn away students who are clearly intoxicated.

ASSIGNMENT:

Decide what you will do. How do you best advocate for a peer when they are unable to advocate for themselves? Does it matter if the risk is self- induced? How do you weigh the benefits of advocating for one person when it can result in potential harm or risk to another person?

R E F E R E N C E S Agency for Healthcare Research and Quality. (2017). Guide to

patient and family engagement in hospital quality and safety. Rockville, MD: Author. Retrieved December 2, 2018, from http://www.ahrq.gov/professionals/systems/hospital/engagingfami lies/index.html

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Huston, C. J. (2020a). The nursing profession’s historic struggle to increase its power base. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 318–333). Philadelphia, PA: Wolters Kluwer.

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U N I T I I I

Roles and Functions in Planning

7

Organizational Planning . . . in the absence of clearly defined goals, we are forced to concentrate on activity and ultimately become enslaved by it.—Chuck Conradt

. . . people buy into the leader long before they buy into the vision.—Neslyn Watson Druee

. . . a goal without a plan is just a wish.—Antoine de Saint-Exupéry

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential III: Scholarship for evidence-based practice BSN Essential V: Health-care policy, finance, and regulatory environments

BSN Essential VIII: Professionalism and professional values MSN Essential II: Organizational and systems leadership MSN Essential IV: Translating and integrating scholarship into practice

MSN Essential VI: Health policy and advocacy AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency III: Leadership AONL Nurse Executive Competency V: Business skills ANA Standard of Professional Performance 10: Collaboration

ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 13: Evidence- based practice and research

ANA Standard of Professional Performance 14: Quality of practice

ANA Standard of Professional Performance 16: Resource utilization

ANA Standard of Professional Performance 17: Environmental health

QSEN Competency: Teamwork and collaboration QSEN Competency: Evidence-based practice

LEARNING OBJECTIVES

The learner will:

identify contemporary paradigm shifts and trends impacting health-care organizations

analyze social, political, and cultural forces that may affect the ability of 21st-century health-care organizations to forecast accurately in strategic planning

describe how tools such as SWOT analysis and balanced scorecards can facilitate the strategic planning process

describe the steps necessary for successful strategic planning identify barriers to planning as well as actions the leader- manager can take to reduce or eliminate these barriers

include evaluation checkpoints in organizational planning to allow for midcourse corrections as needed

discuss the relationship between an organizational mission statement, philosophy, goals, objectives, policies, procedures, and rules

write an appropriate mission statement, organization philosophy, nursing service philosophy, goals, and objectives for a known or fictitious organization

discuss appropriate actions that may be taken when personal values are found to be in conflict with those of an employing organization

recognize the need for periodic value clarification to promote self-awareness

reflect on which personal planning style (reactive, inactive, preactive, or proactive) is used most often

Introduction Planning is critically important to and precedes all other management functions. Without adequate planning, the management process fails, and organizational needs and objectives cannot be met. Planning may be defined as deciding in advance what to do; who is to do it; and how, when, and where it is to be done. Therefore, all planning involves choosing among alternatives.

All planning involves choice: a necessity to choose from among alternatives.

This implies that planning is a proactive and deliberate process that reduces risk and uncertainty. It also encourages unity of goals and continuity of energy expenditure (human and fiscal resources) and directs attention to the objectives of the organization. Adequate planning also provides the manager with some means of control and encourages the most appropriate use of resources.

In effective planning, the manager must identify short- and long- term goals and changes needed to ensure that the unit will continue to meet its goals. Identifying such short- and long-term goals requires leadership skills such as vision and creativity because it is impossible to plan what cannot be dreamed or envisioned.

Likewise, planning requires flexibility and energy—two other leadership characteristics. Yet, planning also requires management skills such as data gathering, forecasting, and transforming ideas into action.

Unit III focuses on several aspects of planning, including organizational planning, planned change, time management, fiscal planning, and career planning. This chapter deals with skills needed by the leader-manager to implement both day-to-day and future organizational planning. In addition, the leadership roles and management functions involved in developing, implementing, and evaluating the planning hierarchy are discussed (Display 7.1).

DISPLAY 7.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH ORGANIZATIONAL PLANNING

Leadership Roles 1. Translates knowledge regarding contemporary paradigm

shifts and trends impacting health care into vision and insights, which foster goal attainment

2. Assesses the organization’s internal and external environment in forecasting and identifying driving forces and barriers to strategic planning

3. Demonstrates visionary, innovative, and creative thinking in organizational and unit planning, thus inspiring proactive rather than reactive planning

4. Influences and inspires group members to be actively involved in both short- and long-term planning

5. Periodically completes value clarification to increase self- awareness

6. Encourages subordinates toward value clarification by actively listening and providing feedback

7. Communicates and clarifies organizational goals and values to subordinates

8. Encourages subordinates to be involved in policy formation, including developing, implementing, and reviewing unit philosophy, goals, objectives, policies, procedures, and rules

9. Is receptive to new and varied ideas 10. Role models proactive planning methods to followers

Management Functions 1. Is knowledgeable regarding legal, political, economic, and

social factors affecting health-care planning 2. Demonstrates knowledge of and uses appropriate techniques

in both personal and organizational planning

3. Provides opportunities for subordinates, peers, competitors, regulatory agencies, and the general public to participate in organizational planning

4. Coordinates unit-level planning to be congruent with organizational goals

5. Periodically assesses unit constraints and assets to determine available resources for planning

6. Develops and articulates a unit philosophy that is congruent with the organization’s philosophy

7. Develops and articulates unit goals and objectives that reflect unit philosophy

8. Develops and articulates unit policies, procedures, and rules that put unit objectives into operation

9. Periodically reviews unit philosophy, goals, policies, procedures, and rules and revises them to meet the unit’s changing needs

10. Actively participates in organizational planning, defining, and operationalizing plans at the unit level

Visioning: Looking to the Future Because of health-care reform, rapidly changing technology, increasing government involvement in regulating health care, and scientific advances, health-care organizations are finding it increasingly difficult to identify long-term needs appropriately and plan accordingly. In fact, most long-term planners find it difficult to plan more than a few years ahead.

Unlike the 20-year strategic plans of the 1960s and 1970s, most long-term planners today find it difficult to look even 5 years in the future.

The health-care system is in chaos, as is much of the business world. Traditional management solutions no longer apply, and a lack of strong leadership in the health-care system has limited the innovation needed to create solutions to the new and complex problems that the future will bring. Because change is occurring so rapidly, managers can easily become focused on short-range plans and miss changes that can drastically alter specific long-term plans.

Health-care facilities are particularly vulnerable to external social, economic, and political forces; long-range planning, then, must address these changing dynamics. It is imperative, therefore, that long-range plans be flexible, permitting change as external forces assert their impact on health-care facilities. In as far as it is possible, a picture of the future should be used to formulate long-range planning. One reason for envisioning the future is to study developments that may have an impact on the organization. This process of learning about the future allows us to determine what we want to happen. Identifying what may or could happen allows us to avert, encourage, or direct the course of events.

There are many factors emerging in the rapidly changing health- care system that must be incorporated in planning for a health-care organization’s future. Some emerging paradigms include the following:

Further consolidation of hospitals/systems, medical groups, ancillary services, health plans, and postacute providers is expected.

The tension between “value” and “volume” has reached a tipping point. With growing linkages between expected quality outcomes and reimbursement, health-care organizations must increasingly determine whether value drives volume or whether volume is necessary to achieve value.

The transformation from revenue management to cost management will continue as declining reimbursement forces

providers to focus on how to maximize limited resources and provide care at less cost.

Physician integration, an interdependence between physicians and health-care organizations (typically hospitals) that may involve employment, as well as shared decision making and mutual goal setting, is changing practice patterns and reimbursement patterns as hospitals increasingly assume more of the financial and liability risks for what was historically private physician practice.

Health-care costs will continue to rise, and employers will be challenged to find ways to provide affordable health-care insurance coverage to employees, including cost shifting via higher copayments and deductibles.

The International Classification of Diseases, 10th revision (ICD- 10), pricing, information technology (IT), in-patient volumes, physician relationships, and physician recruitment will increasingly become intertwined.

The rising cost of pharmaceuticals and ongoing drug shortages will continue to be a problem for US hospitals. Two hundred and fifty-five common brand drugs increased the price of their drugs between February 1 and July 15, 2018, alone. The most common increase in that window was 9% to 10% (Langreth, Koons, & Gu, 2018).

The way in which work relationships are built will need to change because the way we manage systems is changing. For example, health care continues to move toward managing populations rather than individuals. In addition, hospitals and health-care systems now must integrate long-term care and extended care into their continuum of care (Weldon, 2015).

The ongoing movement away from illness care to wellness care and the use of disease management programs will continue to reduce the demand for expensive, acute care services.

The use of complementary and alternative medicine will increase as public acceptance and demand for these services increase.

The interdependence of professionals and the need for interprofessional collaboration rather than professional autonomy will continue. Thus, the autonomy for all health-care professionals will decrease, including managers.

The shift in framework to the patient as a consumer of cost and quality information will continue. Historically, many providers assumed that consumers, both payers and patients, had minimal interest in or knowledge about the services that they received. Currently, a change in the balance of power among payers, patients, and providers has occurred, and providers are increasingly being held accountable for the quality of outcomes that their patients experience. Quality data will be increasingly public, and transparency regarding organizational effectiveness (quality and costs) will be a public expectation.

A transition from continuity of provider to continuity of information will occur. Historically, continuity of care was maintained by continuity of provider. In the future, however, the meaning and operationalizing of continuity will become predicated on having complete, accurate, and timely information that moves with the patient. For example, electronic health records (EHRs) provide such real-time, point-of-care information as well as a longitudinal medical record with full information about each patient.

Technology, which facilitates mobility and portability of relationships, interactions, and operational processes, will increasingly be a part of high-functioning organizations. EHRs and clinical decision support are examples of such technology because both impact not only what health-care data is collected but also how it is used, communicated, and stored.

Commercially purchased expert networks (communities of top thinkers, managers, and scientists) as well as electronic decision support systems will increasingly be used to improve the decision making required of health-care leaders. Such network panels are typically made up of researchers, health- care professionals, attorneys, and industry executives.

The health-care team will be characterized by highly educated, multidisciplinary experts. Although this would appear to ease the leadership challenges of managing such a team, it is far easier to build teams of experts than to build expert teams.

In addition, Huston (2020) suggests the following factors will further influence the future of health care:

Robotic technology and the use of prototype nurse robots called nursebots will serve as an adjunct to scarce human resources in the provision of health care.

Biomechatronics, which creates machines that replicate or mimic how the body works, will increase in prominence in the future. This interdisciplinary field encompasses biology, neurosciences, mechanics, electronics, and robotics to create devices that interact with human muscle, skeleton, and nervous systems to establish or restore human motor or nervous system function.

Biometrics, the science of identifying people through physical characteristics such as fingerprints, handprints, retinal scans, voice recognition, and facial structure, will be used to assure targeted and appropriate access to client records.

Health-care organizations will integrate biometrics with “smart cards” (credit card–sized devices with a chip, stored memory, and an operating system) to ensure that an individual presenting a secure ID credential really has the right to use that credential.

Point-of-care testing will improve bedside care and promote more positive outcomes because of more timely decision

making and treatment. Given declining reimbursement, the current nursing shortage,

and an increasing shift in care to outpatient settings, home care agencies will increasingly explore technology-aided options, such as telehealth, that allow them to avoid the traditional 1:1 nurse–patient ratio with face-to-face contact.

The Internet will continue to improve Americans’ health by enhancing communications and improving access to information for care providers, patients, health plan administrators, public health officials, biomedical researchers, and other health professionals. It will also change how providers interact with patients with consumers increasingly adopting the role of expert patient.

A growing elderly population, medical advances that increase the need for well-educated nurses, consumerism, the increased acuity of hospitalized patients, and a ballooning health-care system will continue to increase the demand for registered nurses (RNs).

An aging workforce, improving economy, inadequate enrollment in nursing schools to meet projected demand, increased employment of nurses in outpatient or ambulatory care settings, and inadequate long-term pay incentives will lead to new nursing shortages.

Such paradigm shifts and trends change almost constantly. Successful leader-managers stay abreast of the dynamic environments in which health care are provided so that this can be reflected in their planning. The result is proactive or visionary planning that allows health-care agencies to function successfully in the 21st century.

An example of such visionary planning was the Federal Health IT Strategic Plan 2015–2020. This plan represents the collective strategy of federal offices that use or influence the use of health IT in

the United States and sets a blueprint for federal partners to implement strategies that will support the nation’s continued development of a responsive and secure health IT and information- use infrastructure (“Federal Health IT Strategic Plan,” 2015) (Display 7.2). The first two goals of this plan prioritized increasing the electronic collection and sharing of health information while protecting individual privacy. The final three goals focused on federal efforts to create an environment where interoperable information is used by health-care providers, public health entities, researchers, and individuals to improve health and health care and reduce costs. With this plan, the federal government signals that although we will continue to work toward more widespread adoption of health IT, efforts will begin to include new sources of information and ways to disseminate knowledge quickly, securely, and efficiently.

DISPLAY 7.2 FEDERAL HEALTH IT STRATEGIC PLAN 2015–2020

The final strategic plan reflecting input from more than 400 public comments, collaboration between federal contributors, and recommendations from the Health IT Policy Committee identified the following strategic goals and objectives:

Goal 1: Expand Adoption of Health IT Objective A: Increase the adoption and effective use of health

information technology (IT) products, systems, and services. Objective B: Increase user and market confidence in the safety

and safe use of health IT products, systems, and services. Objective C: Advance a national communications infrastructure

that supports health, safety, and care delivery.

Goal 2: Advance Secure and Interoperable Health Information Objective A: Enable individuals, providers, and public health

entities to securely send, receive, find, and use electronic health information.

Objective B: Identify, prioritize, and advance technical standards to support secure and interoperable health information.

Objective C: Protect the privacy and security of health information.

Goal 3: Strengthen Health-Care Delivery Objective A: Improve health-care quality, access, and

experience through safe, timely, effective, efficient, equitable, and person-centered care.

Objective B: Support the delivery of high-value health care. Objective C: Improve clinical and community services and

population health.

Goal 4: Advance the Health and Well-Being of Individuals and Communities Objective A: Empower individual, family, and caregiver health

management and engagement. Objective B: Protect and promote public health and healthy,

resilient communities.

Goal 5: Advance Research, Scientific Knowledge, and Innovation Objective A: Increase access to and usability of high-quality

electronic health information and services. Objective B: Accelerate the development and

commercialization of innovative technologies and solutions. Objective C: Invest, disseminate, and translate research on

how health IT can improve health and care delivery.

Sources: Federal Health IT Strategic Plan 2015–2020 released. (2015). American Nurse, 47(5), 9 and Office of the National Coordinator for Health Information Technology, Office of the Secretary, U.S. Department of Health and Human Services. (2015). Federal health strategic plan 2015–2020. Retrieved August 3, 2018, from https://www.healthit.gov/sites/default/files/federal-healthIT-strategic- plan-2014.pdf

LEARNING EXERCISE 7.1

Forces Affecting Health Care

In small groups, identify six additional forces, beyond those identified in this chapter, affecting today’s health- care system. You may include legal, political, economic, social, or ethical forces. Try to prioritize these forces in

terms of how they will affect you as a manager or registered nurse. For at least one of the six forces you have identified, brainstorm how that force would affect your strategic planning as a unit manager or director of a health-care agency.

Proactive Planning Planning has a specific purpose and is one approach to developing strategy. In addition, planning represents specific activities that help achieve objectives; therefore, planning should be purposeful and proactive. Although there is always some crossover between types of planning within organizations, there is generally an orientation toward one of four planning modes: reactive planning, inactivism, preactivism, or proactive planning.

Reactive planning occurs after a problem exists. Because there is dissatisfaction with the current situation, planning efforts are directed at returning the organization to a previous, more comfortable state. Frequently, in reactive planning, problems are dealt with separately without integration with the whole organization. In addition, because it is done in response to a crisis, this type of planning can lead to hasty decisions and mistakes.

Inactivism is another type of conventional planning. Inactivists seek the status quo, and they spend their energy preventing change and maintaining conformity. When changes do occur, they occur slowly and incrementally.

A third planning mode is preactivism. Preactive planners utilize technology to accelerate change and are future oriented. Unsatisfied with the past or present, preactivists do not value experience and believe that the future is always preferable to the present.

Proactive planning is dynamic, and adaptation is considered to be a key requirement because the environment changes so frequently.

The last planning mode is interactive or proactive planning. Planners who fall into this category consider the past, present, and future and attempt to plan the future of their organization rather than react to it. Because the organizational setting changes often, adaptability is a key requirement for proactive planning. Proactive planning occurs, then, in anticipation of changing needs or to promote growth within an organization and is required of all leader- managers so that personal as well as organizational needs and objectives are met.

LEARNING EXERCISE 7.2

What Is Your Planning Style?

How would you describe your planning? Is your planning more likely to be reactive, inactive, preactive, or proactive? Write a brief essay that describes your most commonly used planning style. Use specific examples and then share your insights in a group.

One example of recent, successful organizational proactive planning was evident in pharmacy management at Houston-based hospitals during extensive flooding in 2017 from Hurricane Harvey (see Examining the Evidence 7.1). Having learned lessons from the disastrous flooding of Tropical Storm Allison in 2001, floodgates

were installed, employees who were part of designated “ride-out” teams knew to be ready to stay at their hospital until the storm passed, and the preordering of large quantities of commonly used drugs avoided shortages. As a result, despite receiving more than 30 inches of rain in a 4-day period, Memorial Hermann Health System was able to demonstrate a high degree of organization and teamwork to assure that patient needs were met.

EXAMINING THE EVIDENCE 7.1 Source: Traynor, K. (2017). Planning, teamwork made Harvey manageable for Houston hospitals. American Journal of Health-System Pharmacy, 74(21), 1752– 1753.

A Case Study of Proactive Planning Using Historical Data Flooding is an ongoing problem in Houston, Texas. Heeding lessons learned from the disastrous flooding that accompanied Tropical Storm Allison in 2001, pharmacy directors from Memorial Hermann Health System’s 16 acute care hospitals began planning almost immediately what would be done the next time such a situation emerged.

When Hurricane Harvey (and the 30 inches of rain it brought in over 4 days) hit the Texas coastline in 2017, they were ready and able to serve patients throughout the storm. Floodgates had been installed in and around the hospital campuses allowing them to stay open. Pharmacy directors had already assessed their worst-case-scenario medication needs and placed large orders with their wholesaler before the storm hit, eliminating possible drug shortages. When hospitals urgently needed critical medications that weren’t on hand, the health system used its air ambulance helicopters to ferry those items around town. In addition, pharmacy employees who were part of designated “ride-out” teams knew to be ready to stay at their hospital until

the storm passed. In addition, throughout the storm, health system leaders kept in touch with the pharmacy directors to address urgent needs and ensure that each hospital had enough medications and resources to continue caring for patients.

Because of this proactive planning, Memorial Hermann Health System announced that during the 5 days of Harvey’s disruption, the health system was still able to treat 9,624 emergency center patients, perform 748 surgeries, and deliver 564 babies. The author concludes that planning and teamwork helped these hospitals survive and even thrive during Hurricane Harvey’s disruption.

Forecasting A mistake common to novice managers is a failure to complete adequate proactive planning. Instead, many managers operate in a crisis mode and fail to use available historical patterns to assist them in planning or they fail to examine present clues and projected statistics to determine future needs. In other words, they fail to forecast. Forecasting involves trying to estimate how a condition will be in the future. Forecasting takes advantage of input from others, gives sequence in activity, and protects an organization against undesirable changes.

With changes in technology, payment structures, and resource availability, the manager who is unwilling or unable to forecast accurately impedes the organization’s efficiency and the unit’s effectiveness. Increased competition, changes in government reimbursement, and decreased hospital revenues have reduced

intuitive managerial decision making. To avoid disastrous outcomes when making future professional and financial plans, managers need to stay well informed about the legal, political, and socioeconomic factors affecting health care.

Managers who are uninformed about the legal, political, economic, and social factors affecting health care make planning errors that may have disastrous implications for their professional development and the financial viability of the organization.

Strategic Planning at the Organizational Level Planning also has many dimensions. Two of these dimensions are time span and complexity or comprehensiveness. Generally, complex organizational plans that involve a long period (usually 3 to 7 years) are referred to as long-range or strategic plans. However, strategic planning may be done once or twice a year in an organization that changes rapidly. At the unit level, any planning that is at least 6 months in the future may be considered long-range planning.

Dumaine and Useem (2018) note that external pressures often compel top-level organization leaders to focus heavily on short-term goals and expectations. Although this is important, it is equally—if not more—important to emphasize longer term objectives. Leader- managers who adopt long-term strategies eventually help their organizations become more profitable and have happier employees and shareholders.

Strategic planning at the organizational level then must consider both the short- and long-term goals and needs of the organization. In doing this, strategic planning can forecast the future success of an organization by matching and aligning an organization’s capabilities

with its external opportunities. For instance, an organization could develop a strategic plan for dealing with a nursing shortage, preparing succession managers in the organization, developing a marketing plan, redesigning workload, developing partnerships, or simply planning for organizational success.

Strategic planning typically examines an organization’s purpose, mission, philosophy, and goals in the context of its external environment.

Some experts suggest, however, that the need for increased operational efficiencies has required a reconfiguration of how strategic planning is done in most health-care organizations. Instead of focusing on the external environment and the marketplace, health- care organizations will need to look closely at their competencies and weaknesses, examine their readiness for change, and identify those factors critical to achieving future goals and objectives.

This assessment should begin with gathering data related to financial performance, human resources, strategy, and service offerings as well as outcomes and results. Feedback from senior leadership, the medical staff, and the board is then needed so that consensus can be obtained from stakeholders regarding the organization’s strengths and weaknesses. Then, an action plan can be created that strengthens the organization’s infrastructure. The assessment concludes with an evaluation of how well the organization is achieving its goals and objectives and the process begins once again.

SWOT Analysis There are many effective tools that assist organizations in strategic planning. One of the most commonly used in health-care organizations is SWOT analysis (identification of strengths,

weaknesses, opportunities, and threats) (Display 7.3). SWOT analysis, also known as TOWS analysis, was developed by Albert Humphrey at Stanford University in the 1960s and 1970s.

DISPLAY 7.3 SWOT DEFINITIONS

Strengths are those internal attributes that help an organization to achieve its objectives.

Weaknesses are those internal attributes that pose barriers to an organization achieving its objectives.

Opportunities are external conditions that promote achievement of organizational objectives.

Threats are external conditions that challenge or threaten the achievement of organizational objectives.

The first step in SWOT analysis is to define the desired end state or objective. After the desired objective is defined, the SWOTs are discovered and listed. Decision makers must then decide if the objective can be achieved in view of the SWOTs. If the decision is no, a different objective is selected and the process repeats. An example of an abbreviated SWOT process is shown in Display 7.4.

DISPLAY 7.4 EXAMPLE OF ABBREVIATED SWOT PROCESS

Desired End State or Objective: Hospital Z wishes to increase the number of nurses with baccalaureate and graduate degrees in the staffing mix.

Strengths 1. Local schools of nursing offer online baccalaureate and

master’s degrees at affordable costs for working nurses. 2. Hospital Z offers generous professional development funding

opportunities for staff. 3. This objective is in alignment with recommendations cited in

the Institute of Medicine’s report, The Future of Nursing: Leading Change, Advancing Health, that 80% of registered nurses should have baccalaureate or higher degrees by 2020.

Weaknesses 1. Recent high turnover rates have resulted in tight staffing, and

requests by nurses for reduced workloads to return to school would be difficult to honor.

2. At present, there is no role differentiation for nurses at Hospital Z based on a nurse’s educational level.

3. At present, Hospital Z does not offer a salary differential to nurses with baccalaureate or higher degrees, but another hospital in the immediate area does.

Opportunities 1. Current research evidence suggests that increasing the

number of nurses with baccalaureate or higher degrees in the staffing mix would positively impact quality of care.

2. Hospital Z could consider application for Magnet status if more nurses held higher degrees.

3. Increasing the number of nurses with baccalaureate and graduate degrees better prepares them to assume new and emerging professional roles in an increasingly complex health- care environment.

4. A review of the literature suggests that nurses with graduate degrees are more likely to report being extremely satisfied with their jobs compared with nurses who hold associate degrees.

Threats 1. Local schools of nursing have impacted enrollments, so not all

nurses who want to return to school can be accepted. 2. An impending national nursing shortage could further

exacerbate current staffing shortages. 3. Not all nurses are inherently motivated to return to school.

Performed correctly, SWOT analysis allows strategic planners to identify those issues most likely to impact a particular organization or situation in the future and then to develop an appropriate plan for action. Marketing Teacher (Friesner, 2016), however, warns that several simple rules must be followed for SWOT analysis to be successful, and these are shown in Display 7.5. In essence, they suggest that honesty, specificity, simplicity, and self-awareness are integral to successful SWOT analysis.

DISPLAY 7.5 SIMPLE RULES FOR SWOT ANALYSIS

Be realistic about the strengths and weaknesses of your organization.

Be clear about how the present organization differs from what might be possible in the future.

Be specific about what you want to accomplish. Always apply SWOT analysis in relation to your competitors. Keep SWOT analysis short and simple. Remember that SWOT analysis is subjective.

Source: Adapted from Friesner, T. (2016). SWOT analysis. Retrieved August 2, 2018, from http://www.marketingteacher.com/wordpress/swot-analysis/

Balanced Scorecard Balanced scorecard, developed by Robert Kaplan and David Norton in the early 1990s, is another tool that is highly assistive in strategic planning. Strategic planners using a balanced scorecard develop metrics (performance measurement indicators), collect data, and analyze that data from four organizational perspectives: financial, customers, internal business processes (or simply processes), and learning and growth. Because all the measures are considered to be related and because all of the measures are assumed to eventually lead to outcomes, an overemphasis on financial measures is avoided. The scorecard then is “balanced” in that outcomes are in balance.

Balanced scorecards also allow organizations to align their strategic activities with the strategic plan. The best balanced scorecards are not a static set of measurements but instead reflect the dynamic nature of the organizational environment. Because the balanced scorecard is able to translate strategy into action, it is an effective tool for translating an organization’s strategic vision into clear and realistic objectives.

Strategic Planning as a Management Process Although SWOT analysis and balanced scorecard are different, they are also similar in that they can help organizations assess what they do well and what they need to do to continue to be effective and financially sound. Many other strategic planning tools exist as well, although they are not discussed in this text. Regardless of the tool(s) used, strategic planning as a management process generally includes the following steps:

1. Clearly define the purpose of the organization. 2. Establish realistic goals and objectives consistent with the

mission of the organization. 3. Identify the organization’s external constituencies or

stakeholders and then determine their assessment of the organization’s purposes and operations.

4. Clearly communicate the goals and objectives to the organization’s constituents.

5. Develop a sense of ownership of the plan. 6. Develop strategies to achieve the goals. 7. Ensure that the most effective use is made of the organization’s

resources. 8. Provide a base from which progress can be measured. 9. Provide a mechanism for informed change as needed.

10. Build a consensus about where the organization is going.

It should be noted, though, that some critics argue that strategic planning is rarely this linear or is it static. Strategic planning instead involves various actions and reactions that are partially planned and partially unplanned. As such, strategic plans must be adaptable and flexible, so they can respond to changes in both internal and external environments.

Who Should Be Involved in Strategic Planning?

Long-range planning for health-care organizations historically was accomplished by top-level managers and the board of directors, with limited input from middle-level managers. More contemporary strategies suggest, however, the need to seek input from subordinates from all organizational levels to give the strategic plan meaning and to increase the likelihood of its successful implementation. Indeed, Beckham (2017) suggests that leaders can cascade ownership in the strategic plan by widely articulating vision and driving strategies and then expanding the number of people invited to consider how best to do that.

LEARNING EXERCISE 7.3

Making a Long-Term Plan

The human resource manager in the facility where you are a supervisor has just completed a survey of the potential retirement plans of the nursing staff and found that within 5 years, 45% of the staff will probably be retiring. You know that past and present available statistics show that you normally replace 10% to 15% of your staff each year with new hires. You are concerned as you do not know how you will be able to handle this new increase in your need for staff.

ASSIGNMENT:

Make a 5-year, long-term plan that will increase the likelihood of you being able to meet this new demand. Remember that other units within your facility and other health-care organizations in your region may also be facing the same problem.

All organizations should establish annual strategic planning conferences, involving all departments and levels of the hierarchy; this action should promote increased effectiveness of nursing staff; better communication between all levels of personnel; a cooperative spirit relative to solving problems; and a pervasive feeling that the departments are unified, goal directed, and doing their part to help the organization accomplish its mission.

Organizational Planning: The Planning Hierarchy There are many types of planning; in most organizations, these plans form a hierarchy, with the plans at the top influencing all the plans that follow. As depicted in the pyramid in Figure 7.1, the hierarchy broadens at lower levels, representing an increase in the number of planning components. In addition, planning components at the top of the hierarchy are more general, and lower components are more specific.

FIGURE 7.1 The planning hierarchy.

Vision and Mission Statements Vision statements are used to describe future goals or aims of an organization. It is a description in words that conjures up a picture for all group members of what they want to accomplish together. Prichard (2018) notes that the most consequential leaders throughout history were able to both communicate their vision skillfully and personify it. “At the summit of influence, their every action, gesture or word moves into service of their greater cause. This is at once an extraordinary accomplishment, opportunity and burden. It requires a unity of life and work, of thought and action, an overarching integrity” (para. 17). It is critical, then, that organization leaders recognize that the organization will never be greater than the vision that guides it.

An appropriate vision statement for a hospital is shown in Display 7.6.

DISPLAY 7.6 SAMPLE VISION STATEMENT

County Hospital will be the leading center for trauma care in the region.

An organization will never be greater than the vision that guides it.

The purpose or mission statement is a brief statement (typically no more than three or four sentences) identifying the reason that an organization exists. The mission statement identifies the organization’s constituency and addresses its position regarding ethics, principles, and standards of practice.

A well-written mission statement will identify what is unique about the organization. For example, all hospitals want to have high- quality, patient-centered, cost-effective care, but mission statements that include only this verbiage do not differentiate between organizations. The mission statement should clearly drive action if it is to be a template of purpose for the organization. In addition, it can be challenging to meet an ambitious mission in an era of cost cutting and limited resources; hence, the often-stated adage, “No margin, no mission.”

An example of a mission statement for County Hospital, a teaching hospital, is shown in Display 7.7.

DISPLAY 7.7 SAMPLE MISSION STATEMENT

County Hospital is a tertiary care facility that provides comprehensive, holistic care to all state residents who seek treatment. The purpose of County Hospital is to combine high- quality, evidence-based care with the provision of learning opportunities for students in medicine, nursing, and allied health sciences.

The mission statement is of highest priority in the planning hierarchy because it influences the development of an organization’s philosophy, goals, objectives, policies, procedures, and rules. Managers employed by County Hospital would have two primary goals to guide their planning: (a) to provide high-quality, evidence- based care and (b) to provide learning opportunities for students in medicine, nursing, and other allied health sciences. To meet these goals, adequate fiscal and human resources would have to be allocated for preceptorships and clinical research. In addition, an employee’s performance appraisal would examine the worker’s performance in terms of organizational and unit goals.

Mission statements then have value, only if they truly guide the organization. Indeed, actions taken at all levels of the organization should be congruent with the stated organization mission. Therefore, involving individuals from all levels of the organization in crafting mission statements is so important.

Potential employees should review the mission statement of potential employers and consider what it tells them about the organization’s stakeholders and what beliefs and values are espoused. Only then can the potential employee determine whether this is an organization they want to work for.

An organization must truly believe and act on its mission statement; otherwise, the statement has no value.

LEARNING EXERCISE 7.4

No Margin, No Mission? (Marquis & Huston, 2012)

You are a nurse team leader in Jamestown Hospital, an acute care, for-profit hospital. The mission statement for Jamestown Hospital states that the hospital has two primary purposes: (a) to provide the highest possible quality of care for its clients and (b) to maximize the efficiency and cost-effectiveness of resource utilization in recognition of its obligation to internal and external stakeholders.

Recently, you have become increasingly concerned regarding what you perceive to be the economically motivated, premature discharge of patients with chronic diseases. You know that some diabetic or asthmatic patients yield little, if any, profit for the organization. You are well acquainted with the discharge planner on the unit, and both of you have discussed your concerns with each other, but neither of you have taken any action.

ASSIGNMENT:

Do you feel the dual goal mission statement is in conflict? As a registered nurse, do you feel you can influence the discharge process? How do you plan on handling the conflict you are beginning to feel regarding these early discharges? What alternatives are available to you in deciding what, if anything, to do?

Organizational Philosophy The philosophy flows from the purpose or mission statement and delineates the set of values and beliefs that guide all actions of the organization. It is the foundation that directs all further planning toward that mission. A statement of philosophy can usually be found in policy manuals at the institution or is available upon request. A philosophy that might be generated from County Hospital’s mission statement is shown in Display 7.8.

DISPLAY 7.8 SAMPLE PHILOSOPHY STATEMENT

The board of directors, medical and nursing staff, and administrators of County Hospital believe that human beings are unique due to different genetic endowments; personal experiences in social and physical environments; and the ability to adapt to biophysical, psychosocial, and spiritual stressors. Thus, each patient is considered a unique individual with unique needs. Identifying outcomes and goals, setting priorities, prescribing strategy options, and selecting an optimal evidence-based strategy for care will be negotiated by the patient, physician, and health-care team.

As unique individuals, patients provide medical, nursing, and allied health students invaluable diverse learning opportunities. Because the board of directors, medical and nursing staff, and administrators believe that the quality of health care provided directly reflects the quality of the education of its future health- care providers, students are welcomed and encouraged to seek out as many learning opportunities as possible. Because high- quality health care is defined by and depends on technological advances and scientific discovery, County Hospital encourages research as a means of scientific inquiry.

The organizational philosophy provides the basis for developing nursing philosophies at the unit level and for nursing service as a whole. Written in conjunction with the organizational philosophy, the nursing service philosophy should address fundamental beliefs about nursing and nursing care; the quality, quantity, and scope of nursing services; and how nursing specifically will meet organizational goals. Frequently, the nursing service philosophy draws on the concepts of holistic care, education, and research. The nursing service philosophy in Display 7.9 builds on County Hospital’s mission statement and organizational philosophy.

DISPLAY 7.9 SAMPLE NURSING SERVICE PHILOSOPHY

The philosophy of nursing at County Hospital is based on respect for the individual’s dignity and worth. We believe that all patients have the right to receive effective, evidence-based nursing care. This care is a personal service that is based on patients’ needs and their clinical diseases or conditions.

Recognizing the obligation of nursing to help restore patients to the best possible state of physical, mental, and emotional health and to maintain patients’ sense of spiritual and social well-being, we pledge intelligent cooperation in coordinating nursing service with the medical and allied professional practitioners. Understanding the importance of research and teaching for improving patient care, the nursing department will support, promote, and participate in these activities. Using knowledge of human behavior, we shall strive for mutual trust and understanding between nursing service and nursing employees to provide an atmosphere for developing the fullest possible potential of each member of the nursing team. We believe that nursing personnel are individually accountable to patients and their families for the quality and compassion of the patient care rendered and for upholding the standards of care as delineated by the nursing staff.

The unit philosophy, adapted from the nursing service philosophy, specifies how nursing care provided on the unit will correspond with nursing service and organizational goals. This congruence in philosophy, goals, and objectives among the organization, nursing service, and unit is shown in Figure 7.2.

FIGURE 7.2 Philosophical congruence in the planning hierarchy.

Although unit-level managers have limited opportunity to help develop the organizational philosophy, they are active in determining, implementing, and evaluating the unit philosophy. In formulating this philosophy, the unit manager incorporates knowledge of the unit’s internal and external environments and an understanding of the unit’s role in meeting organizational goals. The manager must understand the planning hierarchy and be able to articulate ideas both verbally and in writing. Leader-managers also must be visionary, innovative, and creative in identifying unit

purposes or goals so that the philosophy not only reflects current practice but also incorporates a view of the future.

Like the mission statement, statements of philosophy in general can be helpful only if they truly direct the work of the organization toward a specific purpose. A department’s decisions, priorities, and accomplishments reflect its working philosophy.

A working philosophy is evident in a department’s decisions, in its priorities, and in its accomplishments.

A person should be able to identify exactly how the organization is implementing its stated philosophy by observing members of the staff, reviewing the budgetary priorities, and talking to consumers of health care. The decisions made in an organization make the philosophy visible to all—no matter what is espoused on paper. A philosophy that is not or cannot be implemented is useless.

LEARNING EXERCISE 7.5

Developing a Philosophy Statement

Recover Inc., a fictitious for-profit home health agency, provides complete nursing and supportive services for in- home care. Services include skilled nursing, bathing, shopping, physical therapy, occupational therapy, meal preparation, housekeeping, speech therapy, and social work. The agency provides around-the-clock care, 7 days a week, to a primarily underserved rural area in Northern California. The brochure the company publishes says that

it is committed to satisfying the needs of the rural community and that it is dedicated to excellence.

ASSIGNMENT:

Based on this limited information, develop a brief philosophy statement that might be appropriate for Recover Inc. Be creative and embellish information if appropriate.

Societal Philosophies and Values Related to Health Care Societies and organizations have philosophies or sets of beliefs that guide their behavior. These beliefs that guide behavior are called values. Values have an intrinsic worth for a society or an individual. Some strongly held American values are individualism, capitalism, and competition. These values profoundly affected health-care policy formation and implementation with the result being a US health-care system that historically promoted structured inequalities. Passage of the Affordable Care Act in 2010 reduced the number of uninsured in the United States and made care more accessible and affordable for many Americans, but numerous health-care disparities still exist. Despite the highest spending as a percentage of gross domestic product, American consumers continue to experience less than desired outcomes.

Although values seem to be of central importance for health-care policy development and analysis, public discussion of this crucial variable is often neglected. Instead, health-care policy makers tend to focus on technology, cost–benefit analysis, and cost- effectiveness. Although this type of evaluation is important, it does

not address the underlying values in the United States that have led to unequal access to health care.

Individual Philosophies and Values As discussed in Chapter 1, values have a tremendous impact on the decisions that people make. For the individual, personal beliefs and values are shaped by that person’s experiences. All people should carefully examine their value system and recognize the role that it plays in how they make decisions and resolve conflicts and even how they perceive things. Therefore, the leader-manager must be self-aware and provide subordinates with learning opportunities or experiences that foster increased self-awareness.

At times, it is difficult to assess whether something is a true value. McNally’s (1980) classic work identified the following four characteristics that determine a true value:

1. It must be freely chosen from among alternatives only after due reflection.

2. It must be prized and cherished. 3. It is consciously and consistently repeated (part of a pattern). 4. It is positively affirmed and enacted.

If a value does not meet all four criteria, it is a value indicator. Most people have many value indicators but few true values. For example, many nurses assert that they value their national nursing organization; yet, they do not pay dues or participate in the organization. True values require that the person take action, whereas value indicators do not. Thus, the value ascribed to the national nursing organization is a value indicator for these nurses and not a true value.

In addition, because our values change with time, periodic clarification is necessary to determine how our values may have changed. Values clarification includes examining values, assigning

priorities to those values, and determining how they influence behavior so that one’s lifestyle is consistent with prioritized values. Sometimes, values change as a result of life experiences or newly acquired knowledge. Most of the values we have as children reflect our parents’ values. Later, our values are modified by peers and role models. Although they are learned, values cannot be forced on a person because they must be internalized. However, restricted exposure to other viewpoints also limits the number of value choices a person is able to generate. Therefore, becoming more worldly increases our awareness of alternatives from which we select our values.

LEARNING EXERCISE 7.6

Reflecting on Your Values

Using what you have learned about values, value indicators, and value clarifications, answer the following questions. Take time to reflect on your values before answering. This may be used as a writing exercise.

1. List three or four of your basic beliefs about nursing. 2. Knowing what you know now, ask yourself, “Do I value

nursing? Was it freely chosen from among alternatives after appropriate reflection? Do I prize and cherish nursing? If I had a choice to do it over, would I still choose nursing as a career?”

3. Are your personal and professional values congruent? Are there any values espoused by the nursing profession that are inconsistent with your personal values? How will you resolve resultant conflicts?

Elliot and Corey (2018) suggest that leaders need to be role models for the values of the organizations they work in. They need to take every opportunity to communicate and apply the organization’s values, incorporating them to guide and help make better decisions.

Occasionally, however, individual values conflict with those of the organization. Because the philosophy of an organization determines its priorities in goal selection and distribution of resources, nurses need to understand the organization’s philosophy. For example, assume that a nurse is employed by County Hospital, which clearly states in its philosophy that teaching is a primary purpose for the hospital’s existence. Consequently, medical students are allowed to practice endotracheal intubation on all people who die in the hospital, allowing the students to gain needed experience in emergency medicine. This practice disturbs the nurse a great deal; it is not consistent with his or her own set of values and thus creates great personal conflict.

Nurses who frequently make decisions that conflict with their personal values may experience confusion and anxiety. This intrapersonal struggle ultimately will lead to job stress and dissatisfaction, especially for the novice nurse who comes to the organization with inadequate values clarification. The choices that nurses make about client care are not merely strategic options; they are moral choices. Internal conflict and burnout may result when personal and organizational values do not mesh.

When a nurse experiences cognitive dissonance between personal and organizational values, the result may be intrapersonal conflict and burnout.

As part of the leadership role, the manager should encourage all potential employees to read and think about the organization’s

mission statement or philosophy before accepting the job. The manager should give a copy of the philosophy to the prospective applicant before the hiring interview. The applicant also should be encouraged to speak to employees in various positions within the organization regarding how the philosophy is implemented at their job level. For example, a potential employee may want to determine how the organization feels about cultural diversity and what policies they have in place to ensure that patients from diverse cultures and languages have a mechanism for translation as needed. Finally, new employees should be encouraged to speak to community members about the institution’s reputation for care. New employees who understand the organizational philosophy will not only have clearer expectations about the institution’s purposes and goals but also have a better understanding of how they fit into the organization.

Although all nurses should have a philosophy comparable with that of their employer, it is especially important for the new manager to have a value system consistent with that of the organization. Institutional changes that closely align with the value system of the nurse-manager will receive more effort and higher priority than those that are not true values or that conflict with the nurse-manager’s value system. Managers who take a position with the idea that they can change the organization’s philosophy to more closely agree with their own philosophy are likely to be disappointed.

It is unrealistic for managers to accept a position under the assumption that they can change the organization’s philosophy to more closely match their personal philosophy.

Such a change will require extraordinary energy and precipitate inevitable conflict because the organization’s philosophy reflects the institution’s historical development and the beliefs of those people

who were vital in the institution’s development. Nursing managers must recognize that closely held values may be challenged by current social and economic constraints and that philosophy statements must be continually reviewed and revised to ensure ongoing accuracy of beliefs.

Goals and Objectives Goals and objectives are the ends toward which the organization is working. All philosophies must be translated into specific goals and objectives if they are to result in action. Thus, goals and objectives “operationalize” the philosophy.

A goal may be defined as the desired result toward which effort is directed; it is the aim of the philosophy. Although institutional goals are usually determined by the organization’s highest administrative levels, there is increasing emphasis on including workers in setting organizational goals. Goals, much like philosophies and values, change with time and require periodic reevaluation and prioritization.

Goals, although somewhat global in nature, should be measurable and ambitious but realistic. Goals also should clearly delineate the desired end product. When goals are not clear, simple misunderstandings may compound, and communication may break down. Organizations usually set long- and short-term goals for services rendered; economics; use of resources, including people, funds, and facilities; innovations; and social responsibilities. Display 7.10 lists sample goal statements.

DISPLAY 7.10 SAMPLE GOAL STATEMENTS

All nursing staff will recognize the patient’s need for independence and right to privacy and will assess the patient’s level of readiness to learn in relation to his or her illness.

The nursing staff will provide effective patient care relative to patient needs insofar as the hospital and community facilities permit through the use of care plans, individual patient care, and discharge planning, including follow-up contact.

An ongoing effort will be made to create an atmosphere that is conducive to favorable patient and employee morale and that fosters personal growth.

The performance of all employees in the nursing department will be evaluated in a manner that produces growth in the employee and upgrades nursing standards.

All nursing units within County Hospital will work cooperatively with other departments within the hospital to further the mission, philosophy, and goals of the institution.

Although goals may direct and maintain the behavior of an organization, there are several dangers in using goal evaluation as the primary means of assessing organizational effectiveness. The first danger is that goals may conflict with each other, creating confusion for employees and consumers. For example, the need for profit maximization in health-care facilities today may conflict with some stated patient goals or quality goals. The second danger with the goal approach is that publicly stated goals may not truly reflect organizational goals. In addition, some organizational goals may be developed simply as a conduit for individual or personal goals. The final danger is that because goals are global, it is often difficult to determine whether they have been obtained.

Objectives are like goals in that they motivate people to a specific end and are explicit, measurable, observable or retrievable, and obtainable. Objectives, however, are more specific and measurable than goals because they identify how and when the goal is to be accomplished.

Goals usually have multiple objectives that are each accompanied by a targeted completion date. The more specific the objectives for a goal can be, the easier for all involved in goal attainment to understand and carry out specific role behaviors. This is especially important for the nurse-manager to remember when writing job descriptions; if there is little ambiguity in the job description, there will be little role confusion or distortion. Clearly written goals and objectives must be communicated to all those in the organization responsible for their attainment. This is a critical leadership role for the nurse-manager.

Objectives can focus on either the desired process or the desired result. Process objectives are written in terms of the method to be used, whereas result-focused objectives specify the desired outcome. An example of a process objective might be “100% of staff nurses will orient new patients to the call-light system, within 30 minutes of their admission, by first demonstrating its appropriate use and then asking the patient to repeat said demonstration.” An example of a result-focused objective might be “95% postoperative patients will perceive a decrease in their pain levels following the administration of parenteral pain medication.” Writing good objectives requires time and practice.

For the objectives to be measurable, they should have certain criteria. There should be a specific time frame in which the objectives are to be completed, and the objectives should be stated in behavioral terms, be objectively evaluated, and identify positive outcomes rather than negative outcomes.

As a sample objective, one of the goals at Mercy Hospital is that “all RNs will be proficient in the administration of intravenous fluids.”

Objectives for Mercy Hospital might include the following:

All RNs will complete Mercy Hospital’s course “IV Therapy Certification” within 1 month of beginning employment. The hospital will bear the cost of this program.

RNs who score less than 90% on a comprehensive examination in “IV Therapy Certification” must attend the remedial 4-hour course “Review of Basic IV Principles” not more than 2 weeks after the completion of “IV Therapy Certification.”

RNs who achieve a score of 90% or better on the comprehensive examination for “IV Therapy Certification” after completing “Review of Basic IV Principles” will be allowed to perform IV therapy on patients. The unit manager will establish individualized plans of remediation for employees who fail to achieve this score on the examination.

The leader-manager clearly must be skilled in determining and documenting goals and objectives. Prudent managers assess the unit’s constraints and assets and determine available resources before developing goals and objectives. The leader must then be creative and futuristic in identifying how goals might best be translated into objectives and thus implemented. The willingness to be receptive to new and varied ideas is a critical leadership skill. In addition, well-developed interpersonal skills allow the leader to involve and inspire subordinates in goal setting. The final step in the process involves clearly writing the identified goals and objectives, communicating changes to subordinates, and periodically evaluating and revising goals and objectives as needed.

LEARNING EXERCISE 7.7

Writing Goals and Objectives

ASSIGNMENT:

Practice writing goals and objectives for County Hospital based on the mission and philosophy statements in this chapter. Identify three goals and three objectives to operationalize each of these goals.

Policies and Procedures Policies are plans reduced to statements or instructions that direct organizations in their decision making. These comprehensive statements, derived from the organization’s philosophy, goals, and objectives, explain how goals will be met and guide the general course and scope of organizational activities. Thus, policies direct individual behavior toward the organization’s mission and define broad limits and desired outcomes of commonly recurring situations while leaving some discretion and initiative to those who must carry out that policy. Although some policies are required by accrediting agencies, many policies are specific to the individual institution, thus providing management with a means of internal control.

Policies also can be implied or expressed. Implied policies, neither written nor expressed verbally, have usually developed over time and follow a precedent. For example, a hospital may have an implied policy that employees should be encouraged and supported in their activity in community, regional, and national health-care organizations. Another example might be that nurses who limit their maternity leave to 3 months can return to their former jobs and shifts with no status change.

Expressed policies are delineated verbally or in writing. Most organizations have many written policies that are readily available to all people and promote consistency of action. Expressed policies

may include a formal dress code, policy for sick leave or vacation time, and disciplinary procedures.

All organizations need to develop facility-wide policies and procedures to guide workers in their actions. These policies and procedures are ideally developed with input from all levels of the organization. Unfortunately, in many health-care organizations, this function falls to isolated policy and procedure committees. Involving more individuals in the process, as in a shared governance approach, should increase the quality of the end product and the likelihood that procedures will be implemented as desired.

Although top-level management is more involved in setting organizational policies (usually by policy committees), unit managers must determine how those policies will be implemented on their units. Input from subordinates in forming, implementing, and reviewing policy allows the leader-manager to develop guidelines that all employees will support and follow. Even if unit-level employees are not directly involved in policy setting, their feedback is crucial to its successful implementation. Having uniform policies and procedures developed through collaboration is critical.

In addition, policies and procedures should be evidence based. The addition of evidence to policies and procedures, however, requires the development of a process that ensures consistency, rigor, and safe nursing practice. Unfortunately, many policies continue to be driven by tradition or regulatory requirements and inadequate evidence exists to guide best practices in policy development.

After policy has been formulated, the leadership role of managers includes the responsibility for communicating that policy to all who may be affected by it. This information should be transmitted in writing and verbally. A policy’s perceived value often depends on how it is communicated.

Procedures are plans that establish customary or acceptable ways of accomplishing a specific task and delineate a sequence of steps

of required action. Established procedures save staff time, facilitate delegation, reduce cost, increase productivity, and provide a means of control. Procedures identify the process or steps needed to implement a policy and are generally found in manuals at the unit level of the organization.

The manager also has a responsibility to review and revise policies and procedure statements to ensure currency and applicability. Given the current explosion of evidence-based research as well as new regulations, technology, and drugs, keeping policies and procedures current and relevant is a tremendous management challenge. In addition, because most units are in constant flux, the needs of the unit and the most appropriate means of meeting those needs constantly change. For example, the unit manager is responsible for seeing that a clearly written policy regarding holiday and vacation time exists and that it is communicated to all those it affects. The unit manager must also provide a clearly written procedural statement regarding how to request vacation or holiday time on that specific unit. The unit manager would assess any long- term change in patient census or availability of human resources and revise the policy and procedural statements accordingly.

Because procedural instructions involve elements of organizing, some textbooks place the development of procedures in the organizing phase of the management process. Regardless of where procedural development is formulated, there must be a close relationship with planning—the foundation for all procedures.

Rules Rules and regulations are plans that define specific action or nonaction. Generally included as part of policy and procedure statements, rules describe situations that allow only one choice of action. Rules are fairly inflexible, so the fewer rules, the better. Existing rules, however, should be enforced to keep morale from

breaking down and to allow organizational structure. Chapter 25, on discipline, includes a more detailed discussion of rules and regulations.

Overcoming Barriers to Planning Benefits of effective planning include timely accomplishment of higher quality work and the best possible use of capital and human resources. Because planning is essential, managers must be able to overcome barriers that impede planning. For successful organizational planning, the manager must remember several points:

The organization can be more effective if movement within it is directed at specified goals and objectives. Unfortunately, the novice manager frequently omits establishing a goal or objective. Setting a goal for a plan keeps managers focused on the bigger picture and saves them from getting lost in the minute details of planning. Just as the nursing care plan establishes patient care goals before delineating problems and interventions, managers must establish goals for their planning strategies that are congruent with goals established at higher levels.

Because a plan is a guide to reach a goal, it must be flexible and allow for readjustment as unexpected events occur. This flexibility is a necessary attribute for the manager in all planning phases and the management process.

The manager should include in the planning process all people and units that could be affected by a plan. Although time consuming, employee involvement in how things are done and by whom increases commitment to goal achievement. Although not everyone will want to contribute to unit or organizational planning, all should be invited. The manager also needs to communicate clearly the goals and specific individual

responsibilities to all those responsible for carrying out the plans so that work is coordinated.

Plans should be specific, simple, and realistic. A vague plan is impossible to implement. A plan that is too global or unrealistic discourages rather than motivates employees. If a plan is unclear, the nurse-leader must restate the plan in another manner or use group process to clarify common goals.

Know when to plan and when not to plan. Some people devote excessive time to arranging details that might be better left to those who will carry out the plan. Other times, managers erroneously assume that people and events will naturally fall into some desired and efficient method of production.

Good plans have built-in evaluation checkpoints so that there can be a midcourse correction if unexpected events occur. A final evaluation should always occur at the end of the plan. If goals were not met, the plan should be examined to determine why it failed. This evaluation process assists the manager in future planning.

Integrating Leadership Roles and Management Functions in Planning Planning requires managerial expertise in health-care economics, human resource management, political and legislative issues affecting health care, and planning theory. Planning also requires the leadership skills of being sensitive to the environment, being able to appraise accurately the social and political climate, and being willing to take risks.

Clearly, the leader-manager must be skilled in determining, implementing, documenting, and evaluating all types of planning in the hierarchy because an organization’s leaders are integral to realizing the mission of the organization. Managers then must draw on the philosophy and goals established at the organizational and

nursing service levels in implementing planning at the unit level. Initially, managers must assess the unit’s constraints and assets and determine its resources available for planning. The manager then draws on his or her leadership skills in creativity, innovation, and futuristic thinking to problem solve how philosophies can be translated into goals, goals into objectives, and so on down the planning hierarchy. The wise manager will develop the interpersonal leadership skills needed to inspire and involve subordinates in this planning hierarchy. The manager also must demonstrate the leadership skill of being receptive to new and varied ideas.

The final step in the process involves articulating identified goals and objectives clearly; this learned management skill is critical to the success of the planning. If the unit manager lacks management or leadership skills, the planning hierarchy fails.

Key Concepts

■ The planning phase of the management process is critical and precedes all other functions.

■ Planning is a proactive function required of all nurses. ■ A plan is a guide for action in reaching a goal and must be

flexible. ■ Plans should be specific, simple, and realistic. ■ All planning must include an evaluation step and requires

periodic reevaluation and prioritization. ■ All people and organizational units affected by a plan should

be included in the planning. ■ Plans must have a time for evaluation built into them so that

there can be a midcourse correction if necessary. ■ New paradigms and trends emerge continuously, requiring

leader-managers to be observant and proactive in

organizational strategic planning. ■ Because of rapidly changing technology, increasing

government regulatory involvement in health care, changing population demographics, and reducing provider autonomy, health-care organizations are finding it increasingly difficult to appropriately identify long-term needs and plan accordingly.

■ Organizations and planners tend to use one of the four planning modes: reactive, inactivism, preactivism, or proactive. A proactive planning style is always the goal.

■ Strategic planning tools such as SWOT analysis and balanced scorecard help planners to identify those issues most likely to impact a particular organization or situation in the future and then to develop an appropriate plan for action.

■ All planning in the organizational hierarchy must flow from and be congruent with planning done at higher levels in the hierarchy.

■ Planning in the organizational hierarchy typically includes the development of organizational vision and mission statements, philosophies, goals, objectives, policies, procedures, and rules.

■ An organizational philosophy that is not or cannot be implemented is useless.

■ To avoid ongoing intrapersonal values conflicts, employees should have a philosophy compatible with that of their employer.

■ Policies and procedures should be evidence based. ■ Rules are fairly inflexible, so the fewer rules, the better.

Existing rules, however, should be enforced to keep morale from breaking down and to provide organizational structure.

Additional Learning Exercises and Applications

LEARNING EXERCISE 7.8

Exploring the Impact of Philosophy on Management Action

Susan is the supervisor of the 22-bed oncology unit at Memorial Hospital, a 150-bed hospital. Unit morale and job satisfaction are high, despite a unit occupancy rate of less than 50% in the last 6 months. Patient satisfaction on this unit is as high as or higher than that of any other unit in the hospital.

Susan’s personal philosophy is that oncology patients have physical, social, and spiritual needs that are different from other patients. Both the unit and nursing service philosophy reflect this belief. Thus, nurses working in the oncology unit receive additional education, orientation, and socialization regarding their unique roles and responsibilities in working with oncology patients.

At this morning’s regularly scheduled department head meeting, the chief nursing officer suggests that because of extreme budget shortfalls and continuing low census, the oncology unit should be closed, and its patients merged with the general medical–surgical patient population. The oncology nursing staff would be reassigned to the medical–surgical unit, with Susan as the unit’s cosupervisor.

The idea receives immediate support from the medical–surgical supervisor because of the current staffing shortage on her unit. Susan, startled by the proposal, immediately voices her disapproval and asks

for 2 weeks to prepare her argument. Her request is granted.

ASSIGNMENT:

What values or beliefs are guiding Susan, the chief nursing officer, and the medical–surgical unit supervisor? Determine an appropriate plan of action for Susan. What impact does a unit or nursing service philosophy have on the actions of management and employees?

LEARNING EXERCISE 7.9

Incremental Goal Setting

Assume that your career goal is to become a nurse- lawyer. You are currently a registered nurse in an acute care facility in a large, metropolitan city. You have your Bachelor of Science in Nursing degree but will need to take at least 12 units of prerequisite classes for acceptance into law school. A law school within commuting distance of your home offers evening classes that would allow you to continue your current day job at least part-time. Quitting your job entirely would be financially unfeasible.

ASSIGNMENT:

Identify at least four objectives that you need to set to achieve your career goal. Be sure that these objectives are explicit, measurable, observable or retrievable, and obtainable. Then identify at least three actions for each objective that delineate how you will achieve them.

LEARNING EXERCISE 7.10

Current Events and Planning

You are a manager in a public health agency. In reading the morning paper before going to work today, you peruse an article about the influx of Hispanic families in your county. This population has increased 10% in the last year alone, and is expected to continue to rise. You

ponder how this will affect your client population and your agency.

You decide to gather your staff together and develop a strategic plan for dealing with the problems and opportunities that this change in client demographics presents.

ASSIGNMENT:

In examining the 10 steps listed in development of strategic plans, what are the things that you can personally influence, and what other individuals in the organization should be involved with the strategic plan? Make a list of 10 to 12 strategies that will assist you in planning for this new client population. What other information or data will you need to help you plan? What are some other future developments in your county that could have a positive or negative influence on your plan?

R E F E R E N C E S Beckham, D. (2017). A strategic plan: Getting results. H&HN:

Hospitals & Health Networks, 91(12), 28–31. Dumaine, B., & Useem, M. (2018). Why leaders should focus on

long-term growth. Retrieved August 8, 2018, from http://knowledge.wharton.upenn.edu/article/why-leaders-should- focus-on-long-term-growth/

Elliott, G., & Corey, D. (2018). 10 Traits of great leaders in this new world of work. Retrieved August 8, 2018, from http://www.greatleadershipbydan.com/2018/08/10-traits-of-great- leaders-in-this-new.html

Federal Health IT Strategic Plan 2015–2020 released. (2015). American Nurse, 47(5), 9.

Friesner, T. (2016). SWOT analysis. Retrieved August 2, 2018, from http://www.marketingteacher.com/wordpress/swot-analysis/

Huston, C. J. (2020). Technology in health care: Opportunities, limitations, and challenges. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., 269– 286). Philadelphia, PA: Wolters Kluwer.

Langreth, R., Koons, C., & Gu, J. (2018). After raising prices for 100s of drugs, industry pledges restraint. Retrieved September 6, 2018, from https://www.bloomberg.com/graphics/2018-drug- price-index/

Marquis, B., & Huston, C. (2012). Leadership and management tools for the new nurse. Philadelphia, PA: Lippincott Williams & Wilkins.

McNally, M. (1980). As individual experience broadens, realistic value systems must be flexible enough to grow: Part 1. Supervisor Nurse, 11, 27–30.

Prichard, S. (2018). Who are you serving? Retrieved August 8, 2018, from https://www.skipprichard.com/who-are-you-serving/

Weldon, D. (2015). Recruiters target new skill sets as healthcare chief financial officer role changes. Retrieved August 3, 2018, from https://www.healthcarefinancenews.com/news/recruiters- target-new-skill-sets-healthcare-chief-financial-officer-role- changes

8

Planned Change . . . The nature of leadership is resistance and change. —Scott Mabry

. . . I can’t understand why people are frightened of new ideas. I’m frightened of old ones.—John Cage

. . . If you want to make enemies, try to change something.—Woodrow Wilson

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential III: Scholarship for evidence-based practice BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

MSN Essential II: Organizational and systems leadership MSN Essential IV: Translating and integrating scholarship into practice

MSN Essential VII: Interprofessional collaboration for improving patient and population health outcomes

MSN Essential IX: Master’s level nursing practice AONL Nurse Executive Competency I: Communication and relationship building

AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency III: Leadership AONL Nurse Executive Competency V: Business skills ANA Standard of Professional Performance 9: Communication

ANA Standard of Professional Performance 10: Collaboration

ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 13: Evidence- based practice and research

ANA Standard of Professional Performance 14: Quality of practice

ANA Standard of Professional Performance 16: Resource utilization

QSEN Competency: Teamwork and collaboration

LEARNING OBJECTIVES

The learner will:

differentiate between planned change and change by drift identify the responsibilities of a change agent develop strategies for unfreezing, movement, and refreezing assess driving and restraining forces for change in given situations

apply rational–empirical, normative–reeducative, and power– coercive strategies for effecting change

describe resistance as a natural and expected response to change

identify and implement strategies to manage resistance to change

involve all those who may be affected by a change in planning for that change whenever possible

identify characteristics of aged organizations as well as strategies to keep them ever-renewing

identify critical features of complex adaptive systems change theory

describe the impact of chaos and the butterfly effect on both short- and long-term planning

plan at least one desired personal change

Introduction Larson (2015) notes that effectively dealing with rapid change while leading ever more complex organizations was identified as a top challenge and critical leadership competency in her interview of more than 50 leaders. These leaders also suggested the need for leaders to develop strategic thinking skills. Larson suggests the two go hand in hand and that strategy is nothing more or less than “planned change” (Larson, 2015, para. 1).

Some of the forces driving change in contemporary health care include rising health-care costs, declining reimbursement, new quality imperatives, workforce shortages, emerging technologies, the dynamic nature of knowledge, and a growing elderly population. Contemporary health-care agencies then must continually institute change to upgrade their structure, promote greater quality, and keep their workers. In fact, most health-care organizations find themselves undergoing continual change directed at organizational restructuring, quality improvement, and employee retention.

In most cases, these changes are planned. Planned change, in contrast to accidental change or change by drift, results from a well- thought-out and deliberate effort to make something happen. Planned change is the deliberate application of knowledge and skills

to bring about a change. Successful leader-managers must be well grounded in change theories and be able to apply such theories appropriately.

Most business leaders today would agree on two things: (a) Organizational change is constant, and (b) leading change is one of the most difficult burdens of a leader’s command (Gleeson, 2018).

Many change attempts fail because the approach used to implement the change lacks structure or planning. Indeed, what often differentiates a successful change effort from an unsuccessful one is the ability of the change agent—a person skilled in the theory and implementation of planned change—to deal appropriately with conflicted human emotions and to connect and balance all aspects of the organization that will be affected by that change. In organizational planned change, the manager is often the change agent.

In some large organizations today, however, multidisciplinary teams of individuals, representing all key stakeholders in the organization, are assigned the responsibility for managing the change process. In such organizations, this team manages the communication between the people leading the change effort and those who are expected to implement the new strategies. In addition, this team manages the organizational context in which change occurs and the emotional connections essential for any transformation.

But having a skilled change agent alone is not enough. Change is never easy, and regardless of the type of change, all major change brings feelings of achievement and pride as well as loss and stress. The leader then must use developmental, political, and relational expertise to ensure that needed change is not sabotaged.

In addition, many good ideas are never realized because of poor timing or a lack of power on the part of the change agent. For example, both organizations and individuals tend to reject outsiders as change agents because they are perceived as having inadequate knowledge or expertise about the current status and their motives often are not trusted. Therefore, there is more widespread resistance if the change agent is an outsider. The outside change agent, however, tends to be more objective in his or her assessment, whereas the inside change agent is often influenced by a personal bias regarding how the organization functions.

Likewise, some greatly needed changes are never implemented because the change agent lacks sensitivity to timing. If the organization or the people within that organization have recently undergone a great deal of change or stress (change fatigue), any other change should wait until group resistance decreases.

For effective change to occur, the change agent needs to have made a thorough and accurate assessment of the extent of and interest in change, the nature and depth of motivation, and the environment in which the change will occur. In addition, because human beings have little control over many changes in their lives, the change agent must remember that people need a balance between stability and change in the workplace. Change for change’s sake subjects employees to unnecessary stress and manipulation.

Change should be implemented only for good reasons.

Initiating and coordinating change then requires well-developed leadership and management skills. Leading organizational change always starts with a bit of mindset transformation because time, budget, and resources must typically be pulled from one important area to invest in another (Gleeson, 2018). It also requires vision and expert planning skills because a vision is not the same as a plan.

The failure to reassess goals proactively and to initiate these changes results in misdirected and poorly used fiscal and human resources. Leader-managers must be visionary in identifying where change is needed in the organization, and they must be flexible in adapting to change they directly initiated as well as change that has indirectly affected them. Display 8.1 delineates selected leadership roles and management functions necessary for leader-managers acting either in the change agent role or as a coordinator of the planned change team.

DISPLAY 8.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN PLANNED CHANGE

Leadership Roles 1. Is visionary in identifying areas of needed change in the

organization and the health-care system 2. Demonstrates risk taking in assuming the role of change

agent 3. Demonstrates flexibility in goal setting in a rapidly changing

health-care system 4. Anticipates, recognizes, and creatively problem solves

resistance to change 5. Serves as a role model to followers during planned change by

viewing change as a challenge and opportunity for growth 6. Is a role model for high-level interpersonal communication

skills in providing support for followers undergoing rapid or difficult change

7. Demonstrates creativity in identifying alternatives to problems 8. Demonstrates sensitivity to timing in proposing planned

change 9. Takes steps to prevent aging in the organization and to keep

current with the new realities of nursing practice 10. Supports and reinforces the individual adaptive efforts of

those affected by change

Management Functions 1. Forecasts unit needs with an understanding of the

organization’s and unit’s legal, political, economic, social, and legislative climate

2. Recognizes the need for planned change and identifies the options and resources available to implement that change

3. Appropriately assesses and responds to the driving and restraining forces when planning for change

4. Identifies and implements appropriate strategies to minimize or overcome resistance to change

5. Seeks subordinates’ input in planned change and provides them with adequate information during the change process to give them some feeling of control

6. Supports and reinforces the individual efforts of subordinates during the change process

7. Identifies and uses appropriate change strategies to modify the behavior of subordinates as needed

8. Periodically assesses the unit/department for signs of organizational aging and plans renewal strategies

9. Continues to be actively involved in the refreezing process until the change becomes part of the new status quo

Lewin’s Change Theory of Unfreezing, Movement, and Refreezing Most of the current research on change builds on the classic change theories developed by Kurt Lewin in the mid-20th century. Lewin (1951) identified three phases through which the change agent must proceed before a planned change becomes part of the system: unfreezing, movement, and refreezing.

Unfreezing Unfreezing occurs when the change agent convinces members of the group to change or when guilt, anxiety, or concern can be elicited. Thus, people become discontent and aware of a need to change. Zenger and Folkman (2015) note that one of Newton’s laws of thermodynamics is that a body at rest tends to stay at rest: “Slowing down, stopping, and staying at rest does not require effort. It happens very naturally. Many change efforts are not successful

because they become one of a hundred priorities” (para. 16). To make a change effort successful, the leader must clear away the competing priorities and shine a spotlight on the need for a change to happen.

Rockwell (2015) suggests, however, that sometimes people are afraid of discontent (unfreezing) and thus put significant energy into simply comforting those experiencing stress related to possible change. This simply prolongs the problem because motivation declines when discomfort is removed. Instead, Rockwell argues that before soothing someone’s discomfort related to change, leaders should ask, “What would you like to do about that?” In doing so, the leader encourages transformational conversations instead of avoiding the real issue or problem. Indeed, Rockwell notes that successful leaders often bring up issues others avoid. Discomfort with discomfort invites a person to ignore issues that should be addressed.

Leaders create pull. Successful leaders run forward more than they run away. The difference is push versus pull (Rockwell, 2015).

Movement The second phase of planned change is movement. In movement, the change agent identifies, plans, and implements appropriate strategies, ensuring that driving forces exceed restraining forces. Because change is such a complex process, it requires a great deal of planning and intricate timing. Recognizing, addressing, and overcoming resistance may be a lengthy process, and whenever possible, change should be implemented gradually. Any change of human behavior, or the perceptions, attitudes, and values underlying that behavior, takes time.

Indeed, addressing and responding appropriately to stress caused by change is a high-level leadership skill. Research by Zenger and Folkman (2015) suggested that helping others to change is not just about being nice or nagging; instead, inspiration, goal setting, building trust, and making change a priority are what matter. These strategies and others identified by Zenger and Folkman are detailed in Display 8.2.

DISPLAY 8.2 BEHAVIORS THAT INSPIRE OTHERS TO CHANGE

1. Inspiring others: Working with individuals to set aspirational goals, exploring alternative avenues to reach objectives, and seeking other’s ideas for the best methods to use going forward.

2. Noticing problems: Recognizing problems (to see situations where change is needed and to anticipate potential snares in advance).

3. Providing a clear goal: Fixing everyone’s sight on the same goal. Therefore, the most productive discussions about any change being proposed are those that start with the strategy that it serves.

4. Challenging standard approaches: Challenging standard approaches and finding ways to maneuver around old practices and policies—even sacred cows. Leaders who excel at driving change will challenge even the rules that seem carved in stone.

5. Building trust in your judgment: Actually improving your judgment and improving others’ perceptions of it.

6. Having courage: A great deal of what leaders do, and especially their change efforts, demands willingness to live in discomfort.

7. Making change a top priority: Clear away the competing priorities and shine a spotlight on this one change effort. Leaders who do this well have a daily focus on the change effort, track its progress carefully, and encourage others.

Source: Zenger, J., & Folkman, J. (2015). 7 Things leaders do to help people change. Retrieved August 8, 2018, from https://hbr.org/2015/07/7-things-leaders- do-to-help-people-change

Hinshaw (2015b) emphasized that change movement, however, should not be delayed solely because of fear of the unknown or

because some ambiguity exists. She notes that a 2010 study of more than 42 organizations found that “top performing leadership teams spent more time in project implementation than they did on project analysis. These organizations did not have different circumstances; all were presented with complex challenges and ever-changing times. The key difference between top performing and low performing teams was speed to action and the ‘we can make this work’ confidence to move quickly into implementation” (Hinshaw, 2015b, para. 7).

Refreezing The last phase is refreezing. During the refreezing phase, the change agent assists in stabilizing the system change so that it becomes integrated into the status quo. If refreezing is incomplete, the change will be ineffective and the prechange behaviors will be resumed. For refreezing to occur, the change agent must be supportive and reinforce the individual adaptive efforts of those affected by the change. Because change needs at least 3 to 6 months before it will be accepted as part of the system, the change agent must be sure that he or she will remain involved until the change is completed.

Change agents must be patient and open to new opportunities during refreezing, as complex change takes time and several different attempts may be needed before desired outcomes are achieved.

It is important to remember, though, that refreezing does not eliminate the possibility of further improvements to the change. Indeed, measuring the impact of change should always be a part of refreezing. Display 8.3 illustrates the change agent’s responsibilities during the various stages of planned change.

DISPLAY 8.3 STAGES OF CHANGE AND RESPONSIBILITIES OF THE CHANGE AGENT

Stage 1—Unfreezing 1. Gather data. 2. Accurately diagnose the problem. 3. Decide if change is needed. 4. Make others aware of the need for change; often involves

deliberate tactics to raise the group’s discontent level; do not proceed to Stage 2 until the status quo has been disrupted and the need for change is perceived by the others.

Stage 2—Movement 1. Develop a plan. 2. Set goals and objectives. 3. Identify areas of support and resistance. 4. Include everyone who will be affected by the change in its

planning. 5. Set target dates. 6. Develop appropriate strategies. 7. Implement the change. 8. Be available to support others and offer encouragement

through the change. 9. Use strategies for overcoming resistance to change. 10. Evaluate the change. 11. Modify the change, if necessary.

Stage 3—Refreezing Support others so that the change continues.

Lewin’s Change Theory of Driving and Restraining Forces

Lewin (1951) also theorized that people maintain a state of status quo or equilibrium by the simultaneous occurrence of both driving forces (facilitators) and restraining forces (barriers) operating within any field. Driving forces advance a system toward change; restraining forces impede change.

The forces that push the system toward change are driving forces, whereas the forces that pull the system away from change are restraining forces.

Examples of driving forces might include a desire to please one’s boss, to eliminate a problem, to get a pay raise, or to receive recognition. Restraining forces include conformity to norms, an unwillingness to take risks, and a fear of the unknown. Lewin’s (1951) model suggested that people like feeling safe, comfortable, and in control of their environment. For change to occur then, driving forces must be increased or restraining forces decreased.

In Figure 8.1, the person wishing to return to school must reduce the restraining forces or increase the driving forces to alter the present state of equilibrium. There will be no change or action until this occurs. Therefore, creating an imbalance within the system by increasing the driving forces or decreasing the restraining forces is one of the tasks required of a change agent.

FIGURE 8.1 Driving and restraining forces.

A Contemporary Adaptation of Lewin’s Model Burrowes and Needs (2009) shared an adaptation of Lewin’s model in their discussion of a five-step stages of change model (SCM). In this model, the first stage is precontemplation. During this stage, the individual “has no intention to change his or her behavior in the foreseeable future” (Burrowes & Needs, 2009, p. 41). Next comes the contemplation stage at which point the individual considers making a change but has not yet made a commitment to take action. This would be the phase in which unfreezing would occur according to Lewin.

A transition from unfreezing to movement begins in the preparation stage, as the individual intends to take action in the short-term future. The action stage then occurs (movement) in which the individual actively modifies his or her behavior. Finally, the process ends with the maintenance stage at which point the individual works to maintain changes made during the action stage and prevent relapse. This stage would be synonymous with refreezing. Table 8.1 illustrates the steps of the SCM.

TABLE 8.1 STAGES OF CHANGE MODEL

Stage 1: Precontemplation

No current intention to change

Stage 2: Contemplation

Individual considers making a change.

Stage 3: Preparation

There is intent to make a change in the near future.

Stage 4: Action Individual modifies his or her behavior. Stage 5: Maintenance

Change is maintained and relapse is avoided.

Source: Burrowes, N., & Needs, A. (2009). Time to contemplate change? A framework for assessing readiness to change with offenders. Aggression & Violent Behavior, 14(1), 39–49.

Classic Change Strategies In addition to being aware of the stages of change, the change agent must be highly skilled in the use of behavioral strategies to prompt change in others. Three such classic strategies for effecting change were described by Bennis, Benne, and Chinn (1969), with the most appropriate strategy for any situation depending on the power of the change agent and the amount of resistance expected from the subordinates.

LEARNING EXERCISE 8.1

Making Change Possible

Identify a change that you would like to make in your personal life (such as losing weight, exercising daily, and stopping smoking). List the restraining forces keeping you from making this change. List the driving forces that make you want to change. Determine how you might be able to change the status quo and make the change possible.

One of these strategies is to give current research as evidence to support the change. This group of strategies is often referred to as rational–empirical strategies. The change agent using this set of strategies assumes that resistance to change comes from a lack of knowledge and that humans are rational beings who will change when given information documenting the need for change. This type of strategy is used when there is little anticipated resistance to the change or when the change is perceived as reasonable. An example of research evidence being used to promote a successful planned change is shown in Examining the Evidence 8.1.

EXAMINING THE EVIDENCE 8.1 Source: McAllen, E. R., Stephens, K., Biearman, B. S., Kerr, K., & Whiteman, K. (2018). Moving shift report to the bedside: An evidence-based quality improvement project. Online Journal of Issues in Nursing, 23(2), 1.

Moving Shift Report to the Bedside: A Planned Change A Midwestern, 532-bed, acute-care, tertiary, Magnet-designated teaching hospital identified concerns about fall rates and patient and nurse satisfaction scores. Because evidence suggests that the implementation of bedside report (BSR) increases patient safety and patient and nurse satisfaction, the implementation of BSR was planned and implemented over a 4-month time on three nursing units.

The team completed a gap analysis to determine evidence-based best practices for shift report as compared to the current practice. At baseline, shift report was done in a conference room, at the desk, or in the hallways. BSR was not a practice on any of the units. Report was not standardized, although all nurses had some preferred form of communication.

An organizational assessment completed using the strengths, weaknesses, opportunities, threats (SWOT) format revealed that the practice change to BSR was feasible and congruent with the hospital’s nursing

model. Tests of change in plan, do, study, act (PDSA) cycles were used to evaluate the practice change in real time and make necessary adjustments throughout implementation. Scripted reports were created with input and consensus of staff, using on the introduction, situation, background, assessment, recommendation, question (ISBARQ) format. In addition, all nursing staff members (n = 67) completed education prior to implementation of BSR.

Performance audits revealed a combined compliance rate of 94% (n = 157). There was no statistically significant difference between mean time for report before and after implementation of BSR. Patient falls, however, decreased by 24% in the 4 months after BSR implementation compared to preimplementation falls. The orthopedic unit experienced the greatest reduction in the number of falls at 55.6%, followed by the neuroscience unit at 16.9%, and the general surgery unit at a 6.9% reduction.

Patient satisfaction also increased after implementation of BSR with the average Press Ganey score for the eight questions producing a result that increased the average score from 87.7% to 91.6%. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) showed improvement, but the changes were not statistically significant.

The researchers also found that sharing success stories (such as the “good catch” of a

patient who had deteriorated on rounds or improving fall rates) helped to encourage continued participation in BSR but noted the need for nursing leadership to continue to monitor performance and reinforce consistent expectations for refreezing to occur.

In contrast, normative–reeducative strategies use group norms and peer pressure to socialize and influence people so that change will occur. The change agent assumes that humans are social creatures, more easily influenced by others than by facts. This strategy does not require the change agent to have a legitimate power base. Instead, he or she gains power by skill in interpersonal relationships, focusing on noncognitive determinants of behavior, such as people’s roles and relationships, perceptual orientations, attitudes, and feelings, to increase acceptance of change.

LEARNING EXERCISE 8.2

Using Change Strategies to Increase Sam’s Compliance

You are a staff nurse in a home health agency. One of your patients, Sam Little, is a 38-year-old man with type 1 diabetes. He has developed some loss of vision and had to have two toes amputated as consequences of his disease process. Sam’s compliance with four-times-daily blood glucose monitoring and sliding-scale insulin administration has never been particularly good, but he

has been worse than usual lately. Sam refuses to use an insulin pump; however, he has been willing to follow a prescribed diabetic diet and has kept his weight to a desired level.

Sam’s wife called you at the agency yesterday and asked you to work with her in developing a plan to increase Sam’s compliance with his blood glucose monitoring and insulin administration. She said that Sam, although believing it “probably won’t help,” has agreed to meet with you to discuss such a plan. He does not want, however, “to feel pressured into doing something he doesn’t want to do.”

ASSIGNMENT:

What change strategy or combination thereof (rational–empirical, normative–reeducative, and power–coercive) do you believe has the greatest likelihood of increasing Sam’s compliance? How could you use this strategy? Who would be involved in this change effort? What efforts might you undertake to increase the unfreezing so that Sam is more willing to actively participate in such a planned change effort?

The third group of strategies, power–coercive strategies, features the application of power by legitimate authority, economic sanctions, or the political clout of the change agent. These strategies include influencing the enactment of new laws and using group power for strikes or sit-ins. Using authority inherent in an individual position to effect change is another example of a power–coercive strategy. These strategies assume that people often are set in their ways and will change only when rewarded for the change or when they are forced by some other power–coercive method. Resistance is handled by authority measures; the individual must accept it or leave.

Often, the change agent uses strategies from each of these three groups. An example may be reflected in the change agent who wants someone to stop smoking. The change agent might present the person with the latest research on cancer and smoking (the rational–empirical approach); at the same time, the change agent might have friends and family encourage the person socially to quit (normative–reeducative approach). The change agent also might refuse to ride in the smoker’s car if the person smokes while driving (power–coercive approach). By selecting from each set of strategies, the change agent increases the chance of successful change.

Resistance: The Expected Response to Change Even though change is inevitable, it creates instability in our lives, and some conflict should always be expected. Indeed, Heathfield (2018) suggests that even the most cooperative, supportive employees may experience resistance because change alters the balance of a group.

Hinshaw (2015a) suggests that the level of resistance often depends on two things: whether the change is mandated and if the change is proactive. Proactive change is generally less emotional than mandated change; yet, the lines often blur between the two because proactive change launched by one group may be perceived as mandated change by another.

The level of resistance also generally depends on the type of change proposed. Technological changes encounter less resistance than changes that are perceived as social or that are contrary to established customs or norms. For example, nursing staff may be more willing to accept a change in the type of intravenous (IV) pump to be used than a change regarding who is able to administer certain types of IV therapy. Nursing leaders also must recognize that subordinates’ values, educational levels, cultural and social backgrounds, and experiences with change (positive or negative) will have a tremendous impact on the degree of resistance. It is also much easier to change a person’s behavior than it is to change an entire group’s behavior. Likewise, it is easier to change knowledge levels than attitudes.

To eliminate resistance to change in the workplace, managers historically used an autocratic leadership style with specific guidelines for work, an excessive number of rules, and a coercive approach to discipline. The resistance, which occurred anyway, was both covert (such as delaying tactics and passive–aggressive behavior) and overt (openly refusing to follow a direct command).

The result was wasted managerial energy and time and a high level of frustration.

Because change disrupts the homeostasis or balance of the group, resistance should always be expected.

Today, resistance is recognized as a natural and expected response to change, and leader-managers must resist the impulse to focus on blaming others when resistance to planned change occurs. Instead, they should immerse themselves in identifying and implementing strategies to minimize or manage this resistance to change. One such strategy is to encourage subordinates to speak openly so that options can be identified to overcome objections. In addition, it is the leader’s role to see the vision of what the future state will be like after the change has taken place and to share that vision with his or her followers.

LEARNING EXERCISE 8.3

What Is Your Attitude Toward Change?

How do you typically respond to change? Do you embrace it? Seek it out? Accept it reluctantly? Avoid it at all cost? Is this behavior like your friends and that of your family? Has your behavior always fit this pattern, or has the pattern changed throughout your life? If so, what life events have altered how you view and respond to change?

Try to remember a situation in your own life that involved unnecessary change. Why do you think that the change was unnecessary? What types of turmoil did it cause? Were there things a change agent could have done that would have increased unfreezing in this situation?

Likewise, workers should be encouraged to talk about their perceptions of the forces driving the planned change so that the leader can accurately assess change support and resources. It takes a strong leader to step up and engage when a change effort meets with pushback.

Still, there are individual variations in terms of risk taking and willingness to accept change. Some individuals, even at very early ages, demonstrate more risk taking than others. Certainly, temperament and personality play at least some role in this. Change agents then should be aware of life history variables as well as risk- taking propensity when assessing the likelihood of an individual or group being willing to change. Early in a planned change then, leader-managers should assess which workers will promote or resist a specific change, by both observation and direct communication. Then, the manager can collaborate with change promoters on how best to convert those individuals more resistant to change.

Perhaps, the greatest factor contributing to the resistance encountered with change, however, is a lack of trust between the employee and the manager or the employee and the organization. Workers want security and predictability. That is why trust erodes when the ground rules change, as the assumed “contract” between the worker and the organization is altered. Subordinates’ confidence in the change agent’s ability to manage change depends on whether they believe that they have adequate resources to cope with it. In addition, the leader-manager must remember that subordinates in an organization will generally focus more on how a specific change will

affect their personal lives and status than on how it will affect the organization. Heathfield (2018) suggests then that the leader should always help employees identify what’s in it for them to make the change. A good portion of the normal resistance to change disappears when employees are clear about the benefits the change brings to them as individuals.

“True change in an organization often means that job positions and titles also change, which means that roles and responsibilities may shift as well. Resistance occurs when employees don’t understand how they fit in with the new way of doing things” (Quain, 2018, para. 4).

Planned Change as a Collaborative Process Often, the change process begins with a few people who meet to discuss their dissatisfaction with the status quo and an inadequate effort is made to talk with anyone else in the organization. This approach virtually guarantees that the change effort will fail. People abhor “information vacuums,” and when there is no ongoing conversation about the change process, gossip usually fills the void. These rumors are generally much more negative than anything that is actually happening. McQuerrey (2018) suggests that leaders should quell this early discord by being as transparent as possible. “Call a meeting or issue a companywide memo that sets the record about imminent change. Even if the situation is still fluid, acknowledge that change is on the horizon and announce you will disseminate information as soon as it is available” (McQuerrey, 2018, para. 2).

Resistance to change can gain its initial footing in unchecked gossip . . . People will speculate, make assumptions, and otherwise develop their thought patterns about what’s going on (McQuerrey, 2018).

In addition, as a general rule, anyone who will be affected by a change should be included in planning it. When information and decision making are shared, subordinates feel that they have played a valuable role in the change. Change agents and the elements of the system—the people or groups within it—must openly develop goals and strategies together. All must have the opportunity to define their interest in the change, their expectation of its outcome, and their ideas on strategies for achieving change. Effective leaders empower the early adopter change agents on his or her team to sway the group (Hinshaw, 2015b).

It is not always easy, however, to attain grassroots involvement in planning efforts. Even when managers communicate that change is needed and subordinate feedback is wanted, the message often goes unheeded. Some people in the organization may need to hear a message repeatedly before they listen, understand, and believe the message. If the message is one that they do not want to hear, it may take even longer for them to come to terms with the anticipated change.

Whenever possible, all those who may be affected by a change should be involved in planning for that change.

When change agents fail to communicate with the rest of the organization, they prevent people from understanding the principles that guided the change, what has been learned from prior experience, and why compromises have been made. Likewise, subordinates affected by the change should thoroughly understand

the change and the impacts that will likely result. Good, open communication throughout the process can reduce resistance. Leaders must ensure that group members share perceptions about what change is to be undertaken, who is to be involved and in what role, and how the change will directly and indirectly affect each person in the organization.

The Leader-Manager as a Role Model During Planned Change Leader-managers must act as role models to subordinates during the change process. Heathfield (2018) suggests it is critical that leader-managers own the planned change, no matter where it originated. In addition, the leader-manager must attempt to view change positively and to impart this view to subordinates. Rather than viewing change as a threat, managers should embrace it as a challenge and the chance or opportunity to do something new and innovative. Indeed, the leader has two responsibilities in facilitating change in nursing practice. First, leader-managers must be actively engaged in change in their own work and model this behavior to staff. Second, leaders must be able to assist staff members in making the needed change requirements in their work.

It is critical that managers not view change as a threat.

Managers must also believe that they can make a difference. This feeling of control is probably the most important trait for thriving in a changing environment. Unfortunately, many leader-managers lack self-confidence in their ability to serve as an effective change agent. When this occurs, there is a lack of engagement in the change process and a role modeling to followers that the change may not be worth the time and energy necessary to bring it to fruition.

Organizational Change Associated With Nonlinear Dynamics Most 21st-century organizations experience fairly brief periods of stability followed by intense transformation. In fact, some later organizational theorists feel that Lewin’s (1951) refreezing to establish equilibrium should not be the focus of contemporary organizational change because change is unforeseeable and ever present. This is particularly true in health-care organizations, where long-term outcomes are almost always unpredictable.

In the past, organizations looked at change and organizational dynamics as linear, occurring both in steps and sequentially. More contemporary theorists maintain that the world is so unpredictable that such dynamics are truly nonlinear. As a result, nonlinear change theories such as complex adaptive systems (CAS) theory and chaos theory now influence the thinking of many organizational leaders.

Complexity and Complex Adaptive Systems Change Theory Complexity science has emerged from the exploration of the subatomic world and quantum physics and suggests that the world is complex as are the individuals who operate within it. Thus, control and order are emergent rather than predetermined, and mechanistic formulas do not provide the flexibility needed to predict what actions will result in what outcomes.

CAS change theory, an outgrowth of complexity theory, suggests that the relationship between elements and agents within any system is nonlinear and that these elements are constantly in play to change the environment or outcome.

For example, although an individual may have behaved one way in the past, CAS theory suggests that future behavior may not always be the same (not always predictable). This is because that

individual’s prior experience and past learning may change his or her future choices. In addition, the rules or parameters of each situation are different, even if these differences are subtle; even small variations can dramatically alter choice of action. CAS theory also suggests that the actions of any agent within the system affect all other agents in the system; that is, that context and action are interconnected. Finally, CAS theory suggests that there are always hidden or unanticipated elements in systems that make linear thinking almost impossible.

In their classic work on CAS, Olson and Eoyang (2001) suggest that the self-organizing nature of human interactions in a complex organization leads to surprising effects. Rather than focusing on the macrolevel of the organization system, complexity theory suggests that most powerful change processes occur at the microlevel, where relationships, interactions, and simple rules shape emerging patterns. The main features of the CAS approach are shown in Display 8.4.

DISPLAY 8.4 MAIN FEATURES OF OLSON AND EOYANG’S (2001) COMPLEX ADAPTIVE SYSTEMS APPROACH TO CHANGE

Change should be achieved through connections among change agents instead of from the top-down.

There should be adaptation to uncertainty during the change instead of trying to predict stages of development.

Goals, plans, and structures should be allowed to emerge instead of depending on clear, detailed plans and goals.

Value differences should be amplified and explored instead of focusing on consensus in change efforts.

Patterns in one part of the organization are often repeated in another part. Thus, change does not need to begin at the top of an organization to be successful. The goal instead is self- similarity rather than differences in how change is implemented in different parts of the organization.

Successful change fits with the current organizational environment instead of with an ideal. This is what makes it sustainable.

In applying CAS theory to planned change, it becomes clear that the multidimensionality of health-care organizations, and the individuals who work within them, results in significant challenges for the change agent. Change agents then must carefully examine and focus on the relationships between the elements and be careful not to look at any one element in isolation from the others. It also suggests that time and attention must be given to trying to understand these relationships and interactions even before unfreezing is attempted and that continual monitoring and adaptation will likely be needed for movement and refreezing to be successful.

Chaos Theory The roots of chaos theory, considered by some to be a subset of complexity science, likely emerged from the early work of meteorologist Edward Lorenz in the 1960s to improve weather forecasting techniques (MIT News, 2008). Lorenz discovered that even tiny changes in variables often dramatically affected outcomes. Lorenz also discovered that even though these chaotic changes appeared to be random, they were not. Instead, he found that there were deterministic sequences and physical laws, which prevail in nature, even if this does not appear to be the case.

Chaos theory is really about finding the underlying order in apparently random data.

Determining this underlying order, however, is challenging, and the order itself is constantly changing. This chaos makes it difficult to predict the future. In addition, chaos theory suggests that even small changes in conditions can drastically alter a system’s long-term behavior (commonly known as the butterfly effect). Thus, changes in outcomes are not proportional to the degree of change in the initial condition. Because of this sensitivity, the behavior of a system exhibiting chaos appears to be random, even though the system is deterministic in the sense that it is well defined and contains no random parameters.

Chaos and complexity theories have great application within the health-care arena. For example, despite putting a great time of energy and time into planning, many plans with sharply delivered strategies and targets are often not effective. This is because hidden variables are not explored, and general goals and boundaries are not developed. For example, a single individual or unit can undermine a planned organizational change, particularly if the actions of that individual or unit to undermine the change are covert.

The change agent might inadvertently focus on the aftermath of the subversive action without ever realizing the root cause of the problem.

Elena Capella, a nurse educator at the University of San Francisco School of Nursing and Health Professions, suggests that students should receive training about chaos theory as a part of their nursing education (Hall, 2017). She introduces chaos theory to her students to help them handle the intense needs of the emergency room, reaching a sense of calm in disaster situations. She notes there are patients in the emergency department who don’t follow protocols, there are patients who have different backgrounds and understandings, there are miscommunications, and there are problems with coordination. In such a disorganized and chaotic setting, you need “someone to step in as a reorganization force, someone who can redirect everyone’s attention and energy in an efficient manner” (Hall, 2017, para. 6).

This is the same behavior that is needed of the change agent. It is imperative then that change agents understand complexity theory and chaos theory because the use of nonlinear theories to explain organizational functioning and change is expected to increase in the 21st century.

Organizational Aging: Change as a Means of Renewal Organizations progress through developmental stages, just as people do—birth, youth, maturity, and aging. As organizations age, structure increases to provide greater control and coordination. The young organization is characterized by high energy, movement, and virtually constant change and adaptation. Aged organizations have established “turf boundaries,” function in an orderly and predictable fashion, and are focused on rules and regulations. Change is limited.

Clearly, organizations must find a balance between stagnation and chaos, between birth and death. In the process of maturing, workers within the organization can become prisoners of procedures, forget their original purposes, and allow means to become the ends. Without change, the organization may stagnate and die. Organizations need to keep foremost what they are going to do, not what they have done.

For example, Gordon (2012) and Owarish (2013) shared insights regarding Kodak, founded in 1880 by George Eastman, and one of America’s most notable companies, helping establish the market for camera film and then dominating the field. But it suffered from a variety of problems over the last four decades—almost all related to being an aged organization. Kodak’s top management never fully grasped how the world around them was changing and they hung on to obsolete assumptions (such as digital prints will never replace film prints) long after they were no longer the case.

In addition, Kodak followed a pattern seen by many aged organizations that face technological change. First, they tried to ignore a new technology hoping it would go away by itself. Then they openly put it down by using various justifications such as it is too expensive, too slow, and too complicated. Then they tried to prolong the life of the existing technology by attempting to create synergies between the new technology and the old (such as photo CD). This further delayed any serious commitment to the new order of things.

In the end, Kodak failed to realize its limitations, ignored the data, and spent an additional 15 years in avoidance mode until it became virtually irrelevant in the market. With only 1 full year of profit after 2004, Kodak ended up filing for bankruptcy in 2012, after 131 years of being the pioneer in the film industry.

Philpot (2013) provides another example in her accounting of Blackberry’s market plunge from having 40% of the smartphone market in North America in 2010 to only 2% by the end of 2012. Philpot suggests this death spiral occurred as the result of

accelerated obsolescence and notes that the “shelf life” of any business model is shorter now than ever before. She concludes that leaders today have to know how to “keep one foot in today and the other in tomorrow. In other words, their responsibility is to successfully execute their current business model while also reinventing their company to compete in a market that they have not yet seen” (Philpot, 2013, para. 4).

LEARNING EXERCISE 8.4

Young or Old Organization?

Reflect on the organization in which you work or the nursing school you attend. Do you believe that this organization has more characteristics of a young or aged organization? Diagram on a continuum from birth to death where you feel that this organization would fall. What efforts has this organization taken to be dynamic and innovative? What further efforts could be made? Do you agree or disagree that most organizations change unpredictably? Can you support your conclusions with examples? If professions were classified in a manner like organizations, do you believe that the nursing profession would be classified as (a) an aging organization, (b) in constant motion and ever renewing, or (c) a closed system that does not respond well to change?

Integrating Leadership Roles and Management Functions in Planned Change

Change and innovation are increasingly critical to organizational survival as well as sustained success (Bligh, Kohles, & Yan, 2018). Leadership and management skills are necessary, however, for successful planned change to occur. The manager must understand the planning process and planning standards and be able to apply both to the work situation. The manager is also cognizant of the specific driving and restraining forces within a specific environment for change and can provide the tools or resources necessary to implement that change. The manager, then, is the mechanic who implements the planned change.

The leader, however, is the inventor or creator. Leaders today are forced to plan in a chaotic health-care system that is changing at a frenetic pace. Out of this chaos, leaders must identify trends and changes that may affect their organizations and units and proactively prepare for these changes. Thus, the leader must retain a big-picture focus while dealing with each part of the system. In the inventor or creator role, the leader displays such traits as flexibility, confidence, tenacity, and the ability to articulate vision through insights and versatile thinking. The leader also must constantly look for and attempt to adapt to the changing and unpredictable interactions between agents and environmental factors as outlined by the complexity science theorists.

Both leadership and management skills then are necessary in planned change. The change agent fulfills a management function when identifying situations where change is necessary and appropriate and when assessing the driving and restraining forces affecting the plan for change. The leader is the role model in planned change. He or she is open and receptive to change and views change as a challenge and an opportunity for growth. Other critical elements in successful planned change are the change agent’s leadership skills—interpersonal communication, group management, and problem-solving abilities.

Perhaps, there is no greater need for the leader, though, than to be the catalyst for professional change as well as organizational change. Many people attracted to nursing now find that their values and traditional expectations no longer fit as they once did. It is the leader’s role to help his or her followers turn around and confront the opportunities and challenges of the realities of emerging nursing practice; to create enthusiasm and passion for renewing the profession; to embrace the change of locus of control, which now belongs to the health-care consumer; and to engage a new social context for nursing practice.

Key Concepts

■ Change should not be viewed as a threat but as a challenge and a chance to do something new and innovative.

■ Change should be implemented only for good reason. ■ Because change disrupts the homeostasis or balance of the

group, resistance should be expected as a natural part of the change process.

■ The level of resistance to change generally depends on the type of change proposed. Technological changes encounter less resistance than changes that are perceived as social or that are contrary to established customs or norms.

■ Perhaps, the greatest factor contributing to the resistance encountered with change is a lack of trust between the employee and the manager or the employee and the organization.

■ It is much easier to change a person’s behavior than it is to change an entire group’s behavior. It is also easier to change knowledge levels than attitudes.

■ Change should be planned and thus implemented gradually, not sporadically or suddenly.

■ Those who may be affected by a change should be involved in planning for it. Likewise, workers should thoroughly understand the change and its effect on them.

■ The feeling of control is critical to thriving in a changing environment.

■ Friends, family, and colleagues should be used as a network of support during change.

■ The successful change agent has the leadership skills of problem solving and decision making as well as good interpersonal skills.

■ In contrast to planned change, change by drift is unplanned or accidental.

■ Historically, many of the changes that have occurred in nursing or have affected the profession are the results of change by drift.

■ People maintain status quo or equilibrium when both driving and restraining forces operating within any field simultaneously occur. For change to happen, this balance of driving and restraining forces must be altered.

■ Emerging theories such as complexity science suggest that change is unpredictable, occurs at random, and is dependent on rapidly changing relationships between agents and factors in the system and that even small changes can affect an entire organization.

■ Organizations are preserved by change and constant renewal. Without change, the organization may stagnate and die.

Additional Learning Exercises and Applications

LEARNING EXERCISE 8.5

Implementing Planned Change in a Family Planning Clinic

You are a Hispanic registered nurse who has recently received a 2-year grant to establish a family planning clinic in an impoverished, primarily Hispanic area of a large city. The project will be evaluated at the end of the grant to determine whether continued funding is warranted. As project director, you have the funds to choose and hire three health-care workers. You will essentially be able to manage the clinic as you see fit.

The average age of your patients will be 14 years, and many come from single-parent homes. In addition, the population with which you will be working has high unemployment, high crime and truancy levels, and great suspicion and mistrust of authority figures. You are aware that many restraining forces exist that will challenge you, but you feel strongly committed to the cause. You believe that the high teenage pregnancy rate and maternal and infant morbidity can be reduced.

ASSIGNMENT:

1. Identify the restraining and driving forces in this situation.

2. Identify realistic short- and long-term goals for implementing such a change. What can realistically be accomplished in 2 years?

3. How might the project director use hiring authority to increase the driving forces in this situation?

4. Is refreezing of the planned change possible so that changes will continue if the grant is not funded again in 2 years?

LEARNING EXERCISE 8.6

Retain the Status Quo or Implement Change?

Assume that morale and productivity are low on the unit where you are the new manager. To identify the root of the problem, you have been meeting informally with staff to discuss their perceptions of unit functioning and to identify sources of unrest on the unit. You believe that one of the greatest factors leading to unrest is the limited advancement opportunity for your staff nurses. You have a fixed charge nurse on each shift. This is how the unit has been managed for as long as everyone can remember. You would like to rotate the charge nurse position but are unsure of your staff’s feelings about the change.

ASSIGNMENT:

Using the phases of change identified by Lewin (1951), identify the actions you could take in unfreezing, movement, and refreezing. What are the greatest barriers to this change? What are the strongest driving forces?

LEARNING EXERCISE 8.7

How Would You Handle This Response to Change?

You are the unit manager of a cardiovascular surgical unit. The workstation on the unit is small, dated, and disorganized. The unit clerks have complained for some time that the chart racks on the counter above their desk are difficult to reach, that staff frequently impinge on the clerks’ work space to discuss patients or to chart, that the call-light system is antiquated, and that supplies and forms need to be relocated. You ask all eight of your shift unit clerks to make a “wish list” of how they would like the workstation to be redesigned for optimum efficiency and effectiveness.

Construction is completed several months later. You are pleased that the new workstation incorporates what each unit clerk included in his or her top three priorities for change. There is a new revolving chart rack in the center of the workstation, with enhanced accessibility to both staff and unit clerks. A new, state-of-the-art call-light system has been installed. A small, quiet room has been created for nurses to chart and conference, and new cubbyholes and filing drawers now put forms within arm’s reach of the charge nurse and unit clerk.

Almost immediately, you begin to be barraged with complaints about the changes. Several of the unit clerks find the new call-light system’s computerized response system overwhelming and complain that patient lights are now going unanswered. Others complain that with the chart rack out of their immediate work area, charts can no longer be monitored and are being removed from the unit by physicians or left in the charting room by nurses. One unit clerk has filed a complaint that she was injured by a staff member who carelessly and rapidly turned the chart rack. She refuses to work again until the old chart racks

are returned. The regular day-shift unit clerk complains that all the forms are filed backward for left-handed people and that after 20 years, she should have the right to put them the way that she likes it. Several of the nurses are complaining that the workstation is “now the domain of the unit clerk” and that access to the telephones and desk supplies is limited by the unit clerks. There have been some rumblings that several staff members believe that you favored the requests of some employees over others.

Today, when you make rounds at change of shift, you find the day-shift unit clerk and charge nurse involved in a heated conversation with the evening-shift unit clerk and charge nurse. Each evening, the charge nurse and unit clerk reorganize the workstation in the manner that they believe is most effective, and each morning, the charge nurse and unit clerk put things back the way they had been the prior day. Both believe that the other shift is undermining their efforts to “fix” the workstation organization and that their method of organization is the best. Both groups of workers turn to you and demand that you “make the other shift stop sabotaging our efforts to change things for the better.”

ASSIGNMENT:

Despite your intent to include subordinate input into this planned change, resistance is high and worker morale is decreasing. Is the level of resistance a normal and anticipated response to planned change? If so, would you intervene in this conflict? How? Was it possible to have reduced the likelihood of such a high degree of resistance?

LEARNING EXERCISE 8.8

Overcoming Resistance to a Needed Change

You are the charge nurse of a medical/surgical unit. Recently, your hospital spent millions of dollars to implement a bedside medication verification (BMV) system to reduce medication errors and to promote a culture of patient safety. In this system, the nurse, using a handheld device, scans the drug he or she is planning to give against the patient’s medication record to make sure that the right drug, at the right dose, is being given at the right time to the right patient. The nurse then scans the patient’s name band/arm band to assure the right patient is receiving the drug and finally scans his or her own name badge to document who is administering the drug to the patient. If any of the codes do not match, a signal goes off, alerting the nurse of the discrepancy.

It has come to your attention, however, that some nurses are overriding the safety features built into the bar coding system. For example, some nurses are reluctant to wake sleeping patients to scan his or her bar code before they administer an intravenous push medication and instead simply scan the chart label. Some nurses have overridden the bar code warning, assuming it was some kind of technological glitch. Some nurses have administered drugs to patients despite having name

bands that have become smudged or torn and no longer scan well. Still, other nurses are carrying multiple prescanned pills on one tray or charting that drugs have been given, even though they were left at the bedside. Finally, you learned that one nurse even affixed extra copies of her patient’s bar codes to her clipboard, so that they could be scanned more quickly.

ASSIGNMENT:

Despite thorough orientation and training regarding BMV, some staff have developed “work-arounds” to the bar coding system, increasing the risk of medication errors and patient harm. Your staff suggests that although they understand BMV reduces risks to patients, the equipment does not always work and performing the additional safety checks often takes them more time than how they did it in the past, ultimately delaying medications to patients who need them. The staff states they will try to be more careful in implementing the BMV procedures, but you continue to sense resistance on their part. What strategies could you employ now to foster refreezing of the new system? Would rational–empirical, power–coercive, or normative– reeducative strategies be more effective? Provide a rationale for your choice.

LEARNING EXERCISE 8.9

Promoting Evidence-Based Practice

In recent years, the implementation of evidence-based practice has been identified as a priority across nearly every nursing specialty (Prevost & Ford, 2020). In addition, nurses are increasingly accepted as essential members, and often as leaders, of the interdisciplinary health-care teams. To effectively participate and lead a health-care team, nurses must have knowledge of the

most effective and reliable evidence-based approaches to care, increase their expertise in critiquing research, and apply the evidence of their findings to select optimal interventions for their patients (Prevost & Ford, 2020).

ASSIGNMENT:

Identify at least five things you might do to increase your knowledge and use of evidence in your practice. What are the most significant driving and restraining forces to make this change? Would you anticipate (overt or covert) resistance to your efforts? Will you need to enlist support from others or acquire additional resources for this planned change to occur? (Examples might be administrative support, access to scholarly journals, or mentoring.)

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9

Time Management . . . nothing is particularly hard if you divide it into small jobs.—Henry Ford

. . . things which matter most must never be at the mercy of things that matter least.—Johann Wolfgang von Goethe

. . . The bad news is time flies. The good news is you’re the pilot.—Michael Altshuler

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

MSN Essential II: Organizational and systems leadership AONL Nurse Executive Competency I: Communication and relationship building

AONL Nurse Executive Competency II: A knowledge of the health-care environment

ANA Standard of Professional Performance 9: Communication

ANA Standard of Professional Performance 10: Collaboration

ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 14: Quality of practice

ANA Standard of Professional Performance 16: Resource utilization

QSEN Competency: Safety QSEN Competency: Teamwork and collaboration

LEARNING OBJECTIVES

The learner will:

analyze how time is managed both personally and at the unit level of the organization

describe the importance of allowing adequate time for daily planning and priority setting

describe how planning fallacies influence the perception of the time needed to complete a task

complete tasks according to the priority level they have been assigned whenever possible

build evaluation steps into planning so that reprioritization can occur

identify common internal and external time wasters as well as interventions that can be taken to reduce their impact

complete a time inventory to increase self-awareness regarding personal priority setting and time management

identify how technology applications such as e-mail, the Internet, telecommunications, and social networking can both facilitate and hinder personal time management

involve subordinates and followers in maximizing time use and guiding work to its successful implementation and conclusion

Introduction Another part of the planning process is short-term planning. This operational planning focuses on achieving specific tasks. Short-term plans involve a period of 1 hour to 3 years and are usually less complex than strategic or long-range plans. Short-term planning may be done annually, quarterly, monthly, weekly, daily, or even hourly.

Previous chapters examined the need for prudent planning of resources, such as money, equipment, supplies, and labor. Time is an equally important resource. Indeed, the Latin for “I waste time” is “tempus tero,” which literally means the rubbing away or gradual unrecognized loss of a valuable commodity (Stone & Treolar, 2015).

“From crossing things off our to-do lists, to achieving long-term goals, it feels good to get things done” (Doyle, 2018, para. 2). Mental health often improves when we can take some action to resolve the challenges facing us. When we lack the time to resolve those challenges, we feel overwhelmed, and this can lead to increased errors, the omission of important tasks, and general feelings of stress and ineffectiveness. If leaders are to empower others to achieve personal and shared goals, they need to become experts in the planning and implementation of goal attainment. If managers are to direct employees effectively and maximize other resources, they must first be able to find the time to do so. In other words, both must become experts at time management.

Time management can be defined as making optimal use of available time. Many people argue that there is not enough time in the day to do everything that must be done. Yet, everyone has the same amount of time in a day, but some people consistently get much more done than others. The problem then may be how the time available is being used.

Optimizing time management must include priority setting, managing and controlling crises, and balancing work and personal

time. All these activities require some degree of both leadership skills and management functions. Leadership roles and management functions needed for effective time management are included in Display 9.1.

DISPLAY 9.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN TIME MANAGEMENT

Leadership Roles 1. Is self-aware regarding personal blocks and barriers to efficient

time management 2. Recognizes how one’s own value system influences his or her

use of time and the expectations of followers 3. Functions as a role model, supporter, and resource person to

others in setting priorities for goal attainment 4. Assists followers in working cooperatively to maximize time use 5. Prevents and/or filters interruptions that prevent effective time

management 6. Role models flexibility in working cooperatively with other

people whose primary time management style is different 7. Presents a calm and reassuring demeanor during periods of

high unit activity 8. Prioritizes conflicting and overlapping requests for time 9. Appropriately determines the quality of work needed in tasks to

be completed

Management Functions 1. Appropriately prioritizes day-to-day planning to meet short-term

and long-term unit goals 2. Builds time for planning into the work schedule 3. Analyzes how time is managed on the unit level by using job

analysis and time-and-motion studies 4. Eliminates environmental barriers to effective time

management for workers 5. Handles paperwork promptly and efficiently and maintains a

neat work area 6. Breaks down large tasks into smaller ones that can more easily

be accomplished by unit members

7. Utilizes appropriate technology to facilitate timely communication and documentation

8. Discriminates between inadequate staffing and inefficient use of time when time resources are inadequate to complete assigned tasks

Good time management skills allow an individual to spend time on things that matter.

Three Basic Steps to Time Management There are three basic steps to time management (Fig. 9.1). The first step requires that time be set aside for planning and establishing priorities. The second step entails completing the highest priority task (as determined in step 1) whenever possible and finishing one task before beginning another. In the final step, the person must reprioritize what tasks will be accomplished based on new information received. Because this is a cyclic process, all three steps must be accomplished sequentially.

FIGURE 9.1 The three basic steps in time management.

Taking Time to Plan and Establishing Priorities Planning is essential if an individual is to manage by efficiency rather than by crisis, and the adage “fail to plan—plan to fail” is timeless. Planning occurs first in the management process because the ability to be organized develops from good planning. During planning, there should be time to think about how plans will be translated into action. The planner must pause and decide how people, activities, and materials are going to be put together to carry out the objectives.

Many individuals believe that they are unproductive if they take time out early in their day to design a plan for action rather than immediately beginning work on tasks. Without adequate planning, however, the individual finds it difficult to get started and begins to

manage by crisis. In addition, there can be no sense of achievement at day’s end if the goals for the day are not clearly delineated. Managers who are new to time management may underestimate the importance of regular planning and fail to allot enough time for it.

In addition, many individuals repeatedly fail to complete planned tasks because they don’t allow adequate resources (time, energy, human or physical resources, etc.) for task completion. For example, the student who carries home a full backpack every night with the expectation that every assignment or task contained within the backpack will always be completed, is likely to be disappointed. Interruptions occur, life events happen, and most people can only sustain high levels of attention to tasks for limited periods of time. Most people simply want to believe that tasks will always go well and that no problems will arise. This unrealistic assumption leads to serious planning errors and poor time management.

Unfortunately, two mistakes common in planning are underestimating the importance of a daily plan and not allowing adequate time for planning.

Similarly, many students fail to establish a plan for completing their learning activities. Sometimes, this is because they are unclear about what the finished product must look like. Other times, they are unsure when assignments are due or how to break large assignments down into workable subcomponents. In all these cases, the result is that the student’s ability to achieve the desired outcome, within the required timeline, is threatened. Tips college students can use to improve their time management effectiveness are shown in Display 9.2.

DISPLAY 9.2 TIME MANAGEMENT TIPS FOR COLLEGE STUDENTS

1. List everything that must be done (school, work, and personal tasks that must be completed).

2. Create a life schedule (use a time management tool if that is helpful).

3. Be flexible but realistic about how much you can accomplish in a day (typically not more than 8 to 10 hours of dedicated time).

4. Allow time for planning to avoid repetition. 5. Avoid procrastination and distraction. Study in environments

where you are most productive. 6. Exercise to clear your head in between study sessions. 7. Constantly review and reassess your schedule to see if

changes are needed or new priorities have emerged.

Source: 7 Time management tips for students. (2017). Retrieved September 4, 2018, from https://www.topuniversities.com/blog/7-time-management-tips-students

In addition, many new electronic apps exist for students who want to better manage their time, whether it is taking notes more efficiently, scheduling workflow better, or sticking to assignment deadlines. Some of these time management and productivity apps are previewed in Display 9.3.

DISPLAY 9.3 SAMPLE TIME MANAGEMENT AND COMMUNICATION PRODUCTIVITY APPS

Time Doctor: tracks other people’s schedules and offers screen monitoring software, a tool to monitor internet usage, website application monitoring, and more.

Roadmap: balances the schedules of multiple people and provides insights as to how project goals are lining up with the realities of available resources so that adjustments can be made accordingly.

Basecamp: organizes all important tasks into three categories and displays them on one convenient dashboard. In addition, there is a “project” section where members of different teams can work together to finish a project. Here people can share tasks and see every step of the project from start to completion.

Asana: a project management app that breaks down tasks into either a list or a calendar. This allows users to see when they have something due on a calendar, and to address them in an orderly fashion. This app also emails notifications about upcoming due dates.

Float: a project management task software with a click and drop scheduler that helps users visualize team work load, assign tasks, and make updates. Also helps make task assignments, mark milestones, group projects, and add tasks notes.

ProofHub: project management software that helps to plan what needs to be done, discusses ideas, organizes documents, and delivers projects of all sizes.

I Done This: productivity app that is essentially a to-do list. When tasks are accomplished, an incomplete red “x” turns to a green completed check mark.

Todoist: productivity app to list tasks to be accomplished. Tasks are labeled, assigned a due date, and then filtered by priority.

Dropbox: cloud storage app for file sharing. Google Drive: cloud storage app for file sharing, collaboration,

editing, commenting on documents, and more. Google Hangouts: video meeting software that allows

meetings and chat through a voice or video call. Skype: communication platform that allows easy messaging,

voice calls, screen sharing, and video conference calls across all desktop, iOS, and Android devices.

join.me: communication system to organize meetings. Includes free conference calling capabilities, video conferencing, screen sharing, and chat (through Slack), but also offers additional benefits like webinar training services and a mobile whiteboard.

Slack: chat tool for quick group or one-on-one communications. Workplace by Facebook: a joint Facebook account for all

individuals involved in a project. This allows members to hold group discussions, post updates about projects, comment and offer suggestions on posts, and also participate in voice and video calling.

Source: 16 Best time management apps to skyrocket productivity in 2019. (2019). Retrieved July 26, 2019, from https://biz30.timedoctor.com/best-time- management-apps/

LEARNING EXERCISE 9.1

Making Big Projects Manageable

Think of the last major paper you wrote for a class. Did you set short-term and intermediate deadlines? Did you break the task down into smaller tasks to eliminate a last-

minute crisis? What short-term and intermediate deadlines have you set to accomplish major projects that have been assigned to you this quarter or semester? Are you realistic about the time that will be required to complete the task or are you likely to experience planning fallacies?

The Time-Efficient Work Environment Whether you are a student, a manager, or a staff nurse, planning takes time; it requires the ability to think, analyze data, envision alternatives, and make decisions. Examples of the types of plans a charge nurse might make in day-to-day planning include staffing schedules, patient care assignments, coordination of lunch- and work-break schedules, and interdisciplinary coordination of patient care. Examples of an acute care staff nurse’s day-to-day planning might include determining how handoff reports will be given and received; the timing and method used for initial patient assessments; the coordination of medication administration, treatments, and procedures; and the organization of documentation of the day’s activities.

Some staff nurses, however, appear disorganized in their efforts to care for patients. This may be the result of poor planning or it may be a symptom of a work environment that is not conducive to efficient time management. The following suggestions, using industrial engineering principles, may assist the staff nurse in planning work activities, especially when the environment poses obstacles to time efficiency:

Gather all the supplies and equipment that will be needed before starting an activity. Breaking a job down mentally into parts before beginning the activity may help the staff nurse identify

what supplies and equipment will be needed to complete the activity.

Get organized. Rampton (2018) notes that the average American spends 2.5 days each year looking for misplaced items. Have a home for everything and make sure that items are put back where they belong. Rampton also suggests single- tasking because most people cite multitasking as the main culprit for misplacing items.

Group activities that are in the same location. If you have walked a long distance down a hallway, attempt to do several things there before going back to the nurses’ station. If you are a home health nurse, group patient visits geographically when possible to minimize travel time and maximize time with patients.

Use time estimates. For example, if you know an intermittent intravenous medication (IV piggyback) will take 30 minutes to complete, then use that time estimate for planning some other activity that can be completed in that 30-minute window of time.

Document your nursing interventions as soon as possible after an activity is completed. Waiting until the end of the workday to complete necessary documentation increases the risk of inaccuracies and incomplete documentation.

Always strive to end the workday on time. Although this is not always possible, delegating appropriately to others and making sure that the workload goal for any given day is reasonable are two strategies that will accomplish this goal.

Like staff nurses, unit managers need to coordinate how their duties will be carried out and devise methods to make work simpler and more efficient. Often, this includes simple tasks such as organizing how supplies are stored or determining the most efficient lunch and break schedules for staff. In addition, it is the manager’s responsibility to see that units are appropriately stocked with the

equipment nurses need to do their work. This reduces the time spent in trying to locate needed supplies.

Daily planning actions that may help the unit manager identify and utilize time as a resource most efficiently might include the following:

At the start of each workday, identify key priorities to be accomplished that day. Identify what specific actions need to be taken to accomplish those priorities and in what order they should be done. Also, identify specific actions that should be taken to meet ongoing, long-term goals.

Determine the level of achievement that you expect for each prioritized task. Is a maximizing or “satisficing” approach more appropriate or more reasonable for each of the goals you have identified?

Assess the staff assigned to work with you. Assign work that must be delegated to staff members who are both capable and willing to accomplish the priority task that you have identified. Be sure that you have clearly expressed any expectations you may have about how and when a delegated task must be completed. (Delegation is discussed further in Chapter 20.)

Review the short- and long-term plans of the unit regularly. Include colleagues and subordinates in identifying unit problems or concerns so that they can be fully involved in planning for needed change.

Plan ahead for meetings. Prepare and distribute agendas in advance.

Allow time at several points throughout the day and at the end of the day to assess progress in meeting established daily goals and to determine if unanticipated events have occurred or if new information has been received that may have altered your original plan. Ongoing realities for the unit manager include work situations that are constantly changing, and with them, setting new priorities and adjusting older ones.

Take regularly scheduled breaks. Planning for periodic breaks from work during the workday is an integral part of an individual’s time and task management. These work breaks allow both managers and staff to refresh physically and mentally.

Using an electronic calendar to organize your day can help make a day feel less chaotic. It can also help you identify pockets of spare time that you could use for breaks.

Setting new priorities or adjusting priorities to reflect ever-changing work situations is an ongoing reality for the manager.

LEARNING EXERCISE 9.2

Setting Daily Priorities

Assume that you are the registered nurse-leader of a team with one licensed vocational nurse and one nursing assistant on the 7 AM to 3 PM shift at an acute care hospital. The three of you are responsible for providing

total care to 10 patients. Prioritize the following list of 10 things that you need to accomplish this morning. Use a “1” for the first thing you will do and a “10” for the last. Be prepared to provide rationale for your priorities.

____ Check medication cards/sheets against the patient medication record.

____ Listen to night shift handoff. ____ Take brief walking rounds to assess the night shift

report and to introduce yourself to patients. ____ Hang four 9:00 AM intravenous medications. ____ Set up the schedule for breaks and lunch among

your team members. ____ Give 8:45 AM preoperative on patient going to

surgery at 9:00 AM. ____ Pass 8:30 AM breakfast trays. ____ Meet with team members to plan the schedule for

the day and to clarify roles. ____ Read charts of patients who are new to you. ____ Check 6:00 AM blood glucose laboratory results for

7:30 AM insulin administration.

Priority Setting and Procrastination Because most individuals are inundated with requests for their time and energy, the next step in time management is prioritizing, which may well be the key to good time management. Unfortunately, some individuals lack self-awareness about what is important and therefore how to spend their time.

Priority setting is perhaps the most critical skill in good time management because all actions we take have some type of relative importance.

One simple means of prioritizing what needs to be accomplished is to divide all requests into three categories: “don’t do,” “do later,” and “do now” (Display 9.4). The don’t do items probably reflect problems that will take care of themselves, are already outdated, or are better accomplished by someone else. The individual either throws away the unnecessary information or passes it on to the appropriate person in a timely fashion. In either case, the individual removes unneeded clutter from his or her work area.

DISPLAY 9.4 THREE CATEGORIES OF PRIORITIZATION

1. “Don’t do” 2. “Do later” 3. “Do now”

Before setting “do later” items aside, the leader-manager must be sure that large projects have been broken down into smaller projects and that a specific timeline and plan for implementation are in place. The plan should include short-term, intermediate, and final deadlines. Likewise, one cannot ignore items without immediate time limits forever and must make a definite time commitment soon to address these requests.

The do now requests most commonly reflect a unit’s day-to-day operational needs. These requests may include daily staffing needs, dealing with equipment shortages, meeting schedules, conducting hiring interviews, and giving performance appraisals. Do now requests also may represent items that had been put off earlier.

Some do later items reflect trivial problems or those that do not have immediate deadlines; thus, they may be procrastinated. To procrastinate means to put off something until a future time, to postpone, or to delay needlessly. Procrastination can be appropriately justified if it is more important to something of greater importance now, but it should not be used to avoid a task because it is overwhelming or unpleasant.

More often, procrastination is a barrier to effective time management. Price (2018) agrees, noting that procrastination offers only an illusion of freedom because it tricks us into believing we have countless hours, only to rob us of them later. Hendriksen (2018) concurs, noting that when we procrastinate, we typically regret the time wasted as deadlines approach, time runs out, and opportunity slips through our fingers. The key in procrastination then is to use it appropriately and selectively.

Procrastination, however, is a difficult problem to solve because it rarely results from a single cause and can involve a combination of dysfunctional attitudes, rationalizations, and resentment. For example, sometimes, procrastination is caused by perfectionism. Price (2018) suggests perfectionists may postpone starting a project because he or she feels overwhelmed by the sheer amount of energy it will take to do something perfectly. Taibbi (2018) suggests another cause is emotionality driving behavior rather than rationality. For individuals driven by emotionality, the impulsive brain overrides the rational one and the result is a delay in action.

New research even suggests that procrastination may have neurobiological causes. Hendriksen (2018) notes that the tendency to procrastinate runs in families and is linked on the genetic level to impulsivity, creating a catchall of difficulty regulating our own behavior. In addition, a team of German researchers found a relation between the gray matter volume of the amygdala in the brain and difficulties in initiating action. Theoretically, this is known as decision- related action orientation. Individuals who tend to hesitate or

procrastinate show higher amygdala volume, providing a neural signature referred to as an “amygdala hijack” (Pychyl, 2018). This neural signature of action suggests that procrastination is a problem with emotion regulation (see Examining the Evidence 9.1).

EXAMINING THE EVIDENCE 9.1 Source: Pychyl, T. A. (2018). The neural signature of procrastination. Retrieved September 3, 2018, from https://www.psychologytoday.com/us/blog/dont- delay/201808/the-neural-signature-procrastination

Is Procrastination a Function of Neural Biology? A team of researchers from Ruhr-University Bochum, Bochum, Germany, took a rare neuroscientific approach to the study of action control and procrastination. Using a sample of 264 young adults, they conducted functional magnetic resonance imaging brain scans to explore the neural correlates of the ability to initiate and sustain action. The researchers found a relation between the gray matter volume of the amygdala and difficulties in initiating action; individuals who tend to hesitate or procrastinate show higher amygdala volume. Because the amygdala is a neuroanatomical hub for fear-motivation behavior (“fight or flight” center of the brain), individuals with a larger amygdala volume evaluate future actions and their possible consequences more extensively. This, in turn, may lead to greater concern and hesitation.

The researchers did note, however, that biology is not destiny because our brains can change. For example, other research has shown that mindfulness meditation can shrink the volume of the amygdala. In addition, individuals can learn skills to better regulate

their emotional response to the tasks in their lives.

Making Lists In prioritizing all the do now items, the leader-manager may find preparing a written list helpful. Remember, however, that a list is a plan, not a product, and that the creation of the list is not the final goal. The list is a planning tool.

LEARNING EXERCISE 9.3

Targeting Personal Procrastination

Spend a few moments reflecting on the last 2 weeks of your life. What are the things you put off doing? Do these things form a pattern? For instance, do you always put off writing a school paper until the last minute? Do you wait to do certain tasks at work until you cannot avoid the task any longer? What things do you do when you really do not want to do something? Do you eat? Play video games? Watch TV? Read?

ASSIGNMENT:

Write a one-page essay on at least two things that you procrastinate and then develop two strategies for breaking each of these habits.

Although the individual may use monthly or weekly lists, a list also can assist in coordinating daily operations. This daily list, however, should not be longer than what can be realistically accomplished in 1 day; otherwise, it demotivates instead of assists.

In addition, although the leader-manager must be cognizant of and plan for routine tasks, it is not always necessary to place them on the list because they may only distract attention from other priority tasks. Lists should allow adequate time for each task and have blocks of time built in for the unexpected. In addition, individuals who use lists to help them organize their day must be careful not to confuse importance and urgency.

Not all important things are urgent, and not all urgent things are important. This is especially true when the urgency is coming from an external source.

In addition, the individual should periodically review lists from previous days to see what was not accomplished or completed. If a task appears on a list for several successive days, the manager must reexamine it and assess why it was not accomplished. Sometimes, tasks just need to be removed from the list. This occurs when a task has low priority or when it is better done by someone else. Other times, undone tasks on the list should be discarded because they are duplicative or unimportant.

Sometimes, however, items on the list remain unaccomplished because they are not divided into steps or tasks that can be completed. Breaking a big job down into smaller parts can make the task seem more manageable. Doyle (2018) agrees, suggesting that when people feel stressed by a big job, they should ask themselves what one thing could be done in the next 24 hours to help make progress on that item. It does not need to be resolved entirely. For example, many well-meaning people begin thinking about

completing their tax returns in early January but feel overwhelmed by a project that cannot be accomplished in 1 day. If preparing a tax return is not broken down into several smaller tasks with intermediate deadlines, it may be almost perpetually procrastinated.

Some projects are not accomplished because they are not broken down into manageable tasks.

Reprioritizing The last step in time management is reprioritizing. Often, one’s priorities or list will change during a day, week, or longer because new information is received. If the individual does not take time to reprioritize after each major task is accomplished, other priorities set earlier may no longer be accurate. In addition, despite outstanding planning, an occasional crisis may erupt.

No amount of planning can prevent an occasional crisis.

If a crisis does occur, the individual may need to set aside the original priorities for the day and reorganize, communicate, and delegate a new plan reflecting the new priorities associated with the unexpected event causing the crisis.

Dealing With Interruptions All managers experience interruptions, but lower level managers typically experience the most. This occurs in part because first- and middle-level managers are more involved in daily planning than higher level managers and thus directly interact with a greater number of subordinates. In addition, many lower level managers do not have a quiet workspace or clerical help to filter interruptions.

LEARNING EXERCISE 9.4

Creating Planning Lists

Do you make a daily plan to organize what needs to be done? Mentally or on paper, develop a list of five items that must be accomplished today. Prioritize that list. Now make a list of five items that must be done this week. Prioritize that list as well.

Interruptions can cause a great deal of time wasting because attention is continually diverted from the task at hand. All managers need protected time to respond to time-sensitive phone calls or e- mails, and it is important not to be disturbed during these times unless there is an urgent request for an answer or guidance on dealing with an emergency.

Frequent work interruptions also result in situational stress and lowered job satisfaction. That’s because interruptions cause us to split our attention between what we should be doing and addressing the new demands. James Clear suggests the result of this divided attention is “half–work,” work that takes twice as long to accomplish

half as much (Rampton, 2018). Managers then need to develop skill in preventing interruptions that threaten effective time management.

Lower level managers experience more interruptions than higher level managers.

Dealing with interruptions also requires leadership skills. Leaders role model flexibility and the ability to regroup when new information or tasks emerge as priorities. Followers often look to see how their leaders are coping with change and even crisis, and their reactions often mirror those of their leaders. That is often why a staff nurse who feels harried or out of control typically finds these same feelings reflected in the individuals he or she is assigned to work with.

Time Wasters There are many time wasters, and the time wasters that are used most often vary by the individual. Four time wasters warrant special attention here (Display 9.5). The first of these surprisingly is technology, which generally has been promoted as a time saver for most people. Indeed, technology can and does save time. E-mail now makes instantaneous, asynchronous communication to multiple parties possible simultaneously, and the Internet provides virtually unlimited access to emerging, state of the science knowledge globally. In addition, social networks such as Facebook, Pinterest, and Twitter have created new opportunities for communicating in real time to vast networks of users.

DISPLAY 9.5 TIME WASTERS

1. Technology (Internet, gaming, e-mail, and social media sites) 2. Socializing 3. Paperwork overload 4. A poor filing system 5. Interruptions

Yet, this same technology increasingly consumes more and more of our time. Many individuals find themselves randomly searching the Internet or playing online games to distract themselves from the tasks at hand. In addition, the need to check and respond to so many different communication mediums (e-mail, blackberries, voice mail, pagers, and social networking sites) is time consuming in and of itself.

Finally, all this technology can make it difficult to find an appropriate balance between the need for virtual and face-to-face interaction and between work and personal life. Staying plugged in and checking e-mails nonstop throughout the day can waste time and use significant energy. This causes boundaries between work and personal life to blur.

A second time waster is socializing. Socializing with colleagues during the workday can waste significant amounts of time in a workday. Although socializing can help workers meet relationship needs or build power, it can tremendously deter productivity. This is especially true for managers with an open-door policy. Subordinates can be discouraged from taking up a manager’s time with idle chatter in several ways:

Do not make yourself overly accessible. Make it easy for people to ignore you. Try not to “work” at the nursing station, if this is possible. If charting is to be done, sit with your back to others. If you have an office, close the door. Have people make

appointments to see you. All these behaviors will discourage casual socializers.

Interrupt. When someone is rambling on without getting to the point, break in and say gently, “Excuse me. Somehow I’m not getting your message. What exactly are you saying?”

Avoid promoting socialization. Having several comfortable chairs in your office, a full candy dish, and posters on your walls that invite comments encourage socializing in your office.

Be brief. Watch your own long-winded comments and stand up when you are finished. This will signal an end to the conversation.

Schedule long-winded pests. If someone has a pattern of lengthy chatter and manages to corner you on rounds or at the nurse’s station, say, “I can’t speak with you now, but I’m going to have some free time at 11 AM. Why don’t you see me then?” Unless the meeting is important, the person who just wishes to chat will not bother to make a formal appointment. If you would like to chat and have the time to do so, use coffee breaks and lunch hours for socializing.

Other external time wasters that a manager must conquer are paperwork overload and a poor filing system. Managers are generally inundated with paper clutter, including organizational memos, staffing requests, quality assurance reports, incident reports, and patient evaluations. Because paperwork is often redundant or unnecessary, the manager needs to become an expert at handling it. Whenever possible, incoming correspondence should be handled the day it arrives; it should either be thrown away or filed according to the date to be completed. Try to address each piece of correspondence only once.

An adequate filing system also is invaluable to handling paper overload. Keeping correspondence organized in easily retrievable files rather than disorganized stacks saves time when the manager

needs to find specific information. The manager also may want to consider increased use of computerization and e-mail to reduce the paper use and to increase response time in time-sensitive communication.

Personal Time Management Personal time management refers in part to self-knowledge. Self- awareness is a leadership skill. For people who are not certain of their own short- and long-term goals, time management, in general, poses difficulties. These goals give structure to what should be accomplished today, tomorrow, and in the future. However, goals alone are not enough; a concrete plan with timelines is needed. Plans outlined in manageable steps are clearer, more realistic, and attainable. By being self-aware and setting goals accordingly, people determine how their time will be spent. If goals are not set, others often end up deciding how a person should spend his or her time.

Indeed, many college students often report feeling time challenged and overwhelmed by their numerous academic, work, and personal commitments. This may reflect a lack of priority or goal setting or it may simply reflect too many things to be reasonably accomplished in the time frame given. Indeed, Greene and Maggs (2015) note that during college, class attendance is discretionary, clubs and organizations vie for members, and employment becomes an important strategy to offset tuition and living expenses. Students must learn to navigate the demands of this new environment in order to maximize their present and future well-being.

To better understand how college students allocate their time, Greene and Maggs (2015) examined longitudinal diary data of college students. They found that the amount of time college students devote to employment and leisure has increased over the past 40 years. They also found support for their hypothesis that increasing time in one productive activity resulted in less time

available for other productive activities. On days when students spent more time than average on employment, they spent less time on academics. These findings suggested that students may be trading academic time for more time in employment, and thus, their time management is more focused on meeting short-term goals than long-term goals.

Think for a moment about last week. Did you accomplish all that you wanted to accomplish? How much time did you or others waste? In your clinical practice, did you spend your time hunting for supplies and medicines instead of teaching your patient about his or her diabetes? Too often, irrelevant decisions and insignificant activities take priority over real purposes. Clearly, work redesign, clarification of job descriptions, or a change in the type of care delivery system may alleviate some of these problems. However, the same general principle holds: Individuals who are self-aware and have clearly identified personal goals and priorities have greater control over how they expend their energy and what they accomplish.

When individuals lack this self-awareness, they may find it difficult to find a balance between time spent on personal and professional priorities. Indeed, a study of more than 50,000 employees from a variety of manufacturing and service organizations found that 2 out of every 5 employees were dissatisfied with the balance between their work and their personal lives (Hansen, 2018). Effective time management then is an essential part of finding that balance between work life and personal life.

Brans (2013), building on thinking done by Benjamin Franklin more than 300 years ago, suggests that there are 12 habits that should be nurtured for optimum personal time management. These are shown in Display 9.6. All 12 habits are directed at being self- aware regarding what is important to accomplish in one’s life, staying focused on the things that matter, taking care of oneself, and following through in a timely and consistent manner.

DISPLAY 9.6 BRANS’S 12 HABITS TO MASTER FOR PERSONAL TIME MANAGEMENT

Habit 1: Strive to be authentic. Be honest with yourself about what you want and why you do what you do.

Habit 2: Favor trusting relationships. Build relationships with people you can trust and count on and make sure those same people can trust and count on you.

Habit 3: Maintain a lifestyle that will give you maximum energy. Exercise, eat well, and get enough sleep.

Habit 4: Listen to your biorhythms and organize your day accordingly. Pay attention to regular fluctuations in your physical and mental energy levels throughout the day and schedule tasks accordingly.

Habit 5: Set very few priorities and stick to them. Select a maximum of two things that are your highest priority and work on them.

Habit 6: Turn down things that are inconsistent with your priorities. Say no to other people when their request is not a priority for you and you do not have the time to help.

Habit 7: Set aside time for focused effort. Schedule time every day to work on just one thing.

Habit 8: Always look for ways of doing things better and faster. Watch for tasks you do over and over again and look for ways of improving how you do them.

Habit 9: Build solid processes. Set up processes that last and that run without your attention.

Habit 10: Spot trouble ahead and solve problems immediately. Set aside time to think about what lies ahead and face all problems as soon as you can.

Habit 11: Break your goals into small units of work and think only about one unit at a time. Spend most of your time

working on the task in front of you and avoid dreaming too much about the big goal.

Habit 12: Finish what is important and stop doing what is no longer worthwhile. Do not stop doing what you considered worth starting unless there is a good reason to give it up.

Source: Adapted from Brans, P. (2013). Twelve time management habits to master in 2013. Retrieved September 3, 2018, from http://www.forbes.com/sites/patbrans/2013/01/01/twelve-time-management-habits- to-master-in-2013/

In addition to being self-aware regarding the values that influence how people prioritize the use of their time, people must be self-aware regarding their general tendency to complete tasks in isolation or in combination. Some people prefer to do one thing at a time, whereas others typically do two or more things simultaneously. Some individuals begin and finish projects on time, have clean and organized desks because of handling each piece of paperwork only once, and are highly structured. Others tend to change plans, borrow and lend things frequently, emphasize relationships rather than tasks, and build longer term relationships. It is important to recognize one’s own preferred time management style and to be self-aware about how this orientation may affect one’s interaction with others in the workplace. A significant part of personal time management depends on self-awareness about how and when a person is most productive. Everyone has ways to waste time or steer clear of certain activities.

Everyone avoids certain types of work or has methods of wasting time.

Likewise, each person works better at certain times of the day or for certain lengths of time. Rampton (2018) suggests the biggest and

most challenging tasks should be addressed in the morning because most people have the greatest amount of energy in the morning. Accomplishing the most important tasks in the morning also provides a sense of accomplishment the rest of the day. Mornings may not be the most productive time, however, for everyone. Self-aware people schedule complex or difficult tasks during the periods they are most productive and simpler or routine tasks during less productive times.

Finally, each individual should be cognizant of how he or she values the time of others. For example, being punctual goes beyond common courtesy. Tardiness reflects some disregard for the value of other people’s time.

A lack of punctuality suggests that you do not value other people’s time.

Using a Time Inventory Because most people have an inaccurate perception of the time they spend on a specific task or the total amount of time they are productive during the day, a time inventory (Display 9.7) may provide insight. A time inventory allows you to compare what you planned to do, as outlined by your appointments and “to-do” entries, with what you actually did. Electronic time inventory apps such as RescueTime, Toggl, or my app Calendar can track everything you do for a week (Rampton, 2018).

DISPLAY 9.7 TIME INVENTORY

5:00 AM

6:00 AM

6:30 AM

7:00 AM

7:30 AM

8:00 AM

8:30 AM

9:00 AM

9:30 AM

10:00 AM

10:30 AM

11:00 AM

11:30 AM

12:00 PM

12:30 PM

1:00 PM

1:30 PM

2:00 PM

2:30 PM

3:00 PM

3:30 PM

4:00 PM

4:30 PM

5:00 PM

5:30 PM

6:00 PM

6:30 PM

7:00 PM

7:30 PM

8:00 PM

8:30 PM

9:00 PM

9:30 PM

10:00 PM

11:00 PM

12:00 PM

1:00 AM

2:00 AM

3:00 AM

4:00 AM

Because the greatest benefit from a time inventory is being able to objectively identify patterns of behavior, it may be necessary to maintain the time inventory for several days or even several weeks. It may also be helpful to repeat the time inventory annually to see if long-term behavior changes have been noted. Remember, there is no way to beg, borrow, or steal more hours in the day. If time is habitually used ineffectively, managing time will be very stressful.

LEARNING EXERCISE 9.5

Writing a Personal Time Inventory ASSIGNMENT:

Use the time inventory shown in Display 9.7 to identify your activities for a 24-hour period. Record your activities on the time inventory on a regular basis. Be specific. Do not trust your memory. Star the periods of time when you were most productive. Circle periods of time when you were least productive. Do not include sleep time. Was this a typical day for you? Could you have modified your activity during your least productive time periods? If so, how?

Integrating Leadership Roles and Management Functions in Time Management There is a close relationship between time management and stress. Managing time appropriately reduces stress and increases productivity. The current status of health care, the nursing shortage, and decreasing reimbursements have resulted in many health-care organizations trying to do more with less. The effective use of time management tools, therefore, becomes even more important to enable leader-managers to meet personal and professional goals.

The leadership skills needed to manage time resources draw heavily on interpersonal communication skills. The leader is a resource and role model to subordinates in how to manage time. As has been stressed in other phases of the management process, the leadership skill of self-awareness is also necessary in time management. Leaders must understand their own value system,

which influences how they use time and how they expect subordinates to use time.

The management functions inherent in using time resources wisely are more related to productivity. The manager must be able to prioritize activities of unit functioning to meet short- and long-term unit needs. To do this, the leader-manager must initiate an analysis of time management on the unit level, involve team members and gain their cooperation in maximizing time use, and guide work to its conclusion and successful implementation.

Successful leader-managers are able to integrate leadership skills and management functions; they accomplish unit goals in a timely and efficient manner in a concerted effort with subordinates. They also recognize time as a valuable unit resource and share responsibility for the use of that resource with subordinates. Perhaps most important, the integrated leader-manager with well-developed, time management skills can maintain greater control over time and energy constraints in his or her personal and professional life.

Key Concepts

■ Because time is a finite and valuable resource, learning to use it wisely is essential for effective management.

■ Time management can be reduced to three cyclic steps: (a) allow time for planning and establish priorities; (b) complete the highest priority task, and whenever possible, finish one task before beginning another; and (c) reprioritize based on remaining tasks and new information that may have been received.

■ Setting aside time at the beginning of each day to plan the day allows the manager to spend appropriate time on high- priority tasks.

■ Many individuals fall prey to planning fallacies, where they are overly optimistic about the time it will take to complete a task.

■ Making lists is an appropriate tool to manage daily tasks. This list should not be any longer than what can realistically be accomplished in a day and must include adequate time to accomplish each item on the list and time for the unexpected.

■ A common cause of procrastination is failure to break large tasks down into smaller ones so that the manager can set short-term, intermediate, and long-term goals.

■ Lower level managers have more interruptions in their work than do higher level managers. This results in situational stress and lowered job satisfaction.

■ Managers must learn strategies to cope with interruptions from socializing.

■ Because so much paperwork is redundant or unnecessary, the manager needs to develop expertise at prioritizing it and eliminating unnecessary clutter at the work site.

■ An efficient filing system is invaluable to handling paper overload.

■ Personal time management refers to “the knowing of self.” Managing time is difficult if a person is unsure of his or her priorities, including personal short-term, intermediate, and long-term goals.

■ Being punctual implies that you value other people’s time and creates an imperative for them to value your time as well.

■ Effective time management is an essential part of finding that balance between work life and personal life.

■ Using a time inventory is one way to gain insight into how and when a person is most productive. It also assists in identifying internal time wasters.

Additional Learning Exercises and Applications

LEARNING EXERCISE 9.6

A Busy Day at the Public Health Agency

You work in a public health agency. It is the agency’s policy that at least one public health nurse is available in the office every day. Today is your turn to remain in the office. From 1 PM to 5 PM, you will be the public health nurse at the scheduled immunization clinic; you hope to be able to spend some time finishing your end-of-month reports, which are due at 5 PM. The office stays open

during lunch; you have a luncheon meeting with a Cancer Society group from noon to 1 PM today. The registered nurse in the office is to serve as a resource to the receptionist and handle patient phone calls and drop-ins. In addition to the receptionist, you may delegate appropriately to a clerical worker. However, the clerical worker also serves the other clinic nurses and is usually fairly busy. While you are in the office today trying to finish your reports, the following interruptions occur:

8:30 AM: Your supervisor, Anne, comes in and requests a count of the diabetic and hypertensive patients seen in the last month.

9:00 AM: An upset patient is waiting to see you about her daughter who just found out that she is pregnant.

9:00 AM: Three drop-in patients are waiting to be interviewed for possible referral to the chest clinic.

9:30 AM: The public health physician calls you and needs someone to contact a family about a child’s immunization.

9:30 AM: The dental department drops off 20 referrals and needs you to pull charts of these patients.

10:00 AM: A confused patient calls to find out what to do about the bills that he has received.

10:45 AM: Six families have been waiting since 8:30 AM to sign up for food vouchers.

11:45 AM: A patient calls about her drug use; she does not know what to do. She has heard about Narcotics Anonymous and wants more information now.

ASSIGNMENT:

How would you handle each interruption? Justify your decisions. Do not forget lunch for yourself and the two office workers. Note: Attempt your own solution before reading the possible solution presented in the back of this book.

LEARNING EXERCISE 9.7

Realistic Priority Setting

You are a registered nurse providing total patient care to four patients on an orthopedic unit during the 7 AM to 3 PM shift. Given the following patient information, prioritize your activities for the shift in eight 1-hour blocks of time. Be sure to include time for handoffs, planning your day’s activities, breaks, and lunch. Be realistic about what you can accomplish. What activities will you delegate to the next shift? What overall goals have guided your time management? What personal values or priorities were factors in setting your goals?

Room 101 A

Ms. Jones

84 years old. Fractured left hip, secondary to fall at home. Disoriented since admission, especially at night. Fall precautions ordered. Moans frequently. Being given IV pain medication every 2 hours prn. Vital signs and checks for circulation, feeling, and movement in toes ordered every 2 hours. Scheduled

for surgery at 10:30 AM. Preoperative medications scheduled for 9:30 AM and 10:00 AM. Consent yet to be signed. Family members will be here at 8:00 AM and have expressed questions about the surgery and recovery period. Patient to return from surgery at approximately 2:30 PM. Will require postoperative vital signs every 15 minutes.

Room 101 B

Ms. Wilkins

26 years old. Compound fracture of the femur with postoperative fat emboli, now resolved. Ten-pound Buck’s traction. Has been in the hospital 3 weeks. Very bored and frustrated with prolonged hospitalization. Upset about roommate who calls out all night and keeps her from sleeping. Wants to be moved to new room. Has also requested to have hair washed today. Has IV medication running at 100 mL/hour. IV antibiotic piggybacks at 8:00 AM and 12:00 PM. Oral medications at 8:00 AM, 9:00 AM, and 12:00 PM.

Room 102 A

Mr. Jenkins

47 years old. C5 quadriplegic due to diving accident 14 years ago. Two days postoperative above-knee amputation due to osteomyelitis. Cultures show methicillin-resistant Staphylococcus aureus. Strict wound isolation. Has been hospitalized for 2 weeks. Expressing great deal of anger and frustration to anyone who enters room. IV site red

and puffy. IV needs to be restarted. Dressing change of operative site ordered daily. Heat lamp treatments ordered b.i.d. to small pressure sores on coccyx. IV antibiotic piggybacks at 8:00 AM, 10:00 AM, 12:00 PM, and 2:00 PM. Main IV bag to run out at 10:00 AM. 6:00 AM laboratory results to be called to physician this morning. Needs total assistance in performing activities of daily living, such as bathing and feeding self.

Room 103 A

Mr. Novak

19 years old. Severe tear of rotator cuff in left shoulder while playing football. One-day postoperative rotator cuff repair. Very quiet and withdrawn. Refusing pain medication, which has been ordered every 2 hours prn. Says he can handle pain and does not want to “mess up his body with drugs.” He wants to be recruited into professional football after this semester. Nonverbal signs of grimacing, moaning, and inability to sleep suggest that moderate pain is present. Physician states that likelihood of Mr. Novak ever playing football again is very low but has not yet told the patient. Girlfriend frequently in room at patient’s bedside. IV infusing at 150 mL/hour. IV antibiotics at 8:00 AM and 2:00 PM. Has not had a sponge bath since admission 2 days ago.

LEARNING EXERCISE 9.8

Creating a Shift Time Inventory

You are a 3 PM to 11 PM shift coordinator for a skilled nursing facility. You are the only registered nurse on your unit this shift. All the other personnel assigned to work with you this evening are unlicensed. The unit census is 21. As the shift coordinator, your responsibility is to make shift assignments, provide needed patient treatments, administer medications, and coordinate the work of team members. This evening, you will need to administer treatments and/or medications to the following patients:

Room 101 A

Gina Adams

88 years old. Senile dementia. Resident for 6 years. Confused—strikes out at staff. Soft wrist restraints bilaterally. Has small grade 2 pressure ulcer on coccyx, which requires evaluation and dressing change each shift.

Room 102 B

Gus Taylor

64 years old. Diabetes. New resident. Bilateral above-knee amputee. Right amputation 2 weeks ago. Left amputation performed 8 years ago. Needs stump dressing on right amputation site this shift. Has developed methicillin-resistant Staphylococcus aureus in wound site. Wound isolation ordered. IV antibiotics due at 4:00 PM and 10:00 PM tonight. Blood glucose monitoring due at 4:30

PM and 9:00 PM with sliding-scale coverage.

Room 106 A

Marvin Young

26 years old. Closed head injury 5 years ago. Resident since that time. Decerebrate posturing only. Does not follow commands. Percutaneous endoscopic gastrostomy feeding tube site red and inflamed; medical doctor has not yet been notified. Needs feeding solution bag change this PM.

Room 107 A

Sheila Abood

93 years old. Functional decline. Refusing to eat. Physician has written an order not to resuscitate in the event of cardiac or respiratory failure but wants an IV line begun this PM to minimize patient dehydration. Family will also be here this PM and wants to talk about their mother’s status.

Room 109 C

Tina Crowden

89 years old. Admit from local hospital, 2 weeks postoperative left hip replacement. Anticipated length of stay —2 weeks. Arrives by ambulance at 3:30 PM. Needs to have admission assessment and paperwork completed and care plan started.

Oral Medications Schedule

Room 101 A—4 PM, 8 PM Room 101 B—4 PM, 8 PM Room 102 A—5 PM, 9 PM Room 103 B—4 PM, 10 PM Room 104 C—5 PM, 6 PM, 9 PM

Room 106 B—6 PM, 9 PM Room 108 C—9 PM Room 109 C—5 PM, 6 PM, 8 PM, 9 PM

ASSIGNMENT:

Create a time inventory from 3:00 PM to 11:30 PM using 1-hour blocks of time. Plan what activities you will do during each 1-hour block. Be sure that you start with the activities you have prioritized for the shift. Also, remember that you will be in shift report from 3:00 PM to 3:30 PM and from 11:00 PM to 11:30 PM and that you need to schedule a dinner break for yourself. Allow adequate time for planning and dealing with the unexpected. Compare the inventory that you created with other students in your class. Did you identify the same priorities? Were you more focused on professional, technical, or amenity care? Will your plan require multitasking? Was the time inventory that you created realistic? Is this a workload that you believe you could handle?

LEARNING EXERCISE 9.9

Plan Your Day

It is October of your second year as nursing coordinator for the surgical department. A copy of your appointment

calendar for Monday, October 27, follows.

Appointment Calendar for Monday, October 27

8:00 AM

Arrive at work

8:15 AM

Daily rounds with each head nurse in your area

8:30 AM

Continuation of daily rounds with head nurses

9:00 AM

Open

9:30 AM

Open

10:00 AM

Department head meeting

10:30 AM

United Givers committee

11:00 AM

United Givers committee continued

11:30 AM

Open

Noon Lunch 12:30 PM

Lunch

1:00 PM

Weekly meeting with administrator—budget and annual report due

1:30 PM

Open

2:00 PM

Infection control meeting

2:30 PM

Infection control meeting continued

3:00 Fire drill and critique of drill

PM 3:30 PM

Fire drill and critique of drill continued

4:00 PM

Open

4:30 PM

Open

5:00 PM

Off duty

You will review your unfinished business from the preceding Friday and look at the new items of business that have arrived on your desk this morning. (The new items follow the appointment calendar.) The unit ward clerk is usually free in the afternoon to provide you with 1 hour of clerical assistance, and you have a charge nurse on each shift to whom you may delegate.

1. Assign a priority to each item, with 1 being the most important and 5 being the least important.

2. Decide when you will deal with each item, being careful not to use more time than you have open on your calendar.

3. If the problem is to be handled immediately, explain how you will do this (e.g., delegated, phone call).

4. Explain the rationale for your decisions.

Correspondence Item 1 From the desk of M. Jones, personnel manager October 24 Dear Joan:

I am sending you the names of two new graduate nurses who are interested in working in your area. I have processed their applications; they seem well qualified.

Could you manage to see them as early as possible in the week? I would hate to lose these prospective employees, and they are anxious to obtain definite confirmation of employment.

Item 2 From the desk of John Brown, purchasing agent October 23 Joan:

We really must get together this week and devise a method to control supplies. Your area has used three times the amount of thermometer covers as any other area. Are you taking that many more temperatures? This is just one of the supplies your area uses excessively. I’m open to suggestions.

Item 3 Roger Johnson, MD, chief of surgical department October 24 Ms. Kerr:

I know you have your budget ready to submit, but I just remembered this week that I forgot to include an arterial pressure monitor. Is there another item that we can leave out? I’ll drop by Monday morning, and we’ll figure something out.

Item 4 October 23 Ms. Kerr:

The following personnel are due for merit raises, and I must have their completed and signed evaluations by Tuesday afternoon: Mary Rocas, Jim Newman, Marge Newfield. M. Jones, personnel manager

Item 5 Roger Johnson, MD, chief of surgical department October 23 Ms. Kerr:

The physicians are complaining about the availability of nurses to accompany them on rounds. I believe you and I need to sit down with the doctors and head nurses to discuss this recurring problem. I have some free time Monday afternoon.

Item 6 5 AM Joan:

Sally Knight (your regular night registered nurse) requested a leave of absence due to her mother’s illness. I told her it would be OK to take the next three nights off. She is flying out of town on the 9 AM commuter flight to San Francisco, so phone her right away if you don’t want her to go. I felt I had no choice but to say yes. Nancy Peters, night supervisor P.S. You’ll need to find a replacement for her for the next three nights.

Item 7 To: Ms. Kerr From: Administrator Re: Patient complaint Date: October 23

Please investigate the following patient complaint. I would like a report on this matter this afternoon. Dear Sir:

My mother, Gertrude Boswich, was a patient in your hospital, and I just want to tell you that no member of my

family will ever go there again. She had an operation on Monday, and no one gave her

a bath for 3 days. Besides that, she didn’t get anything to eat for 2 days, not even water. What kind of a hospital do you run anyway? Elmo Boswich

Item 8 To: Joan Kerr From: Nancy Newton, RN, head nurse Re: Problems with X-ray department Date: October 23

We have been having problems getting diagnostic x- ray procedures scheduled for patients. Many times, patients have had to stay an extra day to get x-ray tests done. I have talked to the radiology chief several times, but the situation hasn’t improved. Can you do something about this?

Item 9 To: All department heads From: Storeroom Re: Supplies Date: October 23

The storeroom is out of the following items: toilet tissue, paper clips, disposable diapers, and pencils. We are expecting a shipment next week.

Telephone Messages Item 10

Sam Surefoot, Superior Surgical Supplies, Inc., returned your call at 7:50 AM on October 27. He will be at the hospital this afternoon to talk about problems with defective equipment received.

Item 11 Donald Drinkley, Channel 32-TV, called at 8:10 AM on

October 27 to say he will be here at 11:30 AM to do a feature story on the open-heart unit.

Item 12 Lila Green, director of nurses at St. Joan’s Hospital,

called at 8:05 AM on October 24 about a phone reference on Jane Jones, RN. Ms. Jones has applied for a job there. Isn’t that the one we fired last year?

Item 13 Betty Brownie, Bluebird Troop 35, called at 8 AM on

October 27 about the Bluebird Troop visit to patients on Halloween with trick-or-treat candy. She will call again.

LEARNING EXERCISE 9.10

Avoiding Crises

Some people always seem to manage by crisis. The following scenarios depict situations that likely could have been avoided with better planning. Write down what could have been done to prevent the crisis. Then outline at least three alternatives to deal with the problem, as it already exists.

It is the end of your 8-hour shift. Your team members are ready to go home. You have not yet begun to chart on any of your six patients. You have neither completed your intake/output totals nor given patients the medications that were due 1 hour ago. The arriving shift asks you to give your handoff report now.

You need to use the home computer to write your midterm essay, which is due tomorrow, but your mother is online doing the family’s taxes, which must be mailed by midnight. The taxes will likely take several additional hours.

Your computer hard drive crashes when you try to print your term paper, which is due tomorrow.

An elderly, frail patient pulls out her intravenous line. You make six attempts, over a 1-hour period, to restart the line but are unsuccessful. You have missed your lunch break and, now, must choose between taking time for lunch and finishing your shift on time.

LEARNING EXERCISE 9.11

The Need to Reprioritize (Marquis & Huston, 2012)

You have just arrived home from a long day at school (it’s 4 PM on Wednesday) and sit down to look at your to- do list for the week. You have several major deadlines looming and are aware that you have procrastinated their

completion far too long. Items on your list that must be completed by week’s end include the following:

1. You have a 15-page term paper due in your leadership class on Friday (9 AM), which you have not begun. This will require 3 to 4 hours of literature review before you can begin and likely 4 to 6 hours to write the paper. There is a 10% loss of points for every day the paper is late, including weekends.

2. You have to create clinical preparation sheets tonight for the four medical/surgical patients you will be caring for tomorrow (Thursday) at the hospital (7:00 AM to 3:30 PM). Each of these preparation sheets will take approximately 30 minutes to complete. These preparation sheets will be used to provide patient care tomorrow and will be discussed at the postclinical conference from 3:30 PM to 4:30 PM.

3. You have a test tomorrow night (Thursday) in your political science class, which begins at 7 PM. You have read the materials but want to review them one last time because the test counts for 25% of your grade.

4. You need to finish writing your reflective journal analysis, a weekly assignment for your clinical course. The analysis is typically 4 to 6 pages and reflects what you learned in your clinical experiences each week. It is due by noon on Friday.

5. You are the maid of honor for your best friend’s wedding and as such are responsible for hosting her bridal shower on Saturday afternoon. You have not yet purchased the food or bought the materials you need for the activities you have planned. You also realize that your apartment is a mess and that it needs cleaned before guests arrive.

6. Your car is critically low on oil. The oil light has been on for the last week, and you know that you are likely to burn up the engine if you keep driving it. You must take it in for an oil change immediately because the campus and hospital are too far away to take your bike and there is no public transportation system.

As you create your time inventory for the next 4 days, you realize just how tight your schedule is. If you work until at least midnight each night and get up just in time to make it to clinical and class (6:00 AM), you should be able to get everything done.

At 6 PM, the phone rings. It is one of your peers from school. She has just broken up with her fiancé and is in a crisis state. She asks that you come over right away and stay with her as she does not want to be alone. In addition, shortly after you hang up the phone, your roommate knocks on your door and says she needs to have a conversation with you about the “house rules” the two of you set. She says the rules are not working and that she has grown increasingly frustrated the last week. She wants to resolve the conflict right now and is threatening to move out. Finally, there is a knock at the door. One of your neighbors tells you that he just saw your dog running down the street. The gate must have been left open when your roommate returned home.

ASSIGNMENT:

How will you reprioritize your plans for this evening as well as the rest of the week? Can any items be eliminated from your list? Can any items be further procrastinated? What satisficing choices will you make regarding the items you will accomplish from your to-do list for the week?

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Marquis, B., & Huston, C. (2012). Leadership and management tools for the new nurse. Philadelphia, PA: Lippincott Williams &

Wilkins. Price, A. (2018). 4 Reasons why teens can’t stop procrastinating.

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10

Fiscal Planning and Health- Care Reimbursement

. . . nurses are practicing caring in an environment where the economics and costs of health care permeate discussions and impact decisions.—Marian C. Turkel

. . . the trouble with a budget is that it’s hard to fill up one hole without digging another.—Dan Bennett

. . . Don’t tell me what you value, show me your budget, and I’ll tell you what you value.—Joe Biden

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential V: Health-care policy, finance, and regulatory environments

MSN Essential II: Organizational and systems leadership MSN Essential III: Quality improvement and safety MSN Essential VI: Health policy and advocacy AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency V: Business skills ANA Standard of Professional Performance 10: Collaboration ANA Standard of Professional Performance 11: Leadership

ANA Standard of Professional Performance 14: Quality of practice

ANA Standard of Professional Performance 16: Resource utilization

QSEN Competency: Quality improvement QSEN Competency: Safety

LEARNING OBJECTIVES

The learner will:

define basic fiscal terminology differentiate among the three major types of budgets (personnel, operating, and capital) and the four most common budgeting methods (incremental, zero-based, flexible, and new performance budgeting)

identify the strengths and weaknesses of flexible budgets recognize the need to involve subordinates and followers in fiscal planning whenever possible

design a decision package to aid in fiscal priority setting anticipate, recognize, and creatively problem solve budgetary constraints

accurately compute the standard formula for calculating nursing care hours per patient-day

describe the impetus for the development of diagnosis-related groups, the prospective payment system, and other managed care initiatives

describe the resulting impact on cost and quality when health-care reimbursement shifted from a health-care system dominated by third-party, fee-for-service plans to capitated, managed care programs

describe the impact of the increasing shift in government and private insurer reimbursement from volume to value based

recognize that rapidly changing federal and state reimbursement policies make long-range budgeting and planning very difficult for health-care organizations

discuss how spiraling health-care costs that had little relationship to health-care outcomes led to comprehensive health-care reform in the United States in 2010

describe key components of the Patient Protection and Affordable Care Act (PPACA or ACA) as well as its implementation plan between 2010 and 2014

consider how current legislative efforts to repeal the ACA and the elimination of the “individual mandate” to have health insurance may affect health care in the future

describe why nurses need to understand and actively be involved in fiscal planning and health-care reform

Introduction For at least 30 years, health-care organizations have faced unprecedented financial challenges because of shrinking reimbursement and rising costs. Regulatory controls have tightened, quality expectations have risen, and the public is increasingly demanding more and higher quality services at little to no out-of-pocket cost.

In addition, costs for health care have soared. In a recent Gallup poll, Americans cited the high cost of health care as their number one financial concern (Allen, 2017). The Kaiser Family Foundation (2017) notes that the average annual premiums for employer-sponsored health insurance in 2017 was $6,690 for single coverage and $18,764 for family coverage, an increase of 19% since 2012 and 55% since 2007, respectively. This translates into the “typical family” paying about 35% of their income for health care in 2016 (Moffit, 2016).

In addition, as we entered the second decade of the 21st century, 44 million people in the United States lacked any type of health insurance and an even greater number were underinsured (Huston, 2020). Of the

millions of people who were too poor to afford health insurance, many did not qualify for federally provided health insurance. In addition, small businesses, in tough economic times, lacked the resources to provide health insurance benefits to all employees (ObamaCare Facts, n.d.). All these factors suggested a need for health-care reform that provided universal health-care insurance coverage.

Comprehensive, systematic efforts to reform this clearly broken health-care system achieved no real momentum, however, until late in the first decade of the 21st century. Even then, convergence on proposals for reform was limited, so the relatively swift passage of controversial national health-care reform in the United States in March 2010 came as a surprise to many. This legislation the Patient Protection and Affordable Care Act (PPACA), hereafter called the Affordable Care Act (ACA), promised significant reductions in numbers of uninsured, greater access to coverage for those with preexisting conditions, and mandated health-care insurance provision by employers. Provisions of the ACA are discussed later in this chapter.

In addition, health-care reform accelerated a shift in reimbursement from volume to value to remove incentives for redundant and inappropriate care. Unlike volume, which simply considers how much of a product is purchased, value considers quality, efficiency, safety, and cost. The ACA’s payment reform provisions included value-based purchasing (VBP), accountable care organizations (ACOs), bundled payments, the medical home, and the health insurance marketplace, all of which are based on value and discussed later in this chapter.

Great change also occurred in fiscal planning at the organizational level over the past three decades in terms of scope of responsibility and accountability for cost and outcomes. Nurse leader-managers in the 21st century are expected to be fiscally knowledgeable because nursing budgets generally account for the greatest share of health-care institutional expenses. Yet, shrinking resources and increasing demands increasingly pose challenges for nursing managers.

Fiscal planning is not intuitive; it is a learned skill that improves with practice.

Unfortunately, many nurses perceive fiscal planning to be the most difficult type of planning. This is often the result of inadequate formal education or training on budget preparation as well as forecasting (making an educated budget estimate by using historical data). It is important to remember that fiscal planning is an acquired skill that improves with use; that’s because it requires vision; creativity; and a thorough knowledge of the political, social, and economic forces that shape health care. Fiscal planning, then, must be included in nursing program curricula and in management preparation programs.

This chapter discusses the leader-manager’s role in fiscal planning, identifies types of budgets, and delineates the budgetary process. Learners will also examine health-care reimbursement concepts with specific attention given to the recent change from volume-based reimbursement to value-based reimbursement. The leadership roles and management functions involved in fiscal planning are outlined in Display 10.1.

DISPLAY 10.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN FISCAL PLANNING

Leadership Roles 1. Is visionary in identifying or forecasting short- and long-term unit

needs, thus inspiring proactive rather than reactive fiscal planning

2. Is knowledgeable about political, social, and economic factors that shape fiscal planning and reimbursement in health care today

3. Demonstrates flexibility in fiscal goal setting in a rapidly changing system

4. Anticipates, recognizes, and creatively solves budgetary constraints

5. Influences and inspires group members to become active in short- and long-range fiscal planning

6. Recognizes when fiscal constraints have resulted in an inability to meet organizational or unit goals and communicates this insight effectively, following the chain of command

7. Ensures that patient safety is not jeopardized by cost containment

8. Role models leadership in needed health-care reform efforts 9. Proactively prepares followers for the plethora of changes in

health care associated with health-care reform and implementation of the Patient Protection and Affordable Care Act

Management Functions 1. Identifies the importance of and develops short- and long-range

fiscal plans that reflect unit needs 2. Articulates and documents unit needs effectively to higher

administrative levels 3. Assesses the internal and external environment of the

organization in forecasting to identify driving forces and barriers to fiscal planning

4. Demonstrates knowledge of budgeting and uses appropriate techniques to budget effectively

5. Provides opportunities for subordinates to participate in relevant fiscal planning

6. Coordinates unit-level fiscal planning to be congruent with organizational goals and objectives

7. Accurately assesses personnel needs by using predetermined standards or an established patient classification system

8. Coordinates the monitoring aspects of budget control 9. Ensures that documentation of patients’ need for services and

services rendered is clear and complete to facilitate organizational reimbursement

10. Collaborates with other health-care administrators to proactively determine how health-care reform initiatives such as value- based purchasing, accountable care organizations, bundled payments, the medical home, and the health insurance marketplace may impact organizational viability and the provision of services

Balancing Cost and Quality Complicating fiscal planning in health-care organizations today are the dual goals of cost containment and quality care. Cost containment refers to the effective and efficient delivery of services while generating needed revenues for operations. Cost containment is the responsibility of every health-care provider, and the viability of most health-care organizations today depends on their ability to use their fiscal resources wisely.

Being cost-effective, however, is not the same as being inexpensive; cost-effective means producing good results for the money spent; in other words, the product is worth the price (YourDictionary, 2018). Expensive items can be cost-effective, and inexpensive items may not. Cost-effectiveness then must consider factors such as anticipated

length of service, need for such a service, and availability of other alternatives.

In addition, cost and quality do not necessarily have a linear relationship in health care. Sometimes, high spending represents a duplication of services, an overutilization of services, and the use of technology that exceeds a specific patient’s needs. In fact, numerous studies over the past decade have examined the relationship between higher spending and the quality and outcomes of care and found that higher spending does not necessarily result in better quality care.

Spending more does not always equate to better quality health outcomes.

These findings are true on the macrolevel as well. The US health- care system is the most expensive in the world, spending almost twice as much on health care, as a percentage of its economy, in 2016, as other advanced industrialized countries—totaling $3.3 trillion, or 17.9% of gross domestic product (GDP) (Frakt & Carroll, 2018).Yet, our outcomes in terms of teenage pregnancy rates, low-birth-weight infants, and access to care are worse than many countries that spend significantly less.

In addition, health-care costs are simply higher in the United States. Frakt and Carroll (2018) agree, noting that Americans don’t consume significantly more health care than citizens in other industrialized countries; they’re just paying more for that care. For example, the average cost of a magnetic resonance imaging (MRI) in the United States in 2015 was $1,119, compared to $811 in New Zealand (Mack, 2017). An MRI in Spain averaged $130. Similarly, the average cost of an appendectomy in the United States was $15,930, whereas it was $8,009 in the United Kingdom and only $3,814 in Australia (Mack, 2017). Similarly, pharmaceuticals cost far more in the United States because of government protected “monopoly” rights for drug manufacturers. The problem then is not a scarcity of resources. The

problem is that we do not use the resources we have available in a cost-effective manner.

Responsibility Accounting An essential feature of fiscal planning is responsibility accounting, which means that each of an organization’s revenues, expenses, assets, and liabilities is someone’s responsibility. The leader-manager at the unit level then should be an active participant in unit budgeting, have a high degree of control over what is included in the unit budget, receive regular data reports that compare actual expenses with budgeted expenses, and be held accountable for the financial results of the operating unit.

The unit manager also can best monitor and evaluate all aspects of a unit’s budget control. Like other types of planning, the unit manager has a responsibility to communicate budgetary planning goals to the staff. The more the staff understands the budgetary goals and the plans to carry out those goals, the more likely the goal attainment is. Sadly, many nurses have little knowledge of the nursing budget model used by their hospital system.

Budget Basics A budget is a financial plan that includes estimated expenses as well as income for a set period of time. Accuracy dictates the worth of a budget; the more accurate the budget blueprint, the better the institution can plan the most efficient use of its resources.

The budget’s value is directly related to its accuracy.

Because a budget is at best a prediction, a plan, and not a rule, however, fiscal planning requires flexibility, ongoing evaluation, and revision. In the budget, expenses are classified as fixed or variable and either controllable or noncontrollable. Fixed expenses do not vary with

volume, whereas variable expenses do. Examples of fixed expenses might be a building’s mortgage payment or a manager’s salary; variable expenses might include the payroll of hourly wage employees and the cost of supplies.

Controllable expenses can be controlled or varied by the manager, whereas noncontrollable expenses cannot. For example, the unit manager can control the number of personnel working on a certain shift and the staffing mix; he or she cannot, however, control equipment depreciation, the number and type of supplies needed by patients, or overtime that occurs in response to an emergency. A list of the fiscal terminology that a manager needs to know is shown in Display 10.2.

DISPLAY 10.2 FISCAL TERMINOLOGY

Accountable care organizations—groups of providers and suppliers of service who work together to better coordinate care for Medicare patients (does not include Medicare Advantage) across care settings

Acuity index—weighted statistical measurement that refers to severity of illness of patients for a given time. Patients are classified according to acuity of illness, usually in one of four categories. The acuity index is determined by taking a total of acuities and then dividing by the number of patients.

Affordable Care Act—officially known as the Patient Protection and Affordable Care Act, this act passed in March 2010 to provide more Americans access to affordable health insurance

Assets—financial resources that a health-care organization receives, such as accounts receivable

Baseline data—historical information on dollars spent, acuity level, patient census, resources needed, hours of care, and so forth. This information is used as basis on which future needs can be projected.

Break-even point—point at which revenue covers costs. Most health-care facilities have high fixed costs. Because per-unit fixed costs in a noncapitated model decrease with volume, health-care facilities under this model need to maintain a high volume to decrease unit costs.

Bundled payment—a payment structure in which different health- care providers who are treating a patient for the same or related conditions are paid an overall sum for taking care of that condition rather than being paid for each individual treatment, test, or procedure. In doing so, providers are rewarded for coordinating care, preventing complications and errors, and reducing unnecessary or duplicative tests and treatments (HealthCare.gov, n.d., para. 1).

Capitation—a prospective payment system (PPS) that pays health plans or providers a fixed amount per enrollee per month for a defined set of health services, regardless of how many (if any) services are used

Case mix—type of patients served by an institution. A hospital’s case mix is usually defined in such patient-related variables as type of insurance, acuity levels, diagnosis, personal characteristics, and patterns of treatment.

Cash flow—rate at which dollars are received and dispersed Controllable costs—costs that can be controlled or that vary. An

example would be the number of personnel employed, the level of skill required, wage levels, and quality of materials.

Cost–benefit ratio—numerical relationship between the value of an activity or procedure in terms of benefits and the value of the activity’s or procedure’s cost. The cost–benefit ratio is expressed as a fraction.

Cost center—smallest functional unit for which cost control and accountability can be assigned. A nursing unit is usually considered a cost center, but there may be other cost centers within a unit (orthopedics is a cost center, but often, the cast room is considered a separate cost center within orthopedics).

Diagnosis-related groups (DRGs)—rate-setting PPS used by Medicare to determine payment rates for an inpatient hospital stay based on admission diagnosis. Each DRG represents a case type for which Medicare provides a flat dollar amount of reimbursement. This set rate may be higher or lower than the cost of treating the patient in a particular hospital.

Direct costs—costs that can be attributed to a specific source, such as medications and treatments; costs that are clearly identifiable with goods or service

Fee-for-service (FFS) system—a reimbursement system whereby insurance companies reimburse health-care providers a billed amount for services after the services are delivered

Fixed budget—style of budgeting that is based on a fixed, annual level of volume, such as number of patient-days or tests performed, to arrive at an annual budget total. These totals are then divided by 12 to arrive at the monthly average. The fixed budget does not make provisions for monthly or seasonal variations.

Fixed costs—costs that do not vary according to volume. Examples of fixed costs are mortgage or loan payments.

For-profit organization—organization in which the providers of funds have an ownership interest in the organization. These providers own stocks in the for-profit organization and earn dividends based on what is left when the cost of goods and of carrying on the business is subtracted from the amount of money taken in.

Full costs—total of all direct and indirect costs Full-time equivalent (FTE)—number of hours of work for which a

full-time employee is scheduled for a weekly period. For example, 1.0 FTE = five 8-hour days of staffing, which equals 40 hours of staffing per week. One FTE can be divided in different ways. For example, two part-time employees, each working 20 hours per week, would equal 1 FTE. If a position requires coverage for more than 5 days or 40 hours per week, the FTE will be greater than 1.0 for that position. Assume a position requires 7-day coverage, or 56 hours, then the position requires 1.4 FTE coverage (56 / 40 = 1.4). This means that more than one person is needed to fill the FTE positions for a 7-day period.

Health maintenance organization—historically, a prepaid organization that provided health care to voluntarily enrolled members in return for a preset amount of money on a per- person, per-month basis; often referred to as a managed care organization

Hours per patient-day (HPPD)—hours of nursing care provided per patient per day by various levels of nursing personnel. HPPD are

determined by dividing total production hours by the number of patients.

Indirect costs—costs that cannot be directly attributed to a specific area. These are hidden costs and are usually spread among different departments. Housekeeping services are considered indirect costs.

International Classification of Disease (ICD) codes—coding used to report the severity and treatment of patient diseases, illnesses, and injuries to determine appropriate reimbursement; currently in its 10th revision (ICD-10)

Managed care—term used to describe a variety of health-care plans designed to contain the cost of health-care services delivered to members while maintaining the quality of care

Medicaid—federally assisted and state-administered program to pay for medical services on behalf of certain groups of low-income individuals. Generally, these individuals are not covered by Social Security. Certain groups of people (e.g., older adults, blind, disabled, members of families with dependent children, and certain other children and pregnant women) also qualify for coverage if their incomes and resources are sufficiently low.

Medicare—nationwide health insurance program authorized under Title 18 of the Social Security Act that provides benefits to people aged 65 years or older. Medicare coverage also is available to certain groups of people with catastrophic or chronic illness, such as patients with renal failure requiring hemodialysis, regardless of age.

Noncontrollable costs—indirect expenses that cannot usually be controlled or varied. Examples might be rent, lighting, and depreciation of equipment.

Not-for-profit organization—this type of organization is financed by funds that come from several sources, but the providers of these funds do not have an ownership interest. Profits generated in the not-for-profit organization are frequently funneled back into the organization for expansion or capital acquisition.

Operating expenses—daily costs required to maintain a hospital or health-care institution

Patient classification system—method of classifying patients. Different criteria are used for different systems. In nursing, patients are usually classified according to acuity of illness.

Pay for performance (also known as P4P) programs—incentives are paid to providers to achieve a targeted threshold (typically a process or outcome measure) of clinical performance, typically a process or outcome measure associated with a specified patient population

Pay for value programs—incentive payments that are linked to both quality and efficiency improvements

Preferred provider organization (PPO)—health-care financing and delivery program with a group of providers, such as physicians and hospitals, who contract to give services on an FFS basis. This provides financial incentives to consumers to use a select group of preferred providers and pay less for services. Insurance companies usually promise the PPO a certain volume of patients and prompt payment in exchange for fee discounts.

Production hours—total amount of regular time, overtime, and temporary time. This also may be referred to as actual hours.

Prospective payment system—a hospital payment system with predetermined reimbursement ratio for services given

Revenue—source of income or the reward for providing a service to a patient

Staffing mix—ratio of registered nurses (RNs), licensed vocational nurses (LVNs)/licensed practical nurses (LPNs), and unlicensed workers (e.g., a shift on one unit might have 40% RNs, 40% LPNs/LVNs, and 20% others). Hospitals vary on their staffing mix policies.

Third-party payment system—a system of health-care financing in which providers deliver services to patients, and a third party, or intermediary, usually an insurance company or a government agency, pays the bill

Turnover ratio—rate at which employees leave their jobs for reasons other than death or retirement. The rate is calculated by dividing the number of employees leaving by the number of workers employed in the unit during the year and then by multiplying by 100.

Value-based purchasing—a payment methodology that rewards quality of care through payment incentives

Variable costs—costs that vary with the volume. Payroll costs are an example.

Workload units—in nursing, workloads are usually the same as patient-days. For some areas, however, workload units might refer to the number of procedures, tests, patient visits, injections, and so forth.

Steps in the Budgetary Process The nursing process provides a model for the steps in budget planning:

1. The first step is to assess what needs to be covered in the budget. Generally, this determination should reflect input from all levels of the organizational hierarchy because budgeting is most effective when all personnel using the resources are involved in the process.

2. The second step is diagnosis. In the case of budget planning, the diagnosis would be the goal or what needs to be accomplished, which is to create a cost-effective budget that maximizes the use of available resources. Unfortunately, some managers artificially inflate their department budgets as a cushion against budget cuts. If several departments partake in this unsound practice, the entire institutional budget may be ineffective. If a major change in the budget is indicated, the entire budgeting process must be repeated. Top-level managers must watch for and correct unrealistic budget projections before they are implemented.

3. The third step is to develop a plan. The budget plan may be developed in many ways. A budgeting cycle that is set for 12 months is called a fiscal-year budget. This fiscal year, which may or may not coincide with the calendar year, is then usually broken down into quarters or subdivided into monthly or semiannual periods.

Most budgets are developed for a 1-year period, but a perpetual budget may be done on a continual basis each month so that 12 months of future budget data are always available. Selecting the optimal time frame for budgeting is also important. Errors are more likely if the budget is projected too far in advance. If the budget is shortsighted, compensating for unexpected major expenses or purchasing capital equipment may be difficult.

4. The fourth step is implementation. In this step, ongoing monitoring and analysis occur to avoid inadequate or excess funds at the end of the fiscal year. In most health-care institutions, monthly statements outline each department’s projected budget and deviations from that budget.

5. The last step is evaluation. The budget must be reviewed periodically and modified as needed throughout the fiscal year. Each unit manager is accountable for budget deviations in his or her unit. Most units can expect some change from the anticipated budget, but large deviations must be examined for possible causes and remedial action taken if necessary.

A budget that is predicted too far in advance has greater probability for error.

LEARNING EXERCISE 10.1

Would You Accept This Gift?

You are the director of the education department in a 40- bed, rural, critical access hospital. A simulation vendor has offered to give you a 5-year-old, used, high-fidelity manikin for staff development training purposes (cardiopulmonary resuscitation, advanced cardiac life support, pediatric advanced life support, annual skills updates). His only request is that all supplies used with the manikin and the maintenance contract be purchased through his company. The chief nursing officer is very excited about the offer and has asked all the unit directors to consider how the manikin might be used for their staff training needs. The hospital currently does not have the funds available to purchase a new manikin.

ASSIGNMENT:

1. Justify acceptance or rejection of the gift. What influenced your choice?

2. What are the fixed and variable costs? 3. What are the controllable and noncontrollable

costs? 4. What factors determine whether this gift is cost-

effective? 5. Who will have control over how and when the

manikin is used?

Types of Budgets Three major types of budgets that the nurse-manager may be directly involved in with fiscal planning are personnel, operating, and capital budgets.

The Personnel Budget

The largest of the budget expenditures is the workforce or personnel budget because health care is labor-intensive. To handle fluctuating patient census and acuity, managers need to use historical data about unit census fluctuations in forecasting short- and long-term personnel needs. Likewise, a manager must monitor the personnel budget closely to prevent understaffing or overstaffing. As patient-days or volume decreases, managers must decrease personnel costs in relation to the decrease in volume.

The largest of the budget expenditures is the workforce or personnel budget because health care is labor-intensive.

In addition to numbers of staff, the manager must be cognizant of the staffing mix. Staffing mix refers to the mix (percentages) of licensed (registered nurse [RN] and licensed vocational nurse [LVN]) and unlicensed assistive personnel (certified nursing assistant [CNA]/nursing assistive personnel) working at a given time. The manager must also be aware of the patient acuity so that the most economical level of nursing care that will meet patient needs can be provided.

Although Unit V discusses staffing, it is necessary to briefly discuss here how staffing needs are expressed in the personnel budget. Most staffing is based on a predetermined standard. This standard may be addressed in hours per patient-day (HPPD) (medical units), visits per month (home health agencies), or minutes per case (the operating room). Because the patient census, number of visits, or cases per day never remains constant, the manager must be ready to alter staffing when volume increases or decreases.

The standard formula for calculating nursing care hours per patient- day (NCH/PPD) is shown in Figure 10.1.

FIGURE 10.1 Standard formula for calculating nursing care hours per patient-day (NCH/PPD). (Copyright © 2006 Lippincott Williams & Wilkins. Instructor’s Resource CR-ROM to Accompany Leadership Roles and Management Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.)

A unit manager in an acute care facility might use this formula to calculate daily staffing needs. For example, assume that your budgeted NCH are 6 NCH/PPD. You are calculating the NCH/PPD for today, January 31; at midnight, it will be February 1. The patient census at midnight is 25 patients. In checking staffing, you find the following information:

Shift Staff on Duty Hours Worked

11:00 PM (1/30) to 7:00 AM (1/31)

2 RNs 8 h each

1 LVN 8 h 1 CNA 8 h

7:00 AM to 3:00 PM (1/31)

3 RNs 8 h each

2 LVNs 8 h each 1 CNA 8 h 1 ward clerk 8 h

3:00 PM to 11:00 PM (1/31)

2 RNs 8 h each

2 LVNs 8 h each 1 CNA 8 h 1 ward clerk 8 h

11:00 PM (1/31) to 7:00 AM (2/1)

2 RNs 8 h each

2 LVNs 8 h each 1 CNA 8 h

RNs, registered nurses; LVNs, licensed vocational nurses; CNA, certified nursing assistant.

Ideally, you would use 12 midnight to compute the NCH/PPD for January 31, but most staffing calculations based on traditional 8-hour shifts are made beginning at 11:00 PM and ending at 11:00 PM the following night. Therefore, in this case, it would be acceptable to figure the NCH/PPD for January 31 by using numerical data from the 11:00 PM to 7:00 AM shift last night and the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts today. The first step in this calculation requires a computation of total NCH worked in 24 hours (including the ward clerk’s

hours). This can be calculated by multiplying the total number of staff on duty each shift by the hours each worked in their shift. Each shift total then is added together to get the total number of nursing hours worked in all three shifts or 24 hours: The nursing hours worked in 24 hours are 136 hours.

The second step in solving NCH/PPD requires that you divide the nursing hours worked in 24 hours by the patient census. The patient census in this case is 25. Therefore, 136 / 25 = 5.44.

The NCH/PPD for January 31 was 5.44, which is less than your budgeted NCH/PPD of 6.0. It would be possible to add up to 14 additional hours of nursing care in the next 24 hours and still maintain the budgeted NCH standard. However, the unit manager must remember that the standard is flexible and that patient acuity and staffing mix may suggest the need for even more staff for February 1 than the budgeted NCH/PPD.

The personnel budget includes actual worked time (also called productive time or salary expense) and time that the organization pays the employee for not working (nonproductive or benefit time). Nonproductive time includes the cost of benefits, new employee orientation, employee turnover, sick and holiday time, and education time. For example, the average 8.5-hour shift includes a 30-minute lunch break and two 15-minute breaks. Thus, this employee would work 7.5 productive hours and have 1.0 hours of nonproductive time.

LEARNING EXERCISE 10.2

Calculating Nursing Care Hours per Patient-Day

Calculate the nursing care hours per patient-day (NCH/PPD) if the midnight census is 25, but use the

following as the number of hours worked:

12 midnight to 12 noon 2 RNs 12 h each

2 LVNs 12 h each 1 CNA 12 h 1 ward clerk 5 h

12 noon to 12 midnight 3 RNs 12 h each

2 LVNs 12 h each 1 CNA 12 h 1 ward clerk 12 h

Now, calculate the NCH/PPD if the following staff were working:

12 midnight to 12 noon 3 RNs 12 h each

1 LVN 12 h 12 noon to 12 midnight 2 RNs 12 h each

1 LVN 12 h 1 ward clerk 4 h

RNs, registered nurses; LVNs, licensed vocational nurses; CNA, certified nursing assistant.

The Operating Budget The operating budget is the second area of expenditure that involves all managers. The operating budget reflects expenses that change in response to the volume of service, such as the cost of electricity,

repairs and maintenance, and supplies. Although personnel costs lead the hospital budget, the cost of supplies typically runs a close second.

Next to personnel costs, supplies are typically the second most significant component in the hospital budget.

Effective unit managers should be alert to the types and quantities of supplies used in their unit. They should also understand the relationship between supply use and patient mix, occupancy rate, technology requirements, and types of procedures performed on the unit. Saving unused supplies from packs or trays, reducing obsolete and slow-moving inventory, eliminating pilferage, and monitoring the uncontrolled usage of supplies and giveaways all represent potential cost savings. Other ways to cut supply costs might be in rental versus facility-owned equipment, stocking products on consignment, and just- in-time stockless inventory. Just-in-time ordering is a process whereby inventory is delivered to the organization by suppliers only when it is needed and immediately before it is to be used.

The Capital Budget The third type of budget used by managers is the capital budget. Capital budgets plan for the purchase of buildings or major equipment, which include equipment that has a long life (usually greater than 5 to 7 years), is not used in daily operations, and is more expensive than operating supplies. Examples of these types of capital expenditures might include the acquisition of a positron emission tomography imager or the renovation of a major wing in a hospital. The short-term component of the capital budget includes equipment purchases within the annual budget cycle, such as call-light systems, hospital beds, and medication carts.

Often, the designation of capital equipment requires that the value of the equipment exceed a certain dollar amount. That dollar amount will vary from institution to institution, but $5,000 is common. Managers are

usually required to complete specific capital equipment request forms to justify their request.

Budgeting Methods Budgeting is frequently classified according to how often it occurs and the base on which budgeting takes place. Four of the most common budgeting methods are incremental budgeting (also called flat- percentage increase budgeting), zero-based budgeting, flexible budgeting, and performance budgeting.

Incremental Budgeting Incremental or the flat-percentage increase method is the simplest method for budgeting. By multiplying current-year expenses by a certain figure, usually the inflation rate or consumer price index, the budget for the coming year may be projected. Although this method is simple and quick and requires little budgeting expertise on the part of the manager, it is generally inefficient fiscally because there is no motivation to contain costs and no need to prioritize programs and services. Hospitals historically used incremental budgeting in fiscal planning.

LEARNING EXERCISE 10.3

Missing Supplies

You are a unit manager in an acute care hospital. You are aware that staff occasionally leave at the end of the shift with forgotten hospital supplies in their pockets. You remember how often as a staff nurse you would unintentionally take home rolls of adhesive tape, syringes,

penlights, and bottles of lotion. Usually, you remembered to return the items, but other times, you did not.

Recently, however, your budget has shown a dramatic and unprecedented increase in missing supplies, including gauze wraps, blood pressure cuffs, stethoscopes, surgical instruments, and personal hygiene kits. Although this increase represents only a fraction of your total operating budget, you believe that it is necessary to identify the source of their use. An audit of patient charts and charges reveals that these items were not used in patient care.

When you ask your charge nurses for an explanation, they reveal that a few employees have openly expressed that taking a few small supplies is, in effect, an expected and minor fringe benefit of employment. Your charge nurses do not believe that the problem is widespread, and they cannot objectively document which employees are involved in pilfering supplies. The charge nurses suggest that you ask all employees to document in writing when they see other employees taking supplies and then turn in the information to you anonymously for follow-up.

ASSIGNMENT:

Because supplies are such a major part of the operating budget, you believe that some action is indicated. You must determine what that action should be. Analyze your actions in terms of the desirable and undesirable effects on the employees involved in taking the supplies and those who are not. Is the amount of the fiscal debit in this situation a critical factor? Is it worth the time and energy that would be required to truly eliminate this problem?

Zero-Based Budgeting In comparison, managers who use zero-based budgeting must rejustify their program or needs every budgeting cycle. This method does not automatically assume that because a program has been funded in the

past, it should continue to be funded. Thus, this budgeting process is labor-intensive for nurse-managers. The use of a decision package to set funding priorities is a key feature of zero-based budgeting. Key components of decision packages are shown in Display 10.3. Display 10.4 presents an example of an abbreviated decision package.

DISPLAY 10.3 KEY COMPONENTS OF DECISION PACKAGES IN ZERO-BASED BUDGETING

1. Listing of all current and proposed objectives or activities in the department

2. Alternative plans for carrying out these activities 3. Costs for each alternative 4. Advantages and disadvantages of continuing or discontinuing an

activity

DISPLAY 10.4 EXAMPLE OF AN ABBREVIATED DECISION PACKAGE FOR IMPLEMENTING MANDATORY FLU VACCINATIONS FOR HOSPITAL EMPLOYEES

Objective: To determine if annual mandatory flu vaccination is an appropriate strategy for reducing the risk of flu transmission to and from hospital employees

Driving forces: The Centers for Disease Control and Prevention (CDC) recommend that all health-care workers receive an annual flu vaccine, arguing it is one of the most important ways to prevent transmission of influenza, not only in the hospital but also in other health-care settings. Flu vaccines typically protect against the three or four viruses (depending on vaccine) that research suggests will be most common that year (CDC, 2018). Individual hospitals and health systems have some latitude to devise and implement policies based on their own strategies within the bounds established by state laws.

Restraining forces: Porter (2018) suggests that mandatory flu vaccine policies can push too far or fail to include proper safeguards that could violate worker rights. In addition, it is not possible to predict what any flu season will be like because the timing, severity, and length of the season varies from one season to another as does the efficacy of the vaccine.

Alternative 1: Require all workers to receive an annual flu vaccination, at the hospital’s expense.

Advantage: There is no out-of-pocket expense to employees for the vaccination. There is greater likelihood that employees will be protected against the flu while working in a high-risk clinical setting.

Disadvantage: The effectiveness of the vaccine varies from year to year. Some employees may believe that requiring the vaccine infringes on their right to control choices about their bodies. In addition, mandatory vaccination policies may violate certain

employee’s religious beliefs or pose health risks. Employee lawsuits arguing a violation of their rights are likely.

Alternative 2: Require all workers to be vaccinated, at the hospital’s expense, unless an employee can show evidence that the vaccination poses a health risk or violates religious beliefs. Require workers who cannot have the flu vaccine, and are approved for an exemption, wear masks during the flu season. Educate employees about the importance of immunization.

Advantage: There is no out-of-pocket expense to employees for the vaccination. Employees can refuse the vaccine for documented medical or religious reasons.

Disadvantage: The effectiveness of the vaccine varies from year to year. Resources will be needed to process requests for religious and medical exemption as well as appeals. Some employees may have less protection against the flu while working in a high- risk clinical setting. Employee lawsuits arguing a violation of their rights may occur.

Alternative 3: Encourage, but do not require, employees to have annual flu vaccinations. Provide education about the value of flu vaccination and provide incentives to workers who do agree to be vaccinated. Require workers who choose not to have the flu vaccine wear masks during the flu season.

Advantage: There is no out-of-pocket expense to employees for the vaccination. Employees have a choice regarding whether to have the vaccinations and assume the responsibility of protecting their health themselves.

Disadvantage: The effectiveness of the vaccine varies from year to year. Some employees may have less protection against the flu while working in a high-risk clinical setting.

Decision packages and zero-based budgeting are advantageous because they force managers to set priorities and to use resources most efficiently. This rather lengthy and complex method also

encourages participative management because information from peers and subordinates is needed to analyze adequately and prioritize the activities of each unit.

Flexible Budgeting Flexible budgets are budgets that flex up and down over the year depending on volume. A flexible budget automatically calculates what the expenses should be, given the volume that is occurring. This works well in many health-care organizations because of changing census and manpower needs that are difficult to predict despite historical forecasting tools.

Performance Budgeting The fourth method of budgeting, performance budgeting, emphasizes outcomes and results instead of activities or outputs. Thus, the manager would budget as needed to achieve specific outcomes and would evaluate budgetary success accordingly. For example, a home health agency would set and then measure a specific outcome in a group, such as diabetic patients, as a means of establishing and justifying a budget.

LEARNING EXERCISE 10.4

Developing a Decision Package

Given the following objective, develop a decision package to aid you in fiscal priority setting.

Objective: To have reliable, economic, and convenient transportation when you enter nursing school in 3 months

Additional information: You currently have no car and rely on public transportation, which is inexpensive and reliable but not very convenient. Your current financial resources are limited, although you could probably qualify for a car loan if your parents were willing to cosign the loan. Your nursing school’s policy states that you must have a car available to commute to clinical agencies outside the immediate area. You know that this policy is not enforced and that some students do carpool to clinical assignments.

ASSIGNMENT:

Identify at least three alternatives that will meet your objective. Choose the best alternative based on the advantages and disadvantages that you identify. You may embellish information presented in the case to help your problem solving.

Critical Pathways and Variance Analysis Critical pathways (also called clinical pathways and care pathways) are a strategy for assessing, implementing, and evaluating the cost- effectiveness of patient care. These pathways reflect relatively standardized predictions of patients’ progress for a specific diagnosis or procedure. For example, a critical pathway for a specific diagnosis might suggest an average length of stay of 4 days, with certain interventions completed by certain points on the pathway (much like a program evaluation and review technique flow diagram; see Fig. 1.5). Patient progress that differs from the critical pathway prompts a variance analysis.

Critical pathways are predetermined courses of progress that patients should make after admission for a specific diagnosis or after a specific surgery.

The advantage of critical pathways is that they do provide some means of standardizing care for patients with similar diagnoses. Their weakness, however, is the difficulties they pose in accounting for and accepting what are often justifiable differentiations between unique patients who have deviated from their pathway. They also pose one more paperwork and utilization review function in a system already burdened with administrative costs. Despite these challenges, research suggests that critical pathways can standardize care according to evidence-based best practices, leading to improved patient outcomes and lower costs.

Health-Care Reimbursement Historically, health-care institutions used incremental budgeting and placed little or no emphasis on budgeting. Because insurance carriers reimbursed fully on virtually a limitless basis, there was little motivation to save costs, and organizations found it unnecessary to justify charges. Reimbursement was based on costs incurred to provide the service plus profit (fee-for-service [FFS]), with no ceiling placed on the total amount that could be charged. Indeed, under FFS, the more services provided, the greater the amount that could be billed, encouraging the overtreatment of clients. The end result of uncontrolled FFS reimbursement was skyrocketing health-care costs with health care increasingly assuming a greater percentage of GDP each year. Few efforts to shift from FFS to more cost-effective reimbursement models began before the late-1970s.

Medicare and Medicaid

The US federal government became a major insurer of health care with the advent of Medicare and Medicaid in the mid-1960s. Medicare is a federally sponsored health insurance program for individuals older than 65 years and for certain groups of people with catastrophic or chronic illness regardless of age. Medicare currently provides coverage for items and services for 64 million beneficiaries, approximately 18% of the US population (Kaiser Family Foundation, 2019b). Approximately 84% of enrollees are elderly, 16% are disabled, and less than 1% have end-stage renal disease (Kaiser Family Foundation, 2019a). Medicare enrollments are expected to increase dramatically in the coming years as the result of the aging population.

Medicare Part A is the hospital insurance program. Medicare Part B is the supplementary medical insurance program that pays for outpatient care (including laboratory and X-ray services) and physician (or other primary care provider) services. Medicare Part C (now called Medicare Advantage) allows patients more choices for participating in managed care plans. And the newest, Medicare Part D, which became effective January 1, 2006, allows Medicare patients to purchase at least limited prescription drug coverage, either through stand-alone prescription drug plans or Medicare Advantage prescription drug (MA- PD) plans. Approximately 22 million beneficiaries (34%) participated in Medicare Advantage in 2019 (Kaiser Family Foundation, 2019c). Out- of-pocket costs for Medicare beneficiaries as of 2018 are shown in Table 10.1.

TABLE 10.1 MEDICARE COSTS PER BENEFICIARY FOR 2019

Medicare Insurance Plan Cost

Part B premium $135.50 each month (or higher depending on your income)

Part B deductible and coinsurance

$185 per year. After the deductible is met, patients typically pay 20% of the Medicare- approved amount for most doctor services (including most doctor services while a hospital inpatient), outpatient therapy, and durable medical equipment.

Part A premium Most people do not pay a monthly premium for Part A. If you must buy Part A, the cost is up to $437 each month.

Part A hospital inpatient deductible and coinsurance

Beneficiaries pay: ● $1,364 deductible for each benefit period ● Days 1–60: $0 coinsurance for each benefit

period ● Days 61–90: $341 coinsurance per day of

each benefit period in 2015 ● Days 91 and beyond: $682 coinsurance per

each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)

● Beyond lifetime reserve days: all costs Part C Monthly premium varies by plan. Part D Monthly premium varies by plan (higher

income consumers may pay more). Source: Medicare.gov. (2019). Medicare costs at a glance. Retrieved July 28, 2019, from https://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at- glance.html

Medicaid is a federal-state cooperative health insurance plan created primarily for low-income children and adults, although it also provides medical and long-term care coverage for people with disabilities and assistance with health and long-term care expenses for low-income seniors. Over the past 20 years, Medicaid enrollment increased substantially during two major recessions and again in 2015 with implementation of the ACA. As a result, Medicaid provided coverage to about one in five Americans, or about 74 million people as of June 2017 (Rudowitz & Valentine, 2017).

During economic downturns, when individuals lose their jobs and incomes decline, more people qualify and enroll in Medicaid, which in turn drives increases in total Medicaid spending. Both Medicare and Medicaid are coordinated by the Centers for Medicare & Medicaid Services (CMS).

The Prospective Payment System With the advent of Medicare, Medicaid, and FFS reimbursement, health-care costs skyrocketed as large segments of the population that previously had no health insurance or inadequate coverage began accessing services. In addition, health-care providers saw the government as having “deep pockets,” which suggested almost limitless reimbursement and began providing services accordingly. Because of rapidly escalating costs, the government began establishing regulations requiring organizations to justify the need for services and to monitor the quality of services. Health-care providers were forced for the first time to submit budgets and justify costs. This new surveillance and existence of external controls had a tremendous effect on the health-care industry.

The advent of diagnosis-related groups (DRGs) in the early 1980s added to the need for monitoring cost containment. DRGs were predetermined payment schedules that reflected historical costs for treatment of specific patient conditions. Medicare Severity DRGs were implemented in 2007 and have been updated annually since.

With DRGs, hospitals joined the prospective payment system (PPS), whereby they receive a specified amount for each Medicare patient’s admission regardless of the actual cost of care. Exceptions to this occur when providers can demonstrate that a patient’s case is an outlier, meaning that the cost of providing care for that patient justifies extra payment. PPS and consequent cost-containment efforts lead to decreased length of stays for most patients.

Because of the PPS and the need to contain costs, the length of stay for most hospital admissions has decreased greatly.

Many argue that quality standards have been lowered because of the PPS and that patients are being discharged before they are ready. It is the nurse-leader’s responsibility to recognize when cost containment is impinging on patient safety and to take appropriate action to guarantee at least a minimum standard of care.

In addition, hospitals must use the International Classification of Diseases (ICD) to code diseases, signs and symptoms, and abnormal findings. Currently in its 10th revision, ICD-10 provides significantly more coding options for treatment, reporting, and payment processes, including more than 68,000 clinical modification codes as compared with 15,000 in ICD-9 (CMS, 2018b).

The government again deeply affected health-care administration in the United States in 1997 with the passage of the Balanced Budget Act (BBA). This act contained numerous cost-containment measures, including reductions in provider payments for traditional FFS Medicare program participants. The bulk of the savings resulted from limiting the growth rates for hospital and physician payments. A second major source of savings derived from restructuring the payment methods for rehabilitation hospitals, home health agencies, skilled nursing facilities, and outpatient services. The BBA also, for the first time, authorized

payments to nurse practitioners for Medicare-provided services at 85% of the physician-fee schedule.

The ever-increasing impact of the federal government on how health care is delivered in the United States must be recognized. Accompanying this funding is an increase in regulations for facilities treating these patients and a system that rewards cost containment. Health-care providers are encountering financial crises as they attempt to meet unlimited health-care needs and services with limited fiscal reimbursement. Competition has intensified, reimbursement levels have declined, and utilization controls have increased. In addition, rapidly changing federal and state reimbursement policies make long- range budgeting and planning very difficult for health-care facilities.

Managed Care Managed care has also been a significant factor affecting health-care delivery and reimbursement since the early 1990s. Broadly defined, managed care is a system that attempts to integrate efficiency of care, access, and cost of care. Common denominators in managed care include the use of primary care providers as “gatekeepers,” a focus on prevention, a decreased emphasis on inpatient hospital care, the use of clinical practice guidelines for providers, and selective contracting (whereby providers agree to lower reimbursement levels in exchange for patient population contracts). Managed care typically uses formularies to manage pharmacy care and focuses on continuous quality monitoring and improvement.

Utilization review is another common component of managed care. Utilization review is a process used by insurance companies to assess the need for medical care and to assure that payment will be provided for the care. Utilization review typically includes precertification or preauthorization for elective treatments, concurrent review, and, if necessary, retrospective review for emergency cases.

Another frequent hallmark of managed care is capitation, whereby providers receive a fixed monthly payment regardless of services used

by that patient during the month. If the cost to provide care to someone is less than the capitated amount, the provider profits. If the cost is greater than the capitated amount, the provider suffers a loss. The goal, then, for capitated providers is to see that patients receive the essential services to stay healthy or to keep from becoming ill but to eliminate unnecessary use of health-care services. Critics of capitation argue that this reimbursement strategy leads to undertreatment of patients. A summary of managed care characteristics is found in Display 10.5.

DISPLAY 10.5 MANAGED CARE AT A GLANCE

Represents a wide range of financing alternatives that focus on managing the cost and quality of health care by Using panels of selectively contracted providers Limiting benefits to subscribers who use noncontracted

providers Implementing some type of authorization system Focusing on primary care rather than specialists and inpatient

services Emphasizing preventive health care Relying on clinical practice guidelines for providers Regularly reviewing the use of health-care resources Continuously monitoring and improving the quality of health

services Patients have less choice about the providers they can see and

services they can access, in exchange for small copayments and no deductibles.

Managed care organizations often use primary care gatekeepers to Be sure that the provider-ordered services are needed and

appropriate See that patients are cared for in outpatient settings whenever

possible Ration care by queuing and wait times for authorizations Encourage providers to follow more standardized care pathways

and clinical guidelines for treatment Managed care is based on the concept of capitation, whereby

providers prospectively receive a fixed monthly payment, regardless of what services are used by that patient during the month. This encourages providers to treat less because their potential profits decline as treatment increases.

Types of Managed Care Organizations One of the most common types of managed care organizations (MCOs) is the health maintenance organization (HMO). An HMO is a network of providers funded by insurance premiums. The HMO’s physicians and other professionals practice medicine within certain financial, geographic, and professional limits to individuals and families who have enrolled in the HMO. Although HMOs originated as an alternative to traditional health insurance plans, some of the largest private insurers, including Blue Cross and Blue Shield and Aetna, have created HMOs within their organization while maintaining their traditional indemnity plans. More than 70 million Americans have enrolled in HMOs since their inception (National Conference of State Legislatures [NCSL], 2017).

In discussing HMOs, it is important to remember that there are different types of HMOs as well as different types of plans within HMOs to which members may subscribe. Several types of HMOs include (a) staff, (b) independent practice association (IPA), (c) group, and (d) network. In staff HMOs, physician providers are salaried by the HMO and under direct control of the HMO. In IPA HMOs, the HMO contracts with a group of physicians through an intermediary to provide services for members of the HMO. In a group HMO, the HMO contracts directly with one independent physician group. In network HMOs, the HMO contracts with multiple independent physician group practices.

The types of plans available within HMOs typically vary according to the degree of provider choice available to enrollees. Two such plans include point-of-service (POS) and exclusive provider organization (EPO) options. In POS plans, the patient has the option, at the time of service, to select a provider outside the network but pays a higher premium as well as a copayment (amount of money enrollees pay out of their pocket at the time a service is provided) for the flexibility to do so. In the EPO option, enrollees must seek care from the designated HMO provider or pay all of the cost out of pocket.

Another common type of MCO is the preferred provider organization (PPO). PPOs render services on an FFS basis but provide financial incentives to consumers (they pay less) when the preferred provider is used. Providers are motivated to become part of a PPO because it ensures them an adequate population of patients. Almost 90 million Americans have become a part of PPOs since their inception (NCSL, 2017).

Medicare and Medicaid Managed Care Although Medicare and Medicaid patients historically were excluded from managed care under the free choice of physician rule, these restrictions were lifted in the 1970s and 1980s. As a result, Medicare and Medicaid patients can now participate in private HMOs and other types of managed care programs through Medicare Part C (formerly the Medicare + Choice program and now known as Medicare Advantage). To join a Medicare Advantage plan, patients must have both Medicare Parts A and Part B. The payment system for these programs (effective 1982) was to be prospective, and the HMO was at risk for providing all benefits in return for the capitated payment.

MCOs receive reimbursement for Medicare-eligible patients based on a formula established by the CMS, which looks at age, gender, geographic region, and the average cost per patient at a given age. Then, the government gives itself a 5% discount and gives the rest to the MCO. The BBA of 1997 expanded the role of private plans under Medicare + Choice to include PPOs, provider-sponsored organizations, private FFS plans, and medical savings accounts, coupled with high- deductible insurance plans.

The CMS is now the largest managed care buyer in the United States.

The CMS is now the largest purchaser of managed care in the United States.

Proponents and Critics of Managed Care Speak Up Proponents of managed care argue that prepaid health-care plans, such as those offered by HMOs, decrease health-care costs, provide broader benefits for patients than under the traditional FFS model, appropriately shift care from inpatient to outpatient settings, result in higher physician productivity, and have high enrollee satisfaction levels.

Critics, however, suggest that participation in MCOs may result in a loss of existing physician–patient relationships, a limited choice of physicians for consumers, a lower level of continuity of care, reduced physician autonomy, longer wait times for care, and consumer confusion about the many rules to be followed. A common complaint heard from managed care subscribers is that services must be preapproved or preauthorized by a gatekeeper or that second opinions must be obtained before surgery. Although this loss of autonomy is difficult for consumers accustomed to an FFS system with few limits on choice and access, such utilization constraints are necessary due to moral hazard, which is the risk that the insured will overuse services just because the insurance will pay the costs. Because the copayment is typically small for patients in managed care programs, the risk of moral hazard rises.

Moral hazard refers to the propensity of insured patients to use more medical services than necessary because their insurance covers so much of the cost.

Another aspect complicating health-care reimbursement through the PPS, an HMO, or a PPO is that clear and comprehensive documentation of the need for services and actual services provided is mandatory. Provision of service no longer guarantees reimbursement. Thus, the fiscal accountability of nurses goes beyond planning and implementing; it includes responsible recording and communication of activities.

Provision of service no longer guarantees reimbursement.

Perhaps the most serious concern about the advancement of managed care in this country is the change in relationships among insurers, physicians, nurses, and patients. The full impact on clinical judgment of tying physician and nursing salaries to bonuses, incentives, and penalties designed to reduce utilization of services and resources and increase profit is unknown. As a result, a need for self- awareness regarding the values that guide individual professional nursing practice has never been greater.

LEARNING EXERCISE 10.5

Providing Care With Limited Reimbursement

You are the manager at a home health agency. One of your elderly patients has insulin-dependent diabetes. He has no family support. He speaks limited English and has little understanding of his disease. He lives alone. Your reimbursement from a government agency pays $90 per visit. Because this gentleman needs so much care, you find that the actual cost to your agency is $130 for each visit to him. What will be the impact to your agency if this patient is seen twice a week for 3 months? How can you recover the lost revenue? How can you make each visit less costly and still meet the needs of the patient?

The Future of Managed Care Managed care continues to change the face of health care in the United States. The contractual complexity and the use of prospective payment in managed care make it much more difficult for providers to anticipate potential revenues and then to bill for and collect reimbursement for services provided. Indeed, some critics of managed care suggest that health-care practitioners and institutions now bear much more of the financial risk for the cost of care than insurers.

Some declines in managed care participation have occurred in part because these plans are no longer significantly less expensive for consumers to purchase or for insurers to provide. In addition, providers have grown increasingly frustrated with limited and delayed reimbursement for services provided as well as the need to justify need for services ordered. Indeed, some providers have filed lawsuits against managed care insurers for delay of payment or nonpayment for services provided. Even with this discontent, managed care is not going

to go away—at least not any time soon. It will, however, continue to change. Certainly, in reviewing the health-care reimbursement milestones of the past 75 years (Display 10.6), one can see that health- care reimbursement has changed dramatically in a relatively short time and that managed care is just one more reimbursement schema that has changed the face of health care in the United States.

DISPLAY 10.6 US HEALTH-CARE MILESTONES: 75 YEARS OF REIMBURSEMENT

1929 First health maintenance organization (HMO), the Ross-Loos Clinic, is established in Los Angeles.

1929 Origins of Blue Cross, when Baylor University Hospital agreed to provide 1,500 school teachers up to 21 days of hospital care for $6.00 per year.

1935 Passage of Social Security Act. This act originally included compulsory health insurance for states that voluntarily chose to participate, but the American Medical Association fought it and the health insurance provisions were omitted from the act.

1942 First nationwide hospital insurance bill introduced into Congress, but it failed to pass.

1946 Hill-Burton Act promoted hospital development and renovation after World War II. Authorized $75 million yearly for 5 years to aid in hospital construction.

1965 Passage of Medicare and Medicaid as part of Lyndon B. Johnson’s Great Society. Resulted in 50% increase in the number of medical schools in the United States.

1972 Professional standards review organizations established by Congress to prevent excess hospitalization and utilization by Medicare and Medicaid patients.

1973 The Health Maintenance Act authorized the spending of $375 million over 5 years to set up and evaluate HMOs in communities across the country.

1974 The National Planning Act created a system of state and local health planning agencies largely supported by federal funds. This created health systems agencies to inventory each community’s health-care resources and to issue Certificates of Need.

1974 The Employment Retirement Income Security Act (ERISA) passed, generally preempting state regulation of self-insuring employee benefit plans.

1983 Diagnosis-related groups established, which changed the structure of Medicare payments from a retrospectively adjusted cost-reimbursement system to a prospective, risk-based one.

1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 passed. Allowed terminated employees or those who lose coverage because of reduced work hours to buy group coverage for themselves and their families for limited periods of time (up to 60 days to decide).

1988 Medicare Catastrophic Coverage Act (MCCA) enacted, which expanded Medicare benefits greatly to include a portion of out-of- pocket drug and physician expenses.

1989 Medicare system of paying physician charges changed to a resource-based relative value scale to be phased in starting in 1992.

1993 Former President William J. Clinton introduced the Health Security Act, legislation assuring universal access to all Americans. The act failed to pass.

1996 Health Insurance Portability and Accountability Act passed. Created medical savings accounts and required the U.S. Department of Health and Human Services to establish national standards for electronic health-care transactions and national identifiers for providers, health plans, and employers. It also addressed the security and privacy of health data.

1997 Approximately one-quarter of Americans enrolled in HMOs. Almost 6 million Medicare beneficiaries enrolled in HMOs. Balanced Budget Act gives states the authority to implement managed care programs without federal waivers.

1999 Health-care spending comprised approximately 15% of the gross domestic product of the United States, exceeding $1 trillion in annual health-care expenditures for the first time. Approximately 37 million Americans were uninsured, and between 50 and 70 million were inadequately insured.

2001 More than 1.5 million elderly Medicare HMO patients forced to find new insurance arrangements as their HMOs pulled out of the

Medicare program after losing money on Medicare enrollees. Increasing disenchantment noted with managed care.

2003 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 passed, providing a voluntary program for prescription drug coverage under the Medicare program. It also commissioned the Institute of Medicine to prioritize options to align performance and payment in Medicare, supporting a “pay for performance” (P4P) approach.

2009 Congressional committees began active debate of a comprehensive health-care reform package. Former President Barack Obama announced the release of nearly $600 million in funding to strengthen community health centers that would serve 500,000 additional patients and use health information technology.

2010 Former President Barack Obama’s Health Care Reform bill Patient Protection and Affordable Care Act (PPACA) passed, resulting in sweeping overhauls of the US health-care system and the introduction of a new Patient’s Bill of Rights related to insurance coverage. Provisions related to eliminating lifetime limits on insurance coverage, extending coverage to young adults, and providing new coverage to individuals who have been uninsured for at least 6 months due to a preexisting condition were implemented.

2011 PPACA provisions related to providing free preventive care to seniors, the establishment of a Community-Based Care Transitions Program, and the creation of a new Center for Medicare & Medicaid Innovation were put into place.

2012 The PPACA established hospital value-based purchasing programs in traditional Medicare to provide incentives for health- care providers to work together to form accountable care organizations as well as new, voluntary options for long-term care insurance.

2013 The PPACA provided new funding to state Medicaid programs that chose to cover preventive services for patients at little or no

cost, expanded the authority to bundle payments, increased medical payments for primary care doctors, and began open enrollment in the Healthcare Insurance Marketplace.

2014 The final provisions of the PPACA were phased in, including the implementation of the Healthcare Insurance Marketplace, prohibition of discrimination due to preexisting conditions or gender, the elimination of annual limits on insurance coverage, and ensuring coverage for individuals participating in clinical trials.

2015 The tax penalty for being uninsured increased. The 2015 penalty was the larger of 2% of income or $325 per person ($162.50 per child younger than 18 years). Businesses with 100 or more full-time equivalent (FTE) employees were required to offer affordable coverage to full-time staff that offered the essential benefits required under the Affordable Care Act (ACA). In addition, these policies were required to cover full-time employees’ dependent children up through age 26 years. If businesses of this size chose not to offer insurance, they had to pay a tax penalty to the government. This provision applied to businesses with 50 or more full-time employees in 2016.

2016 Under the PPACA, all businesses with 100 or fewer FTE employees were able to purchase insurance through the state SHOP Exchange. A new program also began, allowing states to form health-care choice compacts and allowing insurers to sell policies in any state participating in the compact.

2017 Under the PPACA, a state’s ability to allow large employers (with 100+ employees) to provide coverage through a SHOP Exchange took effect.

2017 Multiple bills to repeal and replace the ACA were introduced into either the House or the Senate in fall 2017, although legislative consensus was not achieved. Although the bills were different in some respects, the common theme was a reduction in mandates for individuals and businesses to buy or provide health

insurance and a reduction of government subsidies for vulnerable populations like the elderly and the poor.

2017 The Tax Cuts and Jobs Act (passed by Congress and signed into law by President Donald Trump in late December 2017). This made significant changes to the ACA, including eliminating the penalty of the “individual mandate” to purchase health insurance in 2018 and repealing the individual mandate in 2019. The Congressional Budget Office estimated that repealing the individual mandate will result in 4 million people losing coverage in 2019 and 13 million losing coverage by 2027 (O’Brien, 2017).

2018 President Donald Trump revealed the American Patients First plan. This plan sought to reform the rebates drug companies pay to pharmacy benefit managers (PBMs), who negotiate prices between drug manufacturers, pharmacies, and health insurance companies. The rebates create incentives for PBMs to suggest higher cost drugs. In addition, PBMs can charge insurers more than they’re charging pharmacies (Huston, 2020).

2019 With legislative failure to repeal the ACA in 2017, a stalemate is in place. The ACA is in place, but new laws continue to be introduced to incrementally dismantle it (Huston, 2020).

Health-Care Reform Efforts: The Patient Protection and Affordable Care Act. What Comes Next? In March 2010, former President Barack Obama signed the ACA that put in place comprehensive insurance reforms to be phased in over a 4-year period. The act included a new Patient’s Bill of Rights implemented in 2010, a provision for Medicare beneficiaries to get preventive services for free and discounts on brand name drugs for some patients using Medicare Part D beginning in 2011 as well as the introduction of “bundled payments,” the addition of ACOs and other programs help doctors and health-care providers work together to deliver better care in 2012, hospital VBP and open enrollment in the

Health Insurance Marketplace beginning in October 2013, and greater access for most Americans to affordable health insurance options in 2014 (U.S. Department of Health and Human Services, 2017).

Bundled Payments Passed in October 2011 and implemented in 2013, the Bundled Payments for Care Improvement Initiative gave providers flexibility to work together to coordinate care for patients over the course of a single episode of an illness. There are four broadly defined models of bundled care: Three of these models involve retrospective payment, and one is prospective. In the retrospective payment models, CMS and providers set a target payment amount for a defined episode of care. This target amount would reflect a discount to total costs for a similar episode of care as determined from historical data. Participants then would be paid for their services under the original Medicare FFS system but at a negotiated discount. Models 2 and 3 may include clinical laboratory services and durable medical equipment (CMS, 2018a).

The prospective payment model differs in that CMS makes a single, prospectively determined bundled payment to a hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners would be paid by the hospital out of the bundled payment.

Accountable Care Organizations ACOs are groups of providers and suppliers of service who work together to better coordinate care for Medicare patients (does not include Medicare Advantage) across care settings. The goal of an ACO is to deliver seamless, high-quality care in an environment that is truly patient centered and where patients and providers are partners in decision making.

Although patient and provider participation in ACOs is voluntary at this time, the Medicare Shared Savings Program rewards ACOs that lower growth in health-care costs while meeting performance standards

on quality of care and putting patients first (U.S. Department of Health and Human Services, 2017). ACOs are entitled to these shared savings when savings exceed the minimum sharing rate and if the ACO meets or exceeds the quality performance standards. Additional shared savings can be earned by ACOs that include beneficiaries who receive services from a federally qualified health center or rural health clinic during the performance year (U.S. Department of Health and Human Services, 2017).

Hospital Value-Based Purchasing Beginning in 2013, for the first time, the hospital VBP program paid inpatient acute care services partially on care quality, not just on the quantity of the services they provide. In VBP, providers are held accountable for the quality and cost of the health-care services they provide by a system of rewards and consequences. This requires the reporting of standardized, comparable patient outcomes.

The Patient-Centered Medical Home The patient-centered medical home (PCMH), also known as the medical home, is a coordinated effort to meet patient needs through the better coordination of quality care. The medical home uses a team of providers—such as physicians, nurses, nutritionists, pharmacists, and social workers—to integrate all aspects of health care, including physical health, behavioral health, access to community-based social services, and the management of chronic conditions. Communication occurs through well-developed health information technology including electronic health records.

Payment reform is also a critical part of the medical home initiative as financial incentives are offered to providers to focus on the quality of patient outcomes rather than the volume of services they provide. Although the model is still evolving, national and state medical home accreditation is available, facilitating payment from both public and private payers.

Improved quality of care is also a critical goal for the PCMH. Multiple researchers have compared the connection between medical homes and reduced hospitalizations, reduced emergency department (ED) visits, and lowered costs of care, with differing results (Cline, Sweeney, & Cooper, 2018). One recent study, however, provided compelling evidence that patient utilization of high-cost health-care resources was improved through the enrollment of chronically ill patients in a medical home clinic that incorporated focused medical care and preventive health screenings (see Examining the Evidence 10.1). The study found a statistically significant decrease in the number of hospital admissions and readmissions. In addition, the cost of care showed a significant decrease. This finding suggests the cost of utilizing outpatient clinic care, even with the expanded interprofessional team approach and medications at no cost, was lower compared to the cost of hospital ED and inpatient services (Cline et al., 2018).

EXAMINING THE EVIDENCE 10.1 Source: Cline, E., Sweeney, N. L., & Cooper, P. B. (2018). Medical home model: Reducing cost, increasing care, and improving outcomes for uninsured, chronically ill patients. Nursing Economic$, 36(1), 7–28.

Value and the Medical Nursing Home The purpose of this study was to determine if the implementation of a medical home clinic would reduce costs as well as the number of emergency department (ED) visits, hospitalizations, and hospital readmissions for uninsured patients suffering from specific chronic diseases. Using a retrospective, preexperimental study with a one-group pretest/posttest design, the researchers identified a study sample of 93 patients who met the following inclusion criteria:

● History of overutilization of the ED (four or more visits in 6 months)

● Frequent hospitalizations (three or more inpatient stays in 6 months)

● An inability to pay ● A chronic disease diagnosis of diabetes,

congestive heart failure, or chronic obstructive pulmonary disease

● No primary care physician of record ● A history of noncompliance with treatment

The researchers found that enrollment in the medical home did not reduce ED visits significantly for this population. It did, however, significantly decrease the number of hospital admissions. In addition, hospital readmissions

were reduced by 66%. The mean of total patient costs per patient also showed statistically significant declines. The researchers concluded that moving uninsured patients who access the ED after an exacerbation of a chronic illness to a more proactive, interprofessional medical home clinic model may assist that population to achieve a healthier, happier lifestyle, with an overall reduction in health-care cost.

Health Insurance Marketplaces As of October 2013, new health insurance marketplaces, also called exchanges, were created for individuals without access to health insurance through a job, for implementation in January 2014. Small businesses were also eligible to buy affordable and qualified health benefit plans in this competitive insurance marketplace. Every health insurance plan in the marketplace offered comprehensive coverage (10 essential health benefits). From doctors to medications to hospital visits and options could be compared based on price, benefits, and quality. Prospective clients could not be turned down because of preexisting conditions. Tax credits were also provided to lower insurance costs for individuals and families earning below certain levels.

Outcomes of the Affordable Care Act What were the outcomes of the ACA? There were successes and failures (Huston, 2020). Okoro et al. (2017) note that with the passage of ACA, approximately 20 million uninsured working-aged adults (aged 18 to 64 years) gained health insurance coverage. In addition, during 2013 to 2014, when many of the major coverage provisions of ACA went into effect (e.g., creation of the Health Insurance Marketplace, barring coverage exclusions for preexisting health conditions, expansion of Medicaid, establishment of tax credits, reductions in cost

sharing, and other provisions to increase availability and affordability of coverage), the percentage of working-aged adults with health insurance increased by approximately 3 percentage points.

Despite this progress, major opportunities to improve the health-care system remained. The ACA itself was shrouded in confusion and misinformation, starting well before it was signed into law. This was due partly to partisan politics and poor communication about the law to the public. Indeed, Amadeo (2018b) notes that negative messages about ObamaCare in the media outnumbered positive messages (15:1) and 3 years after it was approved, 54% of Americans opposed the act.

Some of this discontent came about because of the broken promise that people who were satisfied with their previous coverage could remain on their plan. It quickly became apparent this would not be the case. Other consumers found the rollout of the ACA and the marketplace confusing. They felt enrollment periods were too limited and the website was too complicated.

In addition, costs were often prohibitive for both the government and consumers. The costs to implement the ACA increased about 5% each year (5.3% in 2014 and 5.8% in 2015) (Amadeo, 2018a). In addition, despite implementation of the ACA, the cost of health-care insurance continued to be beyond reach for many Americans. Individuals found it difficult to find affordable plans in the Health Insurance Marketplace, often choosing lower cost plans with high deductibles or copayments that, ultimately, they could not pay. In addition, choice was often limited in the Health Insurance Marketplace, existing coverage was disrupted, and bureaucracy created even more rules and regulations. Of even greater concern was the staggering costs of the federal subsidies to insurers as well as what many perceived to be uneven allocation of their use.

With the election of a new president in 2017, the vision for comprehensive health care changed and repeal of the ACA became a priority. Legislative efforts in late 2017 to repeal the ACA, however, failed, and a stalemate is in place. The ACA is still in effect, but recent executive orders, including elimination of the individual mandate, have

undermined many of its key elements. Given this political stalemate, it may be the right time to reassess the deeper issues at stake and ponder a considered compromise on health reform. Anderson (2017) agrees, noting that there is no perfect solution, but an immediate major overhaul of the health-care system is needed if we want to preserve the quality of health care Americans have come to expect. He notes that the ACA had many great benefits, but the key is including these perks without bankrupting the country. He believes a more market-oriented solution is needed—one that allows individuals to choose what level of care is best for them, allows health-care plans to freely move across state lines, and removes the individual mandate that forces every American to get coverage.

Integrating Leadership Roles and Management Functions in Fiscal Planning Managers must understand fiscal planning and health-care reimbursement, be aware of their budgetary responsibilities, and be cost-effective in meeting organizational goals. The ability to forecast unit fiscal needs with sensitivity to the organization’s political, economic, social, and legislative climate is a high-level management function. Managers also must be able to articulate unit needs through budgeting to ensure adequate nursing staff, supplies, and equipment. Finally, managers must be skillful in the monitoring aspects of budget control.

Leadership skills allow the manager to involve all appropriate stakeholders in developing the budget and implementing needed reforms. This has likely never been as important as it currently is, given the current climate of health-care reform with almost countless initiatives and phased-in implementation. Other leadership skills required in fiscal planning include flexibility, creativity, and vision regarding future needs. The skilled leader can anticipate budget constraints and act proactively. In contrast, many managers allow budget constraints to dictate alternatives. In an age of inadequate fiscal

resources, the leader is creative in identifying alternatives to meet patient needs.

The skilled leader, however, also ensures that cost containment does not jeopardize patient safety. As well, leaders are assertive, articulate people who ensure that their department’s budgeting receives a fair hearing. Because leaders can delineate unit budgetary needs in an assertive, professional, and proactive manner, they generally obtain a fair distribution of resources for their unit.

To provide care and appropriately advocate for patients in the 21st century, all nurses need at least a basic understanding of health-care costs. They also need to know how reimbursement strategies directly and indirectly affect their practice. Only then can nurses be active participants in the proactive and visionary fiscal planning required to survive in the current health-care marketplace and to reform a broken health-care system.

Key Concepts

■ Fiscal planning, as in all types of planning, is a learned skill that improves with practice.

■ Historically, nursing management played a limited role in determining resource allocation in health-care institutions.

■ The personnel–workforce budget often accounts for the majority of health-care organization’s expenses because health care is labor intensive.

■ Personnel budgets include actual worked time (productive time or salary expense) and time that the organization pays the employee for not working (nonproductive or benefit time).

■ A budget is at best a forecast or prediction; it is a plan and not a rule. Therefore, a budget must be flexible and open to ongoing evaluation and revision.

■ A budget that is predicted too far in advance is open to greater error. If the budget is shortsighted, compensating for unexpected major expenses or capital equipment purchases may be difficult.

■ The desired outcome of budgeting is maximal use of resources to meet organizational short- and long-term needs. Its value to the institution is directly related to its accuracy.

■ The operating budget reflects expenses that flex up or down in a predetermined manner to reflect variation in volume of service provided.

■ Capital budgets plan for the purchase of buildings or major equipment. This includes equipment that has a long life (usually greater than 5 years), is not used daily, and is more expensive than operating supplies.

■ Managers must rejustify their program or needs every budgeting cycle in zero-based budgeting. Using a decision package to set funding priorities is a key feature of zero-based budgeting.

■ With the advent of state and federal reimbursement for health care in the 1960s, providers were forced to submit budgets and costs to payers that more accurately reflected their actual cost to provide these services.

■ With DRGs, hospitals join the PPS, whereby they receive a specified amount for each Medicare patient’s admission, regardless of the actual cost of care. Exceptions occur when the provider can demonstrate that a patient’s case is an outlier, meaning that the cost of providing care for that patient justifies extra payment.

■ Key principles of managed care include the use of primary care providers as gatekeepers, a focus on prevention, a decreased emphasis on inpatient hospital care, the use of clinical practice guidelines for providers, selective contracting, capitation, utilization review, the use of formularies to manage pharmacy care, and continuous quality monitoring and improvement.

■ The types of plans available within HMOs typically vary according to the degree of provider choice available to enrollees.

■ Managed care has altered the relationships among insurers, physicians, nurses, and patients, with providers today often having to assume a role as an agent for the patient as well as an agent of resource allocation for an insurance carrier, hospital, or particular practice plan.

■ Provision of service no longer guarantees reimbursement. Clear and comprehensive documentation of the need for services and actual services provided is needed for reimbursement.

■ The 2010 PPACA (often shortened as ACA) put in place comprehensive insurance reforms, which were phased in over a 4-year period. Further modifications are occurring every year.

■ With bundled payments, providers agree to accept a discounted payment either retrospectively or prospectively, which represents a coordinated plan of care for patients over the course of a single episode of an illness.

■ ACOs are groups of providers and suppliers of service who work together to better coordinate care for Medicare patients (does not include Medicare Advantage) across care settings with the expectation that efficiency as well as quality of care will result in shared savings.

■ In VBP, providers are held accountable for the quality and cost of the health-care services they provide by a system of rewards and consequences, conditional upon achieving prespecified performance measures.

■ The medical home, or PCMH, relies on a team of providers to integrate all aspects of health care through well-developed health information technology, including electronic health records.

■ Health insurance marketplaces, also called exchanges, are online insurance supermalls created for individuals without access to health insurance through a job or for small businesses

who wish to buy affordable and qualified health benefit plans in a competitive insurance marketplace.

■ The ACA experienced successes and failures. Legislative efforts in late 2017 to repeal the ACA failed, but recent executive orders, including elimination of the individual mandate, have undermined many of its key elements.

Additional Learning Exercises and Applications

LEARNING EXERCISE 10.6

How Does Policy Influence Your Decision?

You are the evening house supervisor of a small, private, rural hospital. In your role as house supervisor, you are responsible for staffing the upcoming shift and for troubleshooting any and all problems that cannot be handled at the unit level.

Tonight, you receive a call to come to the emergency department (ED) to handle a “patient complaint.” When you arrive, you find a Hispanic woman in her mid-20s arguing vehemently with the ED charge nurse and physician. When you intercede, the patient introduces herself as Teresa Garcia and states, “There is something wrong with my father, and they won’t help him because we only have Medicaid insurance. If we had private insurance, you would be willing to do something.” The charge nurse intercedes by saying, “Teresa’s father began vomiting about 2 hours ago and blacked out approximately 45 minutes ago, following a 14-hour drinking binge.” The ED physician added, “Mr.

Garcia’s blood alcohol level is 0.25 [2.5 times the level required to be declared legally intoxicated], and my baseline physical examination would indicate nothing other than he is drunk and needs to sleep it off. Besides, I have seen Mr. Garcia in the ED before, and it’s always for the same thing. He does not need further treatment.”

Teresa persists in her pleas to you that “there is something different this time” and that she believes this hospital should evaluate her father further. She intuitively feels that something terrible will happen to her father if he is not cared for immediately. The ED physician becomes even angrier after this comment and states to you, “I am not going to waste my time and energy on someone who is just drunk, and I refuse to order any more expensive lab tests or X-rays on this patient. I’ve met the legal requirements for care. If you want something else done, you will have to find someone else to order it.” With that, he walks off and returns to the examination room, where other patients are waiting to be seen. The ED nurse turns to look at you and is waiting for further directions.

ASSIGNMENT:

How will you handle this situation? Would your decision be any easier if there were no limitations in resource allocation? Are your values to act as an agent for the patient or for the agency more strongly developed?

LEARNING EXERCISE 10.7

Weighing Choices in Budget Spending

One of your goals as the unit manager of a critical care unit is to prepare all your nurses to be certified in advanced cardiac life support. You currently have five staff nurses who need this certification. You can hire someone to teach this class locally and rent a facility for $1,000; however, the cost will be taken out of the travel and education budget for the unit, and this will leave you short for the rest of the fiscal year. It also will be a time-consuming effort because you must coordinate the preparation and reproduction of educational materials needed for the course and make arrangements for the rental facility. A certification class also will be provided soon in a large city approximately 150 miles from the hospital. The cost per participant will be $300. In addition, there would be travel and lodging expenses.

ASSIGNMENT:

You have several decisions to make. Should the class be held locally? If so, how will you organize it? Are you going to require your staff to have this certification or merely highly recommend that they do so? If it is required, will the unit pay the costs of the certification? Will you pay the staff nurses their regular hourly wage for attending the class on regularly scheduled work hours? Can this certification be cost-effective? Use group process in some way to make your decision.

LEARNING EXERCISE 10.8

How Will You Meet New Budget Restrictions?

You are the director of the local agency that cares for ill and well elderly patients. You are funded by a private corporation grant, which requires matching of city and state funds. You received a letter in the mail today from the state that says state funding will be cut by $35,000, effective in 2 weeks, when the state’s budget year begins. This means that your private funding also will be cut $35,000, for a total revenue loss of $70,000. It is impossible at this time to seek alternative funding sources. In reviewing your agency budget, you note that, as in many

health-care agencies, your budget is labor-intensive. More than 80% of your budget is attributable to personnel costs, and you believe that the cuts must come from within the personnel budget. You may reduce the patient population that you serve, although you do not really want to do so. You briefly discuss this communication with your staff; no one is willing to reduce his or her hours voluntarily, and no one is planning to terminate his or her employment at any time in the near future.

ASSIGNMENT:

Given the following brief description of your position and each of your five employees, decide how you will meet the new budget restrictions. What is the rationale for your choice? Which decision do you believe will result in the least disruption of the agency and of the employees in the agency? Should group decision making be involved in fiscal decisions such as this one? Can fiscal decisions such as this be made without value judgments? Your position is project director. As the project director,

you coordinate the day-to-day activities in the agency. You also are involved in long-term planning, and a major portion of your time is allotted to securing future funding for the agency to continue. As the project director, you have the authority to hire and fire employees. You are in your early 30s and have a master’s degree in nursing and health administration. You enjoy your job and believe that you have done well in this position since you started 4 years ago. Your yearly salary as a full-time employee is $80,000.

Employee 1 is Mrs. Potter. Mrs. Potter has worked at the agency since it started 7 years ago. She is a registered nurse (RN) with 30 years of experience working with the geriatric population in public health nursing, care facilities, and private duty. She plans to retire in 7 years and travel with her independently wealthy husband. Mrs. Potter has a great deal of expertise that she can share with your staff, although at times, you believe she overshadows your authority because of her experience and your young age. Her yearly salary as a full-time employee is $65,000.

Employee 2 is Mr. Boone. Mr. Boone has bachelor of science degrees in both nursing and dietetics and food management. As an RN and registered dietitian, he brings a unique expertise to your staff, which is highly needed when dealing with a chronically ill and improperly nourished elderly population. In the 6 months since he joined your agency, he has proven to be a dependable, well- liked, and highly respected member of your staff. His yearly salary as a full-time employee is $55,000.

Employee 3 is Ms. Barns. Ms. Barns is the receptionist-secretary in the agency. In addition to all the traditional secretarial duties, such as typing, filing, and transcription of dictation, she screens incoming telephone calls and directs people who come to the agency for information. Her efficiency is a tremendous attribute to the agency. Her full- time yearly salary is $26,000.

Employee 4 is Ms. Lake. Ms. Lake is a licensed practical nurse/licensed vocational nurse with 15 years of work experience in a variety of health-care agencies. She is especially attuned to patient needs. Although her technical nursing skills are also good, her caseload frequently is more focused around elderly patients who need companionship and emotional support. She does well at patient teaching because of her outstanding listening and communication skills. Many of your patients request her by name. She is a single mother, supporting six children, and you are aware that she has great difficulty in meeting her personal financial obligations. Her full-time yearly salary is $48,000.

Employee 5 is Mrs. Long. Mrs. Long is an “elderly help aide.” She has completed nurse aide training, although her primary role in the agency is to assist well elderly with bathing, meal preparation, driving, and shopping. The time that Mrs. Long spends in performing basic care has decreased the average visit time for each member of your staff by 30%. She is widowed and uses this job to meet her social and self-esteem needs. Financially, her resources are adequate, and the money she earns is not a motivator for working. Mrs. Long works 3 days a week, and her yearly salary is $23,000.

LEARNING EXERCISE 10.9

Identifying, Prioritizing, and Choosing Program Goals

Jane is the supervisor of a small cardiac rehabilitation program. The program includes inpatient cardiac teaching and an outpatient exercise rehabilitation program. Because of limited reimbursement by third-party insurance payers for patient education, there has been no direct charge for inpatient education. Outpatient program participants pay $240 per month to attend three 1-hour sessions per week, although the revenue generated from the outpatient program still leaves an overall budget deficit for the program of approximately $6,800 per month.

Today, Jane is summoned to the associate administrator’s office to discuss her budget for the upcoming year. At this

meeting, the administrator states that the hospital is experiencing extreme financial difficulties due to declining reimbursements. He states that the program must become self-supporting in the next fiscal year; otherwise, services must be cut. On returning to her office, Jane decided to make a list of several alternatives for problem solving and to analyze each for driving and restraining factors. These alternatives include the following:

1. Implement a charge for inpatient education. This would eliminate the budget deficit, but the cost would probably have to be borne by the patient. (Implication: Only patients with adequate fiscal resources would elect to receive vital education.)

2. Reduce department staffing. There are currently three staff members in the department, and it would be impossible to maintain the same level or quality of services if staffing were reduced.

3. Reduce or limit services. The inpatient education program or educational programs associated with the outpatient program could be eliminated. These are both considered to be valuable aspects of the program.

4. The fee for the outpatient program could be increased. This could easily result in a decrease in program participation because many outpatient program participants do not have insurance coverage for their participation.

ASSIGNMENT:

Identify at least five program goals and prioritize them as you would if you were Jane. Based on the priorities that you have established, which alternative would you select? Explain your choice.

LEARNING EXERCISE 10.10

Addressing Conflicting Values

You are a single parent of two children younger than 5 years and are currently employed as a pediatric office nurse. You enjoy your job, but your long-term career goal is

to become a pediatric nurse practitioner, and you have been taking courses part-time preparing to enter graduate school in the fall. Your application for admission has been accepted, and the next cycle for admissions will not be for another 3 years. Your recent divorce and assignment of sole custody of the children have resulted in a need for you to reconsider your plan.

Restraining Forces You had originally planned to reduce your work hours to part-time to allow time for classes and studying, but this will be fiscally impossible now. You also recognize that tuition and educational expenses will place a strain on your budget even if you continue to work full-time. You have not looked into the availability of scholarships or loans and have missed the deadline for the upcoming fall. In addition, you have not yet overcome your anxiety and guilt about leaving your small children for even more time than you do now.

Driving Forces You also recognize, however, that gaining certification as a pediatric nurse practitioner should result in a large salary increase over what you are able to make as an office nurse and that it would allow you to provide resources for your children in the future that you otherwise may be unable to do. As well, you recognize that although you are not dissatisfied with your current job, you have a great deal of ability that has gone untapped and that your potential for long-term job satisfaction is low.

ASSIGNMENT:

Fiscal planning always requires priority setting, and often, this priority setting is determined by personal values. Priority setting is made even more difficult when there are conflicting values. Identify the values involved in this case. Develop a plan that addresses these value conflicts and has the most desirable outcomes.

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11

Career Planning and Development in Nursing

. . . every individual you hire for a leadership role should have the capability to grow into that role. —Carolyn Hope Smeltzer

. . . career plans are about where you are today and, more importantly, where you’re going tomorrow. —Phil McPeck

. . . The number one role of any leader is to identify and prepare their successor. —Bill Bliss

CROSSWALK

This chapter addresses:

BSN Essential I: Liberal education for baccalaureate generalist nursing practice

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential VIII: Professionalism and professional values BSN Essential IX: Baccalaureate generalist nursing practice MSN Essential I: Background for practice from sciences and humanities

MSN Essential II: Organizational and systems leadership MSN Essential IX: Master’s level nursing practice AONL Nurse Executive Competency III: Leadership AONL Nurse Executive Competency IV: Professionalism

AONL Nurse Executive Competency V: Business skills ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 12: Education ANA Standard of Professional Performance 14: Quality of practice

ANA Standard of Professional Performance 15: Professional practice evaluation

LEARNING OBJECTIVES

The learner will:

describe the impact a career development program has on employee attrition, future employment opportunities, quality of work life, and competitiveness of the organization

differentiate among the promise, momentum, and harvest stages of a career as identified by Shirey (2009)

discuss changes in practical knowledge based on clinical experience that occurs in the transition from novice to expert nurse (Benner, 1982)

differentiate between the employer’s and the employee’s responsibilities for career development

describe three phases of long-term coaching for career development

identify support by top management, systematic planning and implementation, and inclusion of social learning activities as integral components of management development programs

identify the organization’s responsibility for effective promotions recognize lifelong learning as a professional expectation and responsibility

define continued competency and identify strategies for assuring and measuring it

identify driving and restraining forces for specialty certification in professional nursing

identify factors creating the current, pressing need for transition-to- practice programs to retain new graduate nurses and prepare them for successful employment

develop a personal career plan create and/or critique a resumé for content, format, grammar, punctuation, sentence structure, and appropriate use of language

Introduction To be a fully engaged professional requires commitment to career development. Career development is intentional career planning and should be viewed as a critical and deliberate life process involving both the individual and the employer. It provides individuals with choices about career outcomes rather than leaving it to chance.

Before the 1970s, organizations did little to help employees plan and develop their careers. Now, subordinate career development is recognized as essential to organizational success, and most organizations accept at least some responsibility for helping employees with this function. For the most part, however, organizational career development efforts have centered on management development rather than activities that promote growth in nonmanagement employees. Indeed, a recent survey by Infopro Learning found that only 83% of organizations felt it was important to develop leaders at all levels (Velasquez, 2017). Given that more than 80% of an organization’s employees are typically nonmanagement, this is often a neglected part of career development. Wong (2018) agrees, suggesting that career development should be for 100% of employees.

Career development in an organization must include more than management employees.

This chapter examines organizational justifications for employee career development, suggests the existence of career stages, and

emphasizes the need for career coaching. The use of competency assessment, professional certification, and transition-to-practice programs are identified as strategies for career management with the goal of lifelong learning. Finally, professional resumés, reflection, and portfolios are discussed as career planning tools. The leadership roles and management functions inherent in career planning and development in nursing are shown in Display 11.1.

DISPLAY 11.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN CAREER PLANNING AND DEVELOPMENT IN NURSING

Leadership Roles 1. Is self-aware of personal values influencing career development 2. Encourages employees to take responsibility for their own

career planning 3. Identifies, encourages, and develops future leaders 4. Shows a genuine interest in the career planning and career

development of all employees 5. Encourages and supports the development of career paths

within and outside the organization 6. Supports employees’ personal career decisions based on each

employee’s needs and values 7. Is a role model for continued professional development via

specialty certification, continuing education, and portfolio development

8. Emphasizes the need for employees to develop the skill set necessary for evidence-based practice

9. Supports new graduate nurses in their transition to practice through positive role modeling as well as the creation of nurse residencies, internships, and externships

10. Role models lifelong learning as a professional expectation and responsibility

11. Encourages others to continue their formal education as part of their career ladder and professional journey

Management Functions 1. Develops fair policies related to career development

opportunities and communicates them clearly to subordinates 2. Provides fiscal resources and release time for subordinate

training and education

3. Uses a planned system of short- and long-term coaching for career development and documents all coaching efforts

4. Disseminates career and job information 5. Works with employees to establish career goals that meet both

employee and organizational needs 6. Works cooperatively with other departments in arranging for the

release of employees to take other positions within the organization

7. Views transition-to-practice programs as an investment strategy to mitigate nurse turnover and promote employee satisfaction

8. Coaches employees to create professional portfolios that demonstrate reflection as well as the maintenance of continued competence

9. Attempts to match position openings with capable employees who seek new learning opportunities

10. Creates possibilities for career progression 11. Provides opportunities for “legacy” clinicians to “reinvent”

themselves to renew their potential value to the organization and their coworkers

Career Stages Before individuals can plan a successful career development program, they need to understand the typical career stages. Shirey (2009) suggests that there are three different career phases or stages among nurses: promise, momentum, and harvest. Promise is the earliest of the career phases and typically reflects the first 10 years of nursing employment. Individuals in this stage are less experienced and tend to experience reality overload as a result. Making wise early career choices is critical in this phase. Milestones to be attained include socialization to the nursing role (becoming an insider); building knowledge, skills, abilities, credentials, and an education base; gaining exposure to a variety of experiences; identifying strengths and building confidence; and positioning for the future.

Benner (1982) describes this early phase as a transition from novice to expert, arguing that nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of experiences. As nurses progress from novice to advanced beginner, to competent, to proficient, and finally to expert, they extend their practical knowledge (know how) through research and the understanding of the “know how” of clinical experience (Benner, 1982). In other words, the new nurse moves from reliance on past abstract principles to the use of past concrete experience as paradigms and changes his or her perception of situations to whole parts rather than separate pieces (Display 11.2).

DISPLAY 11.2 BENNER’S LEVELS OF NURSING EXPERIENCE

Novice Beginner with no experience Taught general rules to help perform tasks Rules are context-free, independent of specific cases, and applied universally

However, rules cannot express which tasks are most relevant in real life or when exceptions are needed

Advanced Beginner Demonstrates acceptable performance Has gained prior experience in actual situations to recognize

recurring meaningful components Principles, based on experiences, begin to be formulated to guide

actions

Competent Typically, 2 to 3 years’ work experience in the same area or in

similar day-to-day situations More aware of long-term goals Gains perspective from planning own actions based on conscious,

abstract, and analytical thinking and helps to achieve greater efficiency and organization

Proficient Perceives and understands situations as whole parts More holistic understanding improves decision making Learns from experiences what to expect in certain situations and

how to modify plans

Expert No longer relies on principles, rules, or guidelines to connect

situations and determine actions Much more background of experience Has intuitive grasp of clinical situations

Performance is now fluid, flexible, and highly proficient

Source: Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402–407.

Shirey (2009) suggests that momentum is the middle career phase and typically reflects the nurse with 11 to 29 years of experience. Nurses in this phase are experienced clinicians with expert knowledge, skills, abilities, credentials, and education base. This is a time of accomplishment, challenge, and a sense of purpose, and the individual often achieves enough expertise to be a role model to others. Milestones include further building confidence in one’s competence; developing experience, gaining mastery, and establishing a professional track record; and finding a voice through aligning strengths with passion. One of the most significant challenges to nurses in this phase, however, is creating possibilities for career progression rather than stagnation. A commitment to lifelong learning and being willing to seize unexpected opportunities that may present themselves over time are often key to career divergence at this point in life.

Shirey (2009) notes that the last stage, harvest, commences in late career. Shirey labels nurses with 30 to 40 years as having “prime” experience and nurses with more than 40 years of experience as being “legacy” clinicians. Although viewed as expert clinicians, the experiential value of nurses in the harvest phase may begin to decline if others perceive them as obsolescent. These prime or legacy nurse- leaders then must actively strive for ongoing “reinvention” to renew their potential value to their coworkers. Success then is defined not only by being knowledgeable but also by being savvy and adaptable. The potential for career divergence in this phase is mixed, depending on choices made in the momentum phase. Milestones to be conquered include elevating their mastery to sage practice for advancing the profession and positioning as a professional statesperson and establishing a legacy.

Finally, an argument might be made that another career stage exists in nursing—that of reentry. Concurrent with nursing shortages, many

nurses who were no longer working in the profession but who possess the necessary training and experience to do so may reenter the work setting.

LEARNING EXERCISE 11.1

Exploring Career Stages

In a group, discuss the job stages described by Shirey (2009). What stage most closely reflects your present situation? Think about the nurses that you work with or those you aspire to be like. What career stage are they currently in? Do you believe that male and female nurses have similar or dissimilar career stages?

Justifications for Career Development The following, summarized in Display 11.3, is a list of justifications for career development programs:

Reduced employee attrition. Career development can reduce the turnover of ambitious employees who might otherwise seek other jobs because of a lack of job advancement.

Equal employment opportunity. Minorities and other underserved groups have more opportunities to move up in an organization if they are identified and developed early in their careers.

Increased opportunities for employee growth. When employees are kept in jobs that they have outgrown, their productivity is often reduced. People perform better when they have jobs that fit them and provide new challenges.

Improved quality of work life. Nurses increasingly desire to control their own careers. They are less willing to settle for just any role or

position that comes their way. They want greater job satisfaction and more career options.

Improved competitiveness of the organization. Highly educated professionals often prefer organizations that have a good track record of career development. During nursing shortages, a recognized program of career development can be the deciding factor for professionals selecting a position.

Obsolescence can be avoided and new skills acquired. Because of the rapid changes in health care, especially in the areas of consumer demands and technology, employees may find that their skills have become obsolete. A successful career development program begins to retrain employees proactively, providing them with the necessary skills to remain current in their field and, therefore, valuable to the organization. Some of the most basic career development programs, such as financial planning and general equivalency diploma programs, can be the most rewarding programs for the staff.

Evidence-based practice promoted. Evidence-based practice is now the gold standard for nursing practice; yet, many nurses still lack both skill and confidence in knowing how to use research and best practices to inform their practice. The astute leader-manager recognizes this knowledge deficit and uses career planning and goal setting to allow these nurses the time and resources needed to acquire these skills.

DISPLAY 11.3 JUSTIFICATIONS FOR CAREER DEVELOPMENT

Reduces employee attrition Provides equal employment opportunity Increases opportunities for employee growth Improves quality of work life Improves competitiveness of the organization Avoids obsolescence and builds new skills Promotes evidence-based practice

Individual Responsibility for Career Development Despite the many obvious benefits of career development programs, some nurses never create a personal career plan or set goals they wish to accomplish during their career. Instead, nursing becomes just a job. This viewpoint limits the opportunities for professional advancement and personal growth because what cannot be imagined rarely becomes a reality. The impact of positive role modeling by nurse-leaders in influencing this perception cannot be overstated.

Career development should begin with an assessment of self as well as work environment, job analysis, education, training, job search and acquisition, and work experience. This is known as career planning. Career planning includes evaluating one’s strengths and weaknesses, setting goals, examining career opportunities, preparing for potential opportunities, and using appropriate developmental activities.

Career planning in nursing should begin with an individual’s decision about educational entry level for practice and quickly expand to developing advanced skills in an area of nursing practice. Even for the entry-level nurse, career planning should include, at minimum, a commitment to the use of evidence-based practice, learning new skills or bettering practice with the assistance of role models and mentors, staying aware of and being involved in professional issues, and furthering one’s education. It should also include long-term career goals as well as a specific plan to achieve lifelong learning.

Every nurse should proactively develop a career plan that provides opportunities for new learning, challenges, and opportunities for career divergence.

The Organization’s Role in Employee Career Development Organizations also have some responsibility to assist employees with their career development. One such responsibility is the creation of

career paths and advancement/career ladders (a structured sequence of job positions through which a person can progress in an organization) (BusinessDictionary.com, 2019a). It must also attempt to match position openings with appropriate people. This includes accurately assessing employees’ performance and potential to offer the most appropriate career guidance, education, and training. Other organizational responsibilities include the following:

Integrating needs. The human resources department, nursing division, nursing units, and education department must work together to match job openings with the skills and talents of present employees.

Establishing career paths. Career paths must be developed, communicated to the staff, and implemented consistently. When designing career paths, each successive job in each path should contain additional responsibilities and duties that are greater than the previous jobs in that path. Each successive job also must be related to and use previous skills.

Once career paths are established, they must be communicated effectively to all staff. What employees must do to advance in a path should be very clear. Although various forms of career ladders have existed for some time, they are still not widely used. This problem is not unique to nursing. Even when health-care organizations design and use a career structure, the system often breaks down once the nurse leaves that organization. For example, nurses at the level of Clinical Nurse III in one hospital will usually lose that status when they leave the organization for another position.

Disseminating career information. The education department, human resources department, and unit manager are all responsible for sharing career information; however, employees should not be encouraged to pursue unrealistic goals.

Posting job openings. Although this is usually the responsibility of the human resources department, the manager should communicate this information, even when it means staff may

transfer to another area. Effective managers know who should be encouraged to apply for openings and who is ready for more responsibility and challenges.

Assessing employees. One of the benefits of a good appraisal system is the important information that it gives the manager on the performance, potential, and abilities of all staff members. The use of short- and long-term coaching will give managers insight into their employees’ needs and wants so that appropriate career counseling can proceed.

Providing challenging assignments. Planned work experience is one of the most powerful career development tools. This includes jobs that temporarily stretch employees to their maximum skill, temporary projects, assignment to committees, shift rotation, assignment to different units, and shift charge duties.

Giving support and encouragement. Because excellent subordinates make managers’ jobs easier, managers are often reluctant to encourage these subordinates to move up the corporate ladder or to seek more challenging experiences outside the manager’s span of control. Thus, many managers hoard their talent. A leadership role requires that managers look beyond their immediate unit or department and consider the needs of the entire organization. Leaders recognize and share talent.

Developing personnel policies. An active career development program often results in the recognition that certain personnel policies and procedures are impeding the success of the program. When this occurs, the organization should reexamine these policies and make necessary changes.

Providing education and training. The impact of education and training on career development and retention of subordinate staff is discussed more fully in Chapter 16. The need for organizations to develop leaders and managers is presented later in this chapter.

A comparison of roles and responsibilities individuals and organizations have for employee career development is shown in Table 11.1.

TABLE 11.1 ROLES AND RESPONSIBILITIES FOR CAREER DEVELOPMENT

Career Planning (Individual) Career Management (Organizational)

● Self-assess interests, skills, strengths, weaknesses, and values

● Determine goals ● Assess the organization for

opportunities ● Assess opportunities outside

the organization ● Develop strategies ● Implement plans ● Evaluate plans ● Reassess and make new plans

as necessary, at least biannually

● Integrate individual employee needs and organizational needs

● Establish, design, communicate, and implement career paths

● Disseminate career information ● Post and communicate all job

openings within the organization

● Assess employees’ career needs

● Provide work experiences to further employee development

● Give support and encouragement

● Develop new personnel policies as necessary, at least biannually

● Provide training and education

LEARNING EXERCISE 11.2

Encouragement and Coaching for Goal Achievement

In your employment, has someone ever coached you, either formally or informally, to develop your career? For example, has an employer told you about career or educational opportunities? Have they offered tuition reimbursement? If so, how did you find out about such policies? Have you ever coached (something more than just encouraging) someone to pursue educational or career goals? Share the answers to these questions in class.

Career Coaching Organizations also have some responsibility to assist employees with career coaching. Unit managers sometimes take on this role, but it may also be provided by informal organization leaders who are willing to act in a mentoring capacity. Indeed, a Stanford Business study found that 80% of chief executive officers said they received some form of mentorship (Wong, 2018). Wong (2018) notes that such mentoring shapes an individual’s leadership style and sets a benchmark for a long-term commitment in growth that lasts long after the mentoring relationship ends.

Career coaching involves helping others to identify professional goals and career options and then designing a career plan to achieve those goals. The Executive Coaching Network (n.d.) suggests that career coaches serve as facilitators, motivators, consultants, and sounding boards dealing with business goals, people interaction, and self- management issues.

Career coaching typically has three steps:

1. Gathering data. When managers spend time observing employees, they can determine who has good communication skills, who is well organized, who uses effective negotiating skills, and who works collaboratively. Managers also should seek information about the employee’s past work experience, performance appraisals, and educational experiences. Data also

should include academic qualifications and credentials. Most of this information is retrievable in the employee’s personnel file. Finally, employees themselves are an excellent source of information about career needs and wants.

2. Asking what is possible. As part of career planning, the manager should assess the department for possible changes in the future, openings or transfers, and potential challenges and opportunities. The manager should anticipate what needs lie ahead, what projects are planned, and what staffing and budget changes will occur. After carefully assessing the employee’s profile and future opportunities, managers should consider each staff member and ask the following questions: How can this employee be helped so that he or she is better prepared to take advantage of the future? Who needs to be encouraged to return to school, to become credentialed, or to take a special course? Which employees need to be encouraged to transfer to a more challenging position, given more responsibility on their present unit, or moved to another shift? Managers can create a stimulating environment for career development by being aware of the uniqueness of their employees.

3. Conducting the coaching session. The goals of career coaching include helping employees increase their effectiveness; identifying potential opportunities in the organization; and advancing knowledge, skills, and experience. It is important not to intimidate employees when questioning them about their future and their goals. Although there is no standard procedure for career coaching, the main emphasis should be on employee’s growth and future development.

Career coaching, then, can be either short or long term. In short-term career coaching, the manager regularly asks the employees questions to develop and motivate them. Thus, short-term coaching is a spontaneous part of the experienced manager’s repertoire.

Long-term career coaching, on the other hand, is a planned management action that occurs over the duration of employment.

Because this type of coaching may cover a long time, it is frequently neglected unless the manager uses a systematic scheduling plan and a form for documentation. Because employees and managers move frequently within an organization, the lack of record keeping regarding employees’ career needs deters nursing career development. In the present climate of organizational restructuring and downsizing, a manager’s staff is even more in need of career coaching, and documentation of the career coaching takes on an even more important role. Figure 11.1 is an example of a long-term coaching form.

FIGURE 11.1 Sample long-term coaching form.

Long-term coaching is a major step in building an effective team and an excellent strategy to increase productivity and retention. The effective manager should have at least one coaching session with each employee annually, in addition to any coaching that may occur during the appraisal interview. Although some coaching should occur during the performance appraisal interview, additional coaching should be planned at a less stressful time.

LEARNING EXERCISE 11.3

Career Coaching a Bored Employee

You are the registered nurse (RN) team leader on a busy step-down critical care unit. One of the certified nursing assistants (CNAs) assigned to your team is technically very competent and always completes her work on time but frequently appears to be bored. The only time she seems to be excited about work is when she is assisting you or the other RNs with more complex skills such as central line dressing changes, peripherally inserted central catheters, and complex wound packings. She has shared at times that her long-term career goal is to become an RN but has never verbalized any specific plan to achieve this. Although she is highly capable, her formal education to date is limited to a high school diploma she earned 3 years ago. She currently provides full-time financial support for herself and her 3- year-old daughter.

ASSIGNMENT:

1. Identify questions you might ask the CNA that could be a part of both short- and long-term career coaching for this employee.

2. What resources might be explored to support this employee in attaining higher education?

3. What leadership role modeling could be made available to this employee to encourage her in furthering her career goals?

Management Development Management development is a planned system of training and developing people so that they acquire the skills, insights, and attitudes needed to manage people and their work effectively within the organization. Wong (2018) notes that 84% of organizations anticipate a shortfall in leaders in the next 5 years.

Management development is often referred to as succession planning. Many nurses feel uncertain that they have the skills needed to be effective managers, and they lack confidence that the decision- making, interpersonal, and organizational skills they learned as staff nurses can translate to the management role.

Many nurses feel that they lack the knowledge and experience necessary to become a manager.

Although many of these skills do transfer, becoming an effective manager is generally not intuitive. With the flattening of organizational hierarchies, an expected increase in nursing management vacancies due to retirement, and a continued increase in managerial responsibilities, new leader-managers will likely need the formal education and training that are a part of a management development program. The program must include a means of developing appropriate

attitudes through social learning theory as well as adequate content on management theory.

The skill sets needed by leader-managers in the coming decade will be even more complex than they are today. Huston (2008) suggests that essential nurse-leader competencies for 2020 include having a global perspective or mindset regarding health-care and professional nursing issues; technology skills that facilitate mobility and portability of relationships, interactions, and operational processes; expert decision- making skills rooted in empirical science; the ability to create organization cultures that permeate quality health care and patient/worker safety; understanding and appropriately intervening in political processes; highly developed collaborative and team building skills; the ability to balance authenticity and performance expectations; and being able to envision and proactively adapt to a health-care system characterized by rapid change and chaos. Contemporary nursing and health-care organizations must begin now to create the educational models and management development programs necessary to prepare the next generation of leader-managers.

Support for such management development programs by the organization should occur in two ways. First, top-level management must do more than bear the cost of management development classes. They must create an organizational structure that allows managers to apply their new knowledge.

Second, training outcomes improve if nursing executives are active in planning and developing a systematic and integrated program. Whenever possible, nursing administrators should teach some of the classes and, at the very least, make sure that the program supports top management philosophy. Just as nurses are required to be certified in critical care before they accept a position in a critical care unit, nurses should be required to take part in a management development program before their appointment to a management position. This requires early identification and grooming of potential management candidates.

The first step in the process would be an appraisal of the present management team and an analysis of possible future needs. The

second step would be the establishment of a training and development program. This would require decisions such as the following: How often should the formal management course be offered? Should outside educators be involved, or should in-house staff teach it? Who should be involved in teaching the didactic portion? Should there be two levels of classes, one for first-level and one for middle-level managers? Should the management development courses be open to all, or should people be recommended by someone from management? In addition to formal course content, what other methods should be used to develop managers? Should other methods be used, such as job rotation through an understudy system of pairing selected people with a manager and management coaching?

The inclusion of social learning activities also is a valuable part of management development. Management development will not be successful unless learners have ample chance to try out new skills. Providing potential managers with didactic management theory alone does not prepare them for the attitudes, skills, and insights necessary for effective management. Case studies, management games, transactional analysis, and sensitivity training are also effective in changing attitudes and increasing self-awareness. All these techniques appropriately use social learning theory strategies.

Promotion: A Career Management Tool Promotions are reassignments to a position of higher rank. It is normal for promotions to include a pay raise. Most promotions include increased status, title changes, more authority, and greater responsibility; therefore, they can be used as a significant motivational tool.

Because of the importance that US society places on promotions, certain guidelines must accompany promotion selection to ensure that the process is fair, equitable, and motivating. When position openings occur, they are often posted and filled quickly with little thought of long- term organizational or employee goals. This frequently results in

negative personnel outcomes. To avoid this, the following elements should be determined in advance:

Whether recruitment will be internal or external. There are obvious advantages and disadvantages to recruiting for promotions from both inside and outside the organization. Recruiting from within can help to develop employees to fill higher level positions as they become vacant. It can also serve as a powerful motivation and recognition tool because all employees know that opportunities for advancement are possible, and this encourages them to perform at a higher level.

There are advantages to recruiting from outside the organization, however. When promotions are filled with people outside the organization, the organization is infused with people with new ideas. This prevents the stagnation that often occurs when all promotions are internal. External candidates, however, often cost more in terms of salary than internal ones. This is because external candidates generally need a financial incentive to leave their current positions for something else.

Regardless of what the organization decides, the policy should be consistently followed and communicated to all employees. Some companies recruit from within first and recruit from outside the organization only if they are unable to find qualified people from among their own employees.

What the promotion and selection criteria will be. Employees should know in advance what the criteria for promotion are and what selection method is to be used. Some organizations use an interview panel as a selection method to promote all employees beyond the level of charge nurse. Decisions regarding the selection method and promotion criteria should be justified with rationale. In addition, employees need to know what place seniority will have in the selection criteria.

The pool of candidates that exists. When promotions are planned, as in succession management, an adequate pool of candidates must be identified and prepared to seek higher level positions. A

word of caution must be given, however, regarding the zeal with which managers urge subordinates to seek promotions. The leader’s role is to identify and prepare such a pool. It is not the manager’s role to urge the employee to seek a position in a manner that would lead the employee to think that he or she was guaranteed the job or to unduly influence him or her in the decision to seek such a job.

When employees actively seek promotions, they are making a commitment to do well in the new position. When they are pushed into such positions, the commitment to expend the energy to do the job well may be lacking. In addition, for many reasons, the employee may not feel ready, either due to personal commitments or because he or she feels inadequately educated or experienced. Indeed, it is possible to promote an individual beyond his or her level of capability (known as the Peter Principle). In this case, promotions demotivate that individual as well as everyone in the organization.

The Peter Principle suggests that individuals often rise “to the level of their incompetence.”

Handling rejected candidates. All promotion candidates who are rejected must be notified before the selected candidate is notified. This is common courtesy. They should be thanked for applying and, when appropriate, encouraged to apply for future position openings. Sometimes, managers should tell employees which deficiencies kept them from getting the position. For instance, employees should be told if they lack some educational component or work experience that would make them a stronger competitor for future promotions. This can be an effective way of encouraging career development.

How employee releases are to be handled. Knowledge that the best candidate for the position currently holds a critical job or

difficult position to fill should not influence decisions regarding promotions. Managers frequently find it difficult to release employees to another position within the organization. Policies regarding the length of time that a manager can delay releasing an employee should be written and communicated. On the other hand, some managers are so good at developing their employees that they frequently become frustrated because their success at career development results in constantly losing their staff to other departments. In such cases, higher level management should reward such leaders and set release policies that are workable and realistic.

Continued Competency as Part of Career Development Continued competency is also a part of career management. BusinessDictionary.com (2019b) suggests that the definition of a professional is “a person formally certified by a professional body or belonging to a specific profession by virtue of having completed a required course of studies and/or practice, and whose competence can usually be measured against an established set of standards” (para. 1).

Fukada (2018) agrees, noting that nursing competency includes core abilities required for fulfilling one’s role as a nurse. Therefore, it is important to clearly define nursing competency to establish a foundation for nursing education curriculum. It is also important to identify the developmental process of nursing competency for continuous professional development after obtaining a nursing license. However, although the concepts surrounding nursing competency are important for improving nursing quality, they are still not yet completely developed. Thus, challenges remain in establishing definitions and structures for nursing competency, competency levels necessary for nursing professionals, training methods, and so on (Fukada, 2018).

Huston (2020) agrees, noting that unfortunately, in many states, a practitioner is determined to be competent when initially licensed and

thereafter, unless proven otherwise. Yet, clearly, passing a licensing exam and continuing to work as a clinician does not assure competence throughout a career. Competence requires continual updates to knowledge and practice, and this is difficult in a health-care environment characterized by rapidly emerging new technologies, chaotic change, and perpetual clinical advancements.

The Institute of Medicine (IOM, 2010) report The Future of Nursing notes that nursing graduates now need competency in a variety of areas, including continuous improvement of the quality and safety of health-care systems; informatics; evidence-based practice; a knowledge of complex systems; skills and methods for leadership and management of continual improvement; population health and population-based care management; and health policy knowledge, skills, and attitudes. One must at least question how many nurses currently in practice would be able to demonstrate competency in all these areas.

Recent research (Hovland, Kyrkjebø, Andersen, & Råholm, 2018) suggested that nurses in their study perceived their competence as being satisfactory overall but did identify areas that would benefit from improvement such as providing patients’ family members with education and guidance, quality assurance, and using research to evaluate and develop services. The study also suggested a correlation exists between tasks nurses perform often and their perception of having a satisfactory competence level with that task. Often performed tasks then lead to the acquisition of required competencies. The research also found a correlation between age, length of experience, education, and levels of self-assessed competence, but the constant changes in health care supported the need for experienced nurses (see Examining the Evidence 11.1).

EXAMINING THE EVIDENCE 11.1 Source: Hovland, G., Kyrkjebø, D., Andersen, J. R., & Råholm, M. (2018). Self-assessed competence among nurses working in municipal health-care services in

Norway. British Journal of Community Nursing, 23(4), 162–169. doi:10.12968/bjcn.2018.23.4.162

Self-Assessing Nursing Competence Demands made on nursing staff are expanding and changing, requiring a broad set of competencies that require ongoing evaluation and enhancement. Using a descriptive, cross- sectional quantitative design, the researchers used the Norwegian version of the Nurse Competence Scale instrument to measure self- assessed competence among nurses working in three municipal health-care services in Norway.

Results suggested that nurses perceived their competence as being satisfactory overall, but there were areas that would benefit from improvement: providing patients’ family members with education and guidance, quality assurance, and using research to evaluate and develop services.

Teaching/coaching was one area where many nurses perceived they were less competent. This was a matter of discovering and mapping information/training needs for relatives and for patients. What is surprising is that the nurses often noticed family members’ needs for education and guidance but, unlike other areas, had not developed the corresponding competence to handle these needs.

When considering diagnostic functions, nurses perceived they had good skills in analyzing the patient’s well-being from many perspectives and arranging expert assistance for the patient when needed but were not able to see the relatives’ need for support.

The nurses also perceived their competence in managing situations as good except when supervising others in rapidly changing situations. This was likely because most of these nurses worked alone and did not see each other in these situations. Finally, competence in quality assurance scored the lowest of all and raised questions about the need for further education.

The researchers noted how important it is that nurses have a wide range of competencies. They concluded that the development and testing of methodologies for assessing competence could be useful in identifying training needs and areas for professional development at the staff member level but could also be useful for individual nurses to be aware of their own competence and identify areas that need to be enhanced.

Assessing, maintaining, and supporting maintaining continued competence then is a challenge in professional nursing. For example, Huston (2020) notes that some nurses develop high levels of competence in specific areas of nursing practice because of work experience and specialization at the expense of staying current in other areas of practice. In addition, employers often ask nurses to provide care in areas of practice outside their area of expertise because a nursing shortage encourages them to do so. In addition, many current competence assessments focus more on skills than they do on knowledge (Huston, 2020). The issue is also complicated by the fact that there are no national standards for defining, measuring, or requiring continuing competence in nursing.

Managers should appraise each employee’s competency level not only as part of performance appraisal but also as part of career development. This appraisal should lead to the development of a plan

that outlines what the employee must do to achieve desired competencies in both current and future positions. Often, however, competency assessment focuses only on whether the employee has achieved required minimal competency levels to meet current federal, state, or organizational standards and not on how to exceed these competency levels. Thus, competency assessment and goal setting in career planning is proactive, with the employee identifying areas of potential future growth and the manager assisting in identifying strategies that can help the employee achieve that goal.

Competency assessment and goal setting in career planning should help the employee identify how to exceed minimum levels of competency.

Certainly, some individual responsibility for maintaining competence and pursuing lifelong learning is suggested by the American Nurses Association (ANA, 2015) Code of Ethics for Nurses with Interpretive Statements in its assertion that nurses are obligated to provide adequate and competent nursing care. State Nurse Practice Acts also hold nurses accountable for being reasonable and prudent in their practice. Both standards require the nurse to have at least some personal responsibility for continually assessing his or her professional competence through reflective practice (Huston, 2020). In addition, the IOM (2010) report The Future of Nursing calls for nursing schools and nurses to pursue lifelong learning.

The individual registered nurse (RN) has a professional obligation to seek lifelong learning and maintain competence.

Mandatory Continuing Education to Promote Continued Competence

Many professional associations and states have mandated continuing education (CE) for RN license renewal to promote continued competence. Most states in the United States require CE for RN license renewal with requirements varying from a few hours to 30 hours, every 2 years. There is no requirement for CE, however, for RNs in Arizona, Colorado, Connecticut, Georgia, Hawaii, Idaho, Illinois, Maine, Maryland, Mississippi, Missouri, Montana, New York, Oklahoma, South Dakota, Tennessee, Vermont, Virginia, Washington, and Wisconsin (Nursing CEU Requirements, 2017).

The CE approach to continuing competence continues to be very controversial because there is limited research demonstrating correlation among CE, continuing competence, and improved patient outcomes. In addition, many professional organizations have expressed concern about the quality of mandated CE courses and the lack of courses for experts and specialists. Likewise, there is no agreement on the optimal number of annual credits needed to ensure competence, and the type of CE needed to assure continued competence can vary significantly. Until consensus can be reached regarding how CE should be provided, what and how much is needed, and until research findings show an empirical link between CE and provider competence, it is difficult to tout CE as a valid and reliable measure of continuing competence.

LEARNING EXERCISE 11.4

Does Mandatory Continuing Education Assure Competence in Nursing?

Most states in the United States have mandatory requirements for continuing education (CE) for professional nurse license renewal even though there is limited research

demonstrating correlation among CE, continuing competence, and improved patient outcomes. In addition, CE taken is not required to relate to the area a registered nurse (RN) practices in, nor is there agreement on the optimal number of annual credits needed to ensure competence.

ASSIGNMENT:

Determine the CE requirements for RN license renewal in the state in which you live or practice. In small groups, debate the use of CE as a valid and reliable measure of continuing competence in nursing.

Professional Specialty Certification Professional specialty certification is one way an employee can demonstrate advanced achievement of competencies. To achieve professional certification, nurses must meet eligibility criteria that may include years and types of work experience as well as minimum educational levels, active nursing licenses, and successful completion of a nationally administered examination (Huston, 2020). Certifications normally last 5 years.

Professional associations grant specialty certification as a formal but voluntary process of demonstrating expertise in a specific area of nursing. For example, the ANA established the ANA Certification Program in 1973 to provide tangible recognition of professional achievement in a defined functional or clinical area of nursing. The American Nurses Credentialing Center, a subsidiary of ANA, became its own corporation in 1991 and since then has certified hundreds of thousands of nurses throughout the United States and its territories in more than 40 specialty and advanced practice areas of nursing. A few of the other organizations offering specialty certifications for nurses are the American Association of Critical-Care Nurses, the American

Association of Nurse Anesthetists, the American College of Nurse- Midwives, the Board of Certification for Emergency Nursing, and the Rehabilitation Nursing Certification Board.

Huston (2020) notes that it is middle- and top-level nurse-managers who play the most significant role in creating work environments that value and reward certification. For example, nurse-managers can grant tuition reimbursement or salary incentives to workers who seek certification. Managers can also show their support for professional certification by giving employees paid time off to take the certification exam and by publicly recognizing employees who have achieved specialty certification.

The certified nurse often finds many personal benefits related to the attainment of such status, including more rapid promotions on career ladders, advancement opportunities, and feelings of accomplishment. Certified nurses also often earn more than their noncertified counterparts. In addition, research in the past decade suggests that certification leads to both improved patient outcomes and the creation of a positive work environment. A summary of the benefits associated with professional certification are shown in Display 11.4.

DISPLAY 11.4 BENEFITS OF PROFESSIONAL CERTIFICATION

Provides a sense of accomplishment and achievement Validation of specialty knowledge and competence to peers and

patients Increased credibility Increased self-confidence Promotes greater autonomy of practice Provides for increased career opportunities and greater

competitiveness in the job market May result in salary incentives Improved patient outcomes Increased levels of perceived empowerment creating more

positive work cultures Demonstrates commitment to the profession Promotes lifelong learning and professional development

Sources: American Association of Colleges of Nursing. (2018). CNL certification. Retrieved September 7, 2018, from http://www.aacnnursing.org/CNL-Certification; Huston, C. J. (2020). Assuring provider competence through licensure, continuing education, and certification. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 287–300). Philadelphia, PA: Wolters Kluwer.

Reflective Practice and the Professional Portfolio Reflective practice has also been suggested as a strategy for promoting personal growth and continued competence in nursing. Reflective practice is defined by the North Carolina Board of Nursing (NCBN, n.d.) as “a process for the assessment of one’s own practice to identify and seek learning opportunities to promote continued competence” (para. 8). Watkins (2018) adds that in its simplest form, reflective practice is the ability to reflect on your actions and engage in a process of continuous learning. Steps in the reflective process, as noted in the mnemonic REFLECT, are shown in Display 11.5. Inherent in the process is the evaluation and incorporation of this learning into

one’s practice. Such self-assessment is gaining popularity as a means to promote professional practice and maintain competence. Often, this is done using professional portfolios for competence assessment.

DISPLAY 11.5 WATKINS’S SEVEN STEPS OF REFLECTION

R—RECALL the event. E—EXAMINE your responses. F—Acknowledge FEELINGS. L—LEARN from the experience. E—EXPLORE options. C—CREATE a plan of action. T—Set TIMESCALE.

Source: Watkins, A. (2018). Reflective practice as a tool for growth. Retrieved September 8, 2018, from https://www.ausmed.com/articles/reflective-practice/

For example, North Carolina now requires RNs to use a reflective practice approach to carry out a self-assessment of his or her practice and develop a plan for maintaining competence (NCBN, 2018). This assessment is individualized to the licensed nurse’s area of practice. RNs seeking license renewal or reinstatement must attest to having completed the learning activities required for continuing competence and be prepared to submit evidence of completion if requested by the board on random audit (NCBN, 2018). This is typically collated in some type of professional portfolio.

A professional portfolio can be described as a collection of materials that document a nurse’s competencies and illustrate the expertise of the nurse. The professional portfolio typically contains core components, such as biographical information; educational background; certifications achieved; employment history; a resumé; a competence record or checklist; personal and professional goals; professional development experiences, presentations, consultations, and publications; professional and community activities; honors and

awards; and letters of thanks from patients, families, peers, organizations, and others.

All nurses should maintain a portfolio to reflect their professional growth throughout their career.

Maintaining a professional portfolio avoids lost opportunities to save documents because professional nurses should always have documentation readily available to pursue a promotion, to consider a new position, or to apply for another position in their present employment.

LEARNING EXERCISE 11.5

Creating a Professional Portfolio ASSIGNMENT:

1. Identify the categories of evidence you would use to organize a professional portfolio if you were to create one today.

2. Identify specific evidence you could include in each of these categories. What evidence currently exists and what would need to be created?

3. How would you incorporate reflection in creating a personal professional portfolio?

Career Planning and the New Graduate Nurse During the recent economic downturn, many new graduates rushed to find a “job”—any job—in nursing, forgetting that even early employment decisions are critical to the achievement of their long-term career plans.

New graduates must select their first employment wisely and seek work in a facility with a strong reputation for shared governance, positive work cultures, and a reputation of excellence in multiple arenas.

Finding work in a facility with orientation programs, internships, residencies, and fellowships is also important to the new graduate because it takes time to gain the expertise and self-confidence that is a part of being an expert nurse. Mentors and preceptors should also be available to support the new graduate nurse and to role model high- quality, evidence-based decision making and clinical practice. If the new graduate has a positive, nurturing first employment experience, he or she is much more likely to take future career risks, to pursue lifelong learning, and to have the energy and commitment to become involved in the bigger issues of their profession.

New graduates also have responsibility during the crucial first few years of employment to gain the expertise they need to have more opportunities for career divergence in the future. This includes becoming an expert in one or more areas of practice, gaining professional certifications, and being well informed about professional nursing and health-care issues. This is also a time where participation in professional associations has great value because of opportunities for mentoring and networking. Finally, all new graduates should consider at what point continued formal education will be a part of their career ladder and professional journey.

Transition-to-Practice Programs/Residencies for New Graduate Nurses Arguments have grown over the last decade regarding the need for transition-to-practice programs (also known as residences, externships, or internships) for new graduates of nursing programs. West, Wallace, and Fuller (2020) note that new graduate nurses often begin working with little more than a few weeks of orientation, in contrast to most other professions, which require formal and often standardized internships or residencies. This is largely a residual outcome of the

traditional nursing educational system that was grounded in apprenticeship and hospital-based training programs, which led to the student receiving a diploma in nursing.

West et al. (2020) suggest the ever-changing health-care delivery care system, with its increasing complexity of patient care, evolving technology, and focus on patient safety, has raised the bar in terms of expectations for new graduate nurses. New graduates must now hit the ground running with well-developed critical thinking and problem- solving skills, the ability to exercise clinical judgment with know-how to practice from an evidence-based and outcome-driven perspective, and the ability to develop effectively from a novice to an expert in competency.

Such high expectations accompanied by inadequate advanced apprenticeship training often leads to high turnover rates for new graduate nurses. In addition, patient safety and quality of care are at risk if new graduates do not have the critical thinking skills or competencies needed to apply critical judgments to patient situations. West et al. (2020) suggest that transition-to-practice programs bridge the gap by providing the new graduate opportunities to take the learning from nursing school and apply it in an expanded, intensive, and integrated clinical learning situation while providing direct patient care—much in the same way that the internship of physicians is based on applying academic learning to actual care of patients and transition into the professional role.

A well-designed transition-to-practice program strengthens new graduates’ skills and competencies and prepares the new nurse for the demands of caring for patients. Furthermore, a systematic approach to transition not only facilitates “on-boarding” (integration into staffing on the nursing unit to provide direct patient care) but also reduces the turnover of unprepared and dissatisfied new graduates.

The IOM in its landmark 2010 report The Future of Nursing called for the implementation and evaluation of nursing residency programs. Recent compelling evidence suggests that transition-to-practice programs can improve outcomes for new nurses in their first year of

practice including improved quality and safety practices, reduced work stress, and increased job satisfaction. In addition, health-care institutions with transition programs report marked drops in attrition (NCBN, 2018).

West et al. (2020) also suggest that employers and academe share the obligation to provide bridges from student to practicing nurse and that the inclusion of transition-to-practice programs is increasingly considered an expectation of the nursing education process and career development. Indeed, the IOM (2010) report The Future of Nursing identified transition-to-practice programs/residencies as one of the eight key recommendations to actualize nursing contributions to the demands of health-care reform. The IOM suggests “state Boards of Nursing, accrediting bodies, the federal government, and health care organizations should take action to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas” (p. 280).

Multiple types of transition-to-practice programs exist (West et al., 2020). There are programs that begin in the final year of nursing school and continue through licensure, although these programs are generally not intended to take the place of employer-based residencies, which often extend to 1 year and have a planned structured, mentored experience. Most transition-to-practice programs are employer-based “new graduate classes” within a hospital- or employer- (hospital) based programs that take up to a year to complete. Still, others are for new graduates who have yet to be hired, so they may gain skills to become more employable.

Traditional transition-to-practice programs (residencies) are typically funded and provided by employers (usually hospitals). The hospital hires a group of new graduate RNs and provides a curriculum over the first 6 months to 1 year of their employment. The new graduate hires may receive partial to full pay, although they do not have a full patient load for some time into their residency. Transition-to-practice programs are also found, however, in nonacute settings, such as primary care

clinics, behavior health clinics, long-term care, home health, corrections, school of nursing, and public health, and they provide exposure to career paths that new graduates may not have previously considered and also provide an opportunity for nonacute employers to consider hiring new graduate nurses (West et al., 2020).

LEARNING EXERCISE 11.6

Addressing Nurse Residency Concerns

West et al. (2020) note that although many groups are actively working to assure that nurse residences exist to provide a solid foundation for successful career development in nursing, many questions continue to exist about resource allocation (human and fiscal).

ASSIGNMENT:

Select any two of the following four questions and write a one-page essay defending your answers. 1. Schools have voiced concerns that transition-to-

practice programs are taking preceptorship slots that have been historically allocated to prelicensure students. Do you support this reallocation of resources?

2. Should transition-to-practice programs/residencies be a requirement for the completion of entry-level nursing education?

3. Residencies have historically been a cost hospitals or employers have assumed. Should this cost be shared and why?

4. Would you participate in a school-based transition- to-practice program without an associated stipend if it could help you gain experience? Would you pay to participate?

Resumé Preparation Despite the best efforts of organizations to help subordinates identify career needs, wants, and opportunities, it is how employees represent themselves that often determines whether desired career opportunities become a reality. Creating a positive image often depends on having well-developed interviewing skills (see Chapter 15) and a well-prepared resumé.

Resumé Format Various acceptable styles and formats of resumés exist. However, because the resumé represents the professionalism of the applicant and recruiters use it to summarize an applicant’s qualifications, it must be professionally prepared, make an impression, and quickly capture

the reader’s attention. General guidelines for resumé preparation are shown in Display 11.6. A sample resumé is shown in Figure 11.2.

DISPLAY 11.6 GENERAL GUIDELINES FOR RESUMЀ PREPARATION

Keep the resumé one to two pages long (Slack, n.d.). Keep your writing concise and clear. Target the job you desire and your qualifications with what you

write. The average resumé receives only a few seconds of attention from recruiters, so make important points stand out.

Type the document in a single-font format that is easy to read (12- point font or larger is recommended).

Use bulleted points or sentences. Add your LinkedIn address next to your name and contact

information and make sure your LinkedIn profile is as robust as it can be (Bahler, 2018).

Include educational background, work history, awards or honors received, scholarly achievements such as publications and presentations, and community service activities.

Do not include personal information such as marital status, age, whether you have children, ethnicity, or religious affiliations.

Maximize your strong points and minimize your weaknesses. Do not overstate your accomplishments because doing so places

your credibility at great risk. Use good grammar, correct punctuation, and proper sentence

structure. Typographic errors suggest you may not be serious about the job application or that the quality of your work will be substandard.

Try to avoid overuse of “confidence inspiring” words like passionate, driven, or results-oriented as those words have little meaning without context. Instead, keep your resumé direct and to the point and show, do not tell, how you accomplish things (Slack, n.d.).

Choose words carefully. Bahler (2018) notes that when you upload your resumé to an online career portal, many companies use software to scan it for keywords applicable to the job you’re

applying for. If those keywords are not found, your application could be deleted without review.

Use high-quality, heavy white, or off-white, paper to print the resumé.

Consider adding a splash of color to your black-and-white resumé to make it “pop” out from your competition but do not go overboard (Slack, n.d.). Black and another color is good enough. Use the color on your headings and keep your bullet points black.

Include a cover letter (whether by mail or e-mail), addressed to a specific individual when possible, to introduce yourself, briefly highlight key points of the resumé, and make a positive first impression.

Consider adding a professional objective or goal statement specific to your desired job. Bahler (2018) suggests, however, that objective statements are a thing of the past. Instead, she recommends adding a summary statement, which is basically just an elevator pitch for why you’re the best person for this job.

Make sure only to list references who know you well. You should inform the referees that you have listed them in your resumé so that when they are contacted, they are prepared to answer questions about the person who has applied for the job.

FIGURE 11.2 Sample nursing resumé.

Integrating Leadership Roles and Management Functions in Career Planning and Development Appropriate career management should foster positive career planning and development, alleviate burnout, reduce attrition, and promote productivity. Management functions in career planning and development include disseminating career information and posting job openings. The manager should have a well-developed, planned system for career development for all employees; this system should include long-term coaching, the appropriate use of transfers, and a plan for how promotions are to be handled. These policies should be fair and communicated effectively to all employees.

With the integration of leadership, managers become more aware of how their own values shape personal career decisions. In addition, the leader-manager shows genuine interest in the career development of all employees. Career planning is encouraged, and potential leaders are identified and developed. Present leaders are rewarded when they see those, whom they have helped to develop, advance in their careers and in turn develop leadership and management skills in others.

Effective managers recognize that in all career decisions, the employee must decide when he or she is ready to pursue promotions, return to school, or take on greater responsibility. Leaders are aware that every person perceives success differently. Although career development programs benefit all employees and the organization, there is a bonus for the professional nurse. When professional nurses can experience a well-planned career development program, a greater viability for and increased commitment to the profession are often evident.

Key Concepts

■ There are many outcomes of a career development program that justify its implementation.

■ Career job sequencing should assist the manager in career management.

■ Career development programs consist of a set of personal responsibilities called career planning and a set of management responsibilities called career management.

■ Employees often need to be encouraged to make more formalized long-term career plans.

■ Career planning should include, at minimum, a commitment to the use of evidence-based practice, learning new skills or bettering practice through the use of role models and mentors,

staying aware of and being involved in professional issues, and furthering one’s education.

■ Designing career paths is an important part of organizational career management.

■ Managers should plan specific interventions that promote growth and development in each of their subordinates.

■ Most individuals progress through normal and predictable career stages. Shirey (2009) describes these stages as promise, momentum, and harvest.

■ Benner (1982) suggests that in the transition from novice to expert, nurses develop skills and an understanding of patient care over time through a sound educational base as well as a multitude of experiences. Thus, the new nurse moves from reliance on past abstract principles to the use of past concrete experience and changes his or her perception of situations to whole parts rather than separate pieces.

■ Career coaching involves helping others to identify professional goals and career options and designing a career plan to achieve those goals. This coaching should be both short and long term.

■ Because of the importance that American society places on promotions, certain guidelines must accompany promotion selection to ensure that the process is fair, equitable, and motivating.

■ It is possible to promote individuals beyond their level of capability. The Peter Principle, as it is known, suggests that individuals may rise “to the level of their incompetence.”

■ Competency assessment and goal setting in career planning should help the employee identify how to exceed the minimum levels of competency required by federal, state, or organizational standards.

■ Professional specialty certification is one way that an employee can demonstrate advanced achievement of competencies.

■ To be successful, management development must be planned and supported by top-level management. This type of planned

program is called succession planning. ■ If appropriate management attitudes and insight are goals of a

management development program, social learning techniques need to be part of the teaching strategies used.

■ Multiple types of transition-to-practice programs exist, but all are focused on helping nursing students bridge from school into employment.

■ Maintaining a current, professional resumé is a career-planning necessity for the health-care professional and should not be undertaken lightly.

■ Cover letters (whether by mail or e-mail) should always be used when submitting a resumé. Their purpose is to introduce the applicant, briefly highlight key points of the resumé, and make a positive first impression.

■ All nurses should maintain a professional portfolio (a collection of materials that document a nurse’s competencies and illustrate the expertise of the nurse) to reflect their professional growth over their career.

Additional Learning Exercises and Applications

LEARNING EXERCISE 11.7

Developing a 20-Year Career Plan Using a Career Map

Develop a 20-year career plan, considering the constraints of family responsibilities such as marriage, children, and aging parents. Have your career plan critiqued to determine whether it is feasible and whether the timelines and goals are realistic.

In addition, career planning is often made easier when a career map is created to assist in developing a long-term master plan. Use the career guide shown in Figure 11.3 below, along with the individual responsibilities for career development outlined in Table 11.1, to assist with developing your 20-year career plan.

FIGURE 11.3 A career planning guide for a professional nurse.

LEARNING EXERCISE 11.8

Preparing a Resumé

The medical center where you have applied for a position has requested that you submit a resumé along with your application. Prepare a professional resumé using your actual experience and education. You may use any style and format that you desire. The resumé will be critiqued on its professional appearance and appropriateness of included content.

LEARNING EXERCISE 11.9

The Reluctant Preceptor (Marquis & Huston, 2012)

You are a new graduate nurse in your first job as a staff nurse on an oncology unit. You have been assigned to orient with Steve, an experienced registered nurse (RN) and longtime employee on the unit. This is, however, Steve’s first experience as a preceptor. Steve is an expert clinician, and you marvel at his high-quality assessments and how intuitive his nursing diagnoses seem to be. Steve is a role model for you in terms of the level of clinical skills you hope to achieve.

Steve, however, seems to have difficulty teaching in the preceptor role. He accomplishes his work quickly and often, without explanation—even though you are at his side. He also is resistant to allowing you to practice many of the basic skills and tasks you are qualified to do, suggesting instead that you should just watch him do it and learn by shadowing. When you question Steve about this practice, he reassures you that he believes you are competent and that you will be a good nurse but states that he does not yet feel comfortable in “letting you do things on your own.”

You are becoming increasingly frustrated with this style of preceptorship and worry that you are not getting the experience you will need to autonomously function as an RN when your orientation ends in 4 weeks. Yet, you also value the opportunity to work so closely with such a skilled clinician and wonderful role model.

ASSIGNMENT:

Determine what you will do. What goals are driving your decision? What are the potential risks and benefits inherent in your plan?

R E F E R E N C E S American Nurses Association. (2015). Code of ethics for nurses with

interpretive statements. Washington, DC: Author. Bahler, K. (2018). What your resume should look like in 2018.

Retrieved September 7, 2018, from http://time.com/money/5053350/resume-tips-free-template/

Benner, P. (1982). From novice to expert. The American Journal of Nursing, 82(3), 402–407.

BusinessDictionary.com. (2019a). Career ladder. Retrieved August 14, 2019, from http://www.businessdictionary.com/definition/career- ladder.html

BusinessDictionary.com. (2019b). Professional. Retrieved August 14, 2019, from http://www.businessdictionary.com/definition/professional.html

Executive Coaching Network. (n.d.). What is executive coaching? Retrieved September 7, 2018, from http://www.execcoachnetwork.com.au/whatis.html

Fukada, M. (2018). Nursing competency: Definition, structure and development. Yonago Acta Medica, 61(1), 1–7. doi:10.33160/yam.2018.03.001

Hovland, G., Kyrkjebø, D., Andersen, J. R., & Råholm, M. (2018). Self- assessed competence among nurses working in municipal health- care services in Norway. British Journal of Community Nursing, 23(4), 162–169. doi:10.12968/bjcn.2018.23.4.162

Huston, C. J. (2008). Preparing nurse leaders for 2020. Journal of Nursing Management, 16(8), 905–911.

Huston, C. J. (2020). Assuring provider competence through licensure, continuing education, and certification. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 287–300). Philadelphia, PA: Wolters Kluwer.

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

Marquis, B., & Huston, C. (2012). Leadership and management tools for the new nurse. Philadelphia, PA: Lippincott Williams & Wilkins.

North Carolina Board of Nursing. (2018). Continuing competence requirements. Retrieved September 7, 2018, from https://www.ncbon.com/licensure-listing-continuing-competence- continuing-competence-requirements

North Carolina Board of Nursing. (n.d.). Continuing competence—A reflective practice approach. Retrieved September 7, 2018, from https://www.ncbon.com/vdownloads/abcd.pdf

Nursing CEU requirements. (2017). Retrieved September 7, 2018, from http://www.ehow.com/facts_4969045_continuing-education-does- nurse-need.html

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Slack, M. (n.d.). 5 Ways to spruce up your resume right now. Retrieved September 7, 2018, from http://theundercoverrecruiter.com/spruce- up-resume-new-year/

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Wong, C. (2018). Empowering the next generation of leaders. Retrieved September 19, 2018, from https://www.ceo.com/organizations/empowering-the-next- generation-of-leaders

U N I T I V

Roles and Functions in Organizing

12

Organizational Structure . . . The days of the traditional pyramid shaped corporate hierarchy as a viable business model are coming to an end.—Michael Hugos

. . . Basic philosophy, spirit and drive of an organization have far more to do with its relative achievements than do technological or economic resources, organizational structure, innovation and timing.—Marvin Bower

. . . Every company has two organizational structures: The formal one is written on the charts; the other is the everyday relationship of the men and women in the organization.—Harold Geneen

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

BSN Essential VIII: Professionalism and professional values MSN Essential II: Organizational and systems leadership MSN Essential III: Quality improvement and safety MSN Essential VII: Interprofessional collaboration for improving patient and population health outcomes

AONL Nurse Executive Competency I: Communication and relationship building

AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency IV: Professionalism AONL Nurse Executive Competency V: Business skills ANA Standard of Professional Performance 10: Collaboration ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 14: Quality of practice

ANA Standard of Professional Performance 16: Resource utilization

ANA Standard of Professional Performance 17: Environmental health

QSEN Competency: Teamwork and collaboration QSEN Competency: Quality improvement QSEN Competency: Safety

LEARNING OBJECTIVES

The learner will:

describe how the structure of an organization facilitates or impedes communication, flexibility, and job satisfaction

identify characteristics of a bureaucracy as defined by Max Weber identify line-and-staff relationships, span of control, unity of command, and scalar chains on the organization chart

describe components of the informal organization structure including employee interpersonal relationships, the formation of primary and secondary groups, and group leaders without formal authority

differentiate between first, middle, and top levels of management contrast centralized and decentralized decision making

analyze how position on the organization chart is related to centrality

describe common components of shared governance models and differentiate shared governance from participatory decision making

contrast individual authority, responsibility, and accountability in given scenarios

identify appropriate strategies the leader-manager may take to create a constructive organizational culture

describe characteristics of effective committees and committee members

define “groupthink” and discuss the impact of groupthink on organizational decision making and risk taking

identify symptoms of poorly designed organizations describe the five model components of Magnet-designated health- care organizations as well as the 14 foundational forces required to achieve Magnet status

provide examples of an organization’s potential stakeholders

Introduction Unit III provided a background in planning, the first phase of the management process. Organizing follows planning as the second phase of the management process and is explored in this unit. In the organizing phase, relationships are defined, procedures are outlined, equipment is readied, and tasks are assigned. Organizing also involves establishing a formal structure that provides the best possible coordination or use of resources to accomplish unit objectives. This chapter looks at how the structure of an organization facilitates or impedes communication, flexibility, productivity, and job satisfaction. Chapter 13 examines the role of authority and power in organizations and how power may be used to meet individual, unit, and organizational goals. Chapter 14 looks at how human resources can be organized to accomplish patient care.

Formal and Informal Organizational Structure Organizations are necessary because they accomplish more work than can be done by individual effort. Because people spend most of their lives in social, personal, and professional organizations, they need to understand how organizations are structured—their formation, methods of communication, channels of authority, and decision-making processes.

Each organization has a formal and an informal organizational structure. In the formal organization, the emphasis is on organizational positions and formal power, whereas in the informal organization, the focus is on the employees, their relationships, and the informal power that is inherent within those relationships (Hartzell, 2003–2019). In addition, the formal structure is generally highly planned and visible, whereas the informal structure is unplanned and often hidden.

Formal structure provides a framework for defining managerial authority, responsibility, and accountability. In a well-defined formal structure, roles and functions are defined and systematically arranged, different people have differing roles, and rank and hierarchy are evident.

Organizational structure refers to the way in which a group is formed, its lines of communication, and its means for channeling authority and making decisions.

Informal structure is generally a naturally forming social network of employees. Hartzell (2003–2019) suggests that it is the informal structure that fills in the gaps with connections and relationships that illustrate how employees’ network with one another to get work done. Because informal structures are typically based on camaraderie, they often result in a more immediate response from individuals, saving people’s time and effort (Schatz, 2018). People also rely on informal structure if the formal structure has stopped being effective, which often

happens as an organization grows or changes but does not reevaluate its hierarchy or work groups (Schatz, 2018).

The informal structure even has its own communication network, known as the grapevine. Hartzell (2003–2019) suggests that grapevine communication is at the heart of the informal organization; it is the conversations that occur in the break room, down the halls, during the carpool, and in between work that allows the relationships of informal groups to develop. In addition, social media sites (Facebook, Instagram, Snapchat, Twitter, etc.) and electronic communication such as e-mail and text messages are also used to facilitate communication among informal group members.

Although grapevine communication is fast and can facilitate information upward, downward, and horizontally, it is difficult to control or to stop. With little accountability for the message, grapevine communication often becomes a source for rumor or gossip.

The informal structure also has its own leaders. In addition, it also has its own communication channels, often referred to as the grapevine.

People need to be aware that informal authority and lines of communication exist in every group, even when they are never formally acknowledged. The primary emphasis of this chapter, however, is the identification of components of organizational structure, the leadership roles and management functions associated with formal organizational structure (Display 12.1), and the proper utilization of committees to accomplish organizational objectives.

DISPLAY 12.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH ORGANIZATIONAL STRUCTURE

Leadership Roles 1. Evaluates the organizational structure frequently to determine if

management positions should be eliminated to shorten the chain of command

2. Encourages and guides employees to follow the chain of command and counsels employees who do not do so

3. Supports personnel in advisory (staff) positions 4. Models responsibility and accountability for subordinates 5. Assists staff to see how their roles are congruent with and

complement the organization’s mission, vision, and goals 6. Facilitates constructive informal group structure 7. Encourages upward communication 8. Fosters a positive organizational culture between work groups

and subcultures that facilitates shared values and goals 9. Promotes participatory decision making and shared governance

to empower subordinates 10. Uses committees to facilitate group goals, not to delay decisions

Management Functions 1. Is knowledgeable about the organization’s internal structure,

including personal and department authority and responsibilities within that structure

2. Facilitates constructive formal group structure 3. Provides the staff with an accurate unit organization chart and

assists with interpretation 4. When possible, maintains unity of command 5. Clarifies unity of command when there is confusion 6. Follows appropriate subordinate complaints upward through the

chain of command 7. Establishes an appropriate span of control

8. Strives to create a constructive organizational culture and positive organizational climate

9. Uses the informal organization to meet organizational goals 10. Uses committee structure to increase the quality and quantity of

work accomplished 11. Works, as appropriate, to achieve a level of operational

excellence befitting an organization such as Magnet status or some other recognition of excellence

12. Continually identifies, analyzes, and promotes stakeholder interests in the organization

Organizational Theory and Bureaucracy Max Weber, a German social scientist, is known as the father of organizational theory. Generally acknowledged to have developed the most comprehensive classic formulation on the characteristics of bureaucracy, Weber wrote from the vantage point of a manager instead of that of a scholar. During the 1920s, Weber saw the growth of the large-scale organization and correctly predicted that this growth required a more formalized set of procedures for administrators. His statement on bureaucracy, published after his death, is still the most influential statement on the subject.

Weber postulated three “ideal types” of authority or reasons why people throughout history have obeyed their rulers. One of these, legal- rational authority, was based on a belief in the legitimacy of the pattern of normative rules and the rights of those elevated to authority under such rules to issue commands. Obedience, then, was owed to the legally established impersonal set of rules rather than to a personal ruler. It is this type of authority that is the basis for Weber’s concept of bureaucracy.

Weber argued that the great virtue of bureaucracy—indeed, perhaps its defining characteristic—was that it was an institutional method for applying general rules to specific cases, thereby making the actions of

management fair and predictable. Other characteristics of bureaucracies as identified by Weber include the following:

There must be a clear division of labor (i.e., all work must be divided into units that can be undertaken by individuals or groups of individuals competent to perform those tasks).

A well-defined hierarchy of authority must exist in which superiors are separated from subordinates; based on this hierarchy, remuneration for work is dispensed, authority is recognized, privileges are allotted, and promotions are awarded.

There must be impersonal rules and impersonality of interpersonal relationships. In other words, bureaucrats are not free to act in any way they please. Bureaucratic rules provide superiors systematic control over subordinates, thus limiting the opportunities for arbitrary behavior and personal favoritism.

A system of procedures for dealing with work situations (i.e., regular activities to get a job done) must exist.

A system of rules covering the rights and duties of each position must be in place.

Selection for employment and promotion is based on technical competence.

Bureaucracy was the ideal tool to harness and routinize the energy and prolific production of the Industrial Revolution. Weber’s work did not, however, consider the complexity of managing organizations in the 21st century. Weber wrote during an era when worker motivation was taken for granted, and his simplification of management and employee roles did not examine the bilateral relationships between employee and management prevalent in most organizations today.

Since Weber’s research, management theorists have learned much about human behavior, and most organizations have modified their structures and created alternative organizational designs that reduce rigidity and impersonality. Yet, almost 100 years after Weber’s findings, components of bureaucratic structure continue to be found in the design of most large organizations.

Current research suggests that changing an organization’s structure in a manner that increases autonomy and work empowerment for health care employees will lead to more effective patient care.

Components of Organizational Structure Weber is also credited with the development of the organization chart to depict an organization’s structure. Because the organization chart (Fig. 12.1) is a picture of an organization, the knowledgeable manager can derive much information from reading the chart. For example, an organization chart can help identify roles and their expectations.

FIGURE 12.1 Sample organizational chart. (Copyright © 2006 Lippincott Williams & Wilkins. Instructor’s Resource CD-ROM to Accompany Leadership Roles and Management Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.)

In addition, by observing elements, such as which departments report directly to the chief executive officer (CEO), the novice manager can make some inferences about the organization. For instance, reporting to a middle-level manager rather than an executive officer suggests that person has less status and influence than someone who reports to an individual higher on the organization chart. Managers who understand an organization’s structure and relationships will be able to expedite decisions and have a greater understanding of the organizational environment.

Relationships and Chain of Command The organization chart defines formal relationships within the institution. Formal relationships, lines of communication, and authority are depicted on a chart by unbroken (solid) lines. These line positions can be shown by solid horizontal or vertical lines. Solid horizontal lines represent communication between people with similar spheres of responsibility and power but different functions. Solid vertical lines between positions denote the official chain of command, the formal paths of communication and authority. Those having the greatest decision-making authority are located at the top; those with the least are at the bottom. The level of position on the chart also signifies status and power.

Dotted or broken lines on the organization chart represent staff positions. Because these positions are advisory, a staff member provides information and assistance to the manager but has limited organizational authority. Used to increase his or her sphere of influence, staff positions enable a manager to handle more activities and interactions than would otherwise be possible. These positions also provide for specialization that would be impossible for a manager to achieve alone. Although staff positions can make line personnel more effective, organizations can function without them.

Advisory (staff) positions, however, do not have inherent legitimate authority. Clinical specialists and education directors in staff positions

often lack the authority that accompanies a line relationship. Accomplishing the role expectations in a staff position may therefore be more difficult because formal authority is limited. Because only line positions have authority for decision making, staff positions may result in an ineffective use of support services unless job descriptions and responsibilities for these positions are clearly spelled out.

Unity of command is indicated by the vertical solid line between positions on the organizational chart. This concept is best described as one person/one boss in which employees have one manager to whom they report and to whom they are responsible. This greatly simplifies the manager–employee relationship because the employee needs to maintain only a minimum number of relationships and accept the influence of only one person as his or her immediate supervisor.

Unity of command is difficult to maintain in some large health-care organizations because the nature of health care requires an interprofessional approach.

Nurses frequently feel as though they have many individuals to account to because health care often involves an interprofessional approach. Additional individuals the nurse may need to be accountable to include the immediate supervisor, the patient, the patient’s family, central administration, and the physician. All have some input in directing a nurse’s work. Weber was correct when he determined that a lack of unity of command results in some conflict and lost productivity. This is demonstrated frequently when health-care workers become confused about unity of command.

LEARNING EXERCISE 12.1

Who Is the Boss?

In groups or individually, analyze the following and give an oral or written report.

1. Have you ever worked in an organization in which the lines of authority were unclear? Have you been a member of a social organization in which this happened? How did this interfere with the organization’s functioning?

2. Do you believe that the “one boss/one person” rule is a good idea? Do hospital clerical workers frequently have many bosses? If you have worked in a situation in which you had more than one boss, what was the result?

Span of Control Span of control also can be determined from the organization chart. The number of people directly reporting to any one manager represents that manager’s span of control and determines the number of interactions expected of him or her. Thus, there is an inverse relation between the span of control and the number of levels in hierarchy in an organization, that is, the narrower the span, the greater is the number of levels in an organization (Juneja, 1996–2019).

Theorists are divided regarding the optimal span of control for any one manager. Quantitative formulas for determining the optimal span of control have been attempted, with suggested ranges from 3 to 50 employees. The ideal span of control in an organization depends on various factors, such as the nature of the job, the manager’s abilities, the employees’ maturity, the task complexity, and the level in the organization at which the work occurs. The number of people directly reporting to any one supervisor must be the number that maximizes productivity and worker satisfaction.

Too many people reporting to a single manager delays decision making, whereas too few results in an inefficient, top-heavy organization.

Until the last decade, the principle of narrow spans of control at top levels of management, with slightly wider spans at other levels, was widely accepted. Indeed, Juneja (1996–2019) suggests that most modern management theorists would suggest an ideal span of control as 15 to 20 subordinates per manager, as compared with the 6 subordinates per manager touted in the past. With increased financial pressures on health-care organizations to remain fiscally solvent and electronic communication technology advances, many have increased their spans of control and reduced the number of administrative levels in the organization. This is often termed flattening the organization.

One of the leadership responsibilities of organizing is to periodically examine the number of people in the chain of command and the span of control each person has. Organizations frequently add levels until there are too many managers. Therefore, the leader-manager should carefully weigh the advantages and disadvantages of adding a management level. For example, does having a charge nurse on each shift aid or hinder decision making? Does having this position solve or create problems?

Managerial Levels In large organizations, several levels of managers often exist. Top-level managers look at the entire organization, coordinating internal and external influences, and generally make decisions with few guidelines or structures. Examples of top-level managers include the organization’s CEO and the highest level nursing administrator. Current nomenclature for top-level nurse-managers include vice president of nursing, nurse administrator, director of nursing, chief nurse, assistant administrator of patient care services, or chief nurse officer (CNO).

Some top-level nurse-managers may be responsible for nonnursing departments. For example, a top-level nurse-manager might oversee the respiratory, physical, and occupational therapy departments in addition to all nursing departments. Likewise, the CEO might have various titles, such as president and director. It is necessary to remember only that the CEO is the organization’s highest ranking person, and the top-level nurse-manager is its highest ranking nurse. Responsibilities common to top-level managers include determining the organizational philosophy, setting policy, and creating goals and priorities for resource allocation. Top-level managers have a greater need for leadership skills and are not as involved in routine daily operations as are lower level managers.

Middle-level managers coordinate the efforts of lower levels of the hierarchy and are the conduit between lower and top-level managers. Middle-level managers carry out day-to-day operations but are still involved in some long-term planning and in establishing unit policies. Examples of middle-level managers include nursing supervisors, department heads, coordinators, directors, and unit managers.

Currently, there are many health facility mergers and acquisitions, and reduced levels of administration are frequently apparent within these consolidated organizations. Consequently, many health-care facilities have expanded the scope of responsibility for middle-level managers and given them the title of “director” to indicate new roles. The proliferation of titles among health-care administrators has made it imperative that individuals understand what roles and responsibilities go with each position.

First-level managers are concerned with their specific unit’s workflow. They deal with immediate problems in the unit’s daily operations, with organizational needs, and with personal needs of employees. First- level managers need good management skills. Because they work so closely with patients and health-care teams, first-level managers also have an excellent opportunity to practice leadership roles that will greatly influence productivity and subordinates’ satisfaction. Examples of first-level managers include primary care nurses, team leaders, case

managers, and charge nurses. In many organizations, every registered nurse (RN) is considered a first-level manager. A composite look at top-, middle-, and first-level managers is shown in Table 12.1.

TABLE 12.1 LEVELS OF MANAGERS

Top Level Middle Level First Level

Examples Chief nursing officer

Chief executive officer

Chief financial officer

Unit supervisor Department

head Director

Charge nurse Team leader Primary nurse

Scope of responsibility

Look at organization as a whole as well as external influences

Focus is on integrating unit- level day-to-day needs with organizational needs

Focus primarily on day-to-day needs at unit level

Primary planning focus

Strategic planning

Combination of long- and short- range planning

Short-range, operational planning

Communication flow

More often top- down but receives subordinate feedback both directly and via middle-level managers

Upward and downward with great centrality

More often upward; generally relies on middle-level managers to transmit communication to top-level managers

Centrality

Centrality, or where a position falls on the organizational chart, is determined by organizational distance. Employees with relatively small organizational distance can receive more information than those who are more peripherally located. Therefore, the middle manager often has a broader view of the organization than other levels of management. A middle manager has a large degree of centrality because this manager receives information upward, downward, and horizontally.

Centrality refers to the location of a position on an organization chart where frequent and various types of communication occur.

Because all communication involves a sender and a receiver, messages may not be received clearly because of the sender’s hierarchical position. Similarly, status and power often influence the receiver’s ability to hear information accurately. An example of the effect of status on communication is found in the “principal syndrome.” Most people can recall panic, when they were school age, at being summoned to the principal’s office. Thoughts of “What did I do?” travel through one’s mind. Even adults find discomfort in communicating with certain people who hold high status. This may be fear or awe, but both interfere with clear communication. The difficulties with upward and downward communication are discussed in more detail in Chapter 19.

It is important, then, to be aware of how the formal structure affects overall relationships and communication. This is especially true because organizations change their structure frequently, resulting in new communication lines and reporting relationships. Unless one understands how to interpret a formal organization chart, confusion and anxiety will result when organizations are restructured.

Is it ever appropriate to go outside the chain of command? Of course, there are isolated circumstances when the chain of command must be breached. However, those rare conditions usually involve a question of ethics. In most instances, those being bypassed in a chain of command

should be forewarned. Remember that unity of command provides the organization with a workable system for procedural directives and orders so that productivity is increased and conflict is minimized.

LEARNING EXERCISE 12.2

Change Is Coming

This Learning Exercise refers to the organization chart in Figure 12.1. Because Memorial Hospital is expanding, the board of directors has made several changes that require modification of the organization chart. The directors have just announced the following changes:

The name of the hospital has been changed from Memorial Hospital to Memorial Medical Center.

State approval has been granted for open-heart surgery. One of the existing medical–surgical units will be

remodeled and will become two critical care units (one six-bed coronary and open-heart unit and one six-bed trauma and surgical unit).

A part-time medical director will be responsible for medical care on each critical care unit.

The hospital administrator’s title has been changed to executive director.

An associate hospital administrator has been hired. A new hospital-wide educational department has been

created. The old pediatric unit will be remodeled into a seven-bed

pediatric wing and a seven-bed rehabilitation unit. The director of nursing’s new title is vice president of

patient care services.

ASSIGNMENT:

If the hospital is viewed as a large, open system, it is possible to visualize areas where problems might occur. In particular, it is necessary to identify changes anticipated in the nursing department and how these changes will affect the organization as a whole. Depict all of these changes on the old organization chart, delineating both staff and line positions. Give the rationale for your decisions. Why did you place the education department where you did? What was the reasoning in your division of authority? Where do you believe there might be potential conflict in the new organization chart? Why?

Limitations of Organization Charts Because organization charts show only formal relationships, what they can reveal about an institution is limited. The chart does not show the informal structure of the organization. Every institution has in place a dynamic informal structure that can be powerful and motivating. Knowledgeable leaders never underestimate its importance because the informal structure includes employees’ interpersonal relationships, the formation of primary and secondary groups, and the identification of group leaders without formal authority.

These groups are important in organizations because they provide workers with a feeling of belonging. They also have a great deal of power in an organization; they can either facilitate or sabotage planned change. Their ability to determine a unit’s norms and acceptable behavior has a great deal to do with the socialization of new employees. Informal leaders are frequently found among long-term employees or people in select gatekeeping positions, such as the CNO’s secretary. Frequently, the informal organization evolves from

social activities or from relationships that develop outside the work environment.

Organization charts are also limited in their ability to depict each line position’s degree of authority. Authority is defined as the official power to act. It is power given by the organization to direct the work of others. A manager may have the authority to hire, fire, or discipline others.

Equating status with authority, however, frequently causes confusion. The distance from the top of the organizational hierarchy usually determines the degree of status: the closer to the top, the higher the status. Status also is influenced by skill, education, specialization, level of responsibility, autonomy, and salary accorded a position. People frequently have status with little accompanying authority.

Because organizations are so dynamic, an organization chart becomes obsolete very quickly, so trying to keep an organization chart current is almost impossible. It is also possible that the organization chart may depict how things are supposed to be, when the organization is still functioning under an old structure because employees have not yet accepted new lines of authority.

Another limitation of the organization chart is that although it defines authority, it does not define responsibility and accountability. A responsibility is a duty or an assignment. It is the implementation of a job. For example, a responsibility common to many charge nurses is establishing the unit’s daily patient care assignment. Individuals should always be assigned responsibilities with concomitant authority. If authority is not commensurate to the responsibility, role confusion occurs for everyone involved. For example, supervisors may have the responsibility of maintaining high professional care standards among their staff. If the manager is not given the authority to discipline employees as needed, however, this responsibility is virtually impossible to implement.

Accountability is similar to responsibility, but it is internalized. Thus, to be accountable means that individuals agree to be morally responsible for the consequences of their actions. Therefore, one individual cannot be accountable for another. Society holds us

accountable for our assigned responsibilities, and people are expected to accept the consequences of their actions. A nurse who reports a medication error is being accountable for the responsibilities inherent in the position.

The leader-manager should understand the interrelationships and differences among these three terms. Display 12.2 discusses the advantages and limitations of an organization chart. Because the use of authority, power building, and political awareness are so important to functioning effectively in any structure, Chapter 13 discusses these organizational components in depth.

DISPLAY 12.2 ADVANTAGES AND LIMITATIONS OF THE ORGANIZATION CHART

Advantages 1. Maps lines of decision-making authority 2. Helps people understand their assignments and those of their

coworkers 3. Reveals to managers and new personnel how they fit into the

organization 4. Contributes to sound organizational structure 5. Shows formal lines of communication

Limitations 1. Shows only formal relationships 2. Does not indicate degree of authority 3. Are difficult to keep current 4. May show things as they are supposed to be or used to be rather

than as they are 5. May define roles too narrowly 6. Possibility of confusing authority with status exists

Types of Organizational Structures

Traditionally, organizations have used one of the following structural patterns: bureaucratic, ad hoc, matrix, flat, or various combinations of these. The type of structure used in any health-care facility affects communication patterns, relationships, and authority.

Line Structures Bureaucratic organizational designs are commonly called line structures or line organizations. Those with staff authority may be referred to as staff organizations. Both types of organizational structures are found frequently in large health-care facilities and usually resemble Weber’s original design for effective organizations. Because of most people’s familiarity with these structures, there is little stress associated with orienting people to these organizations. In these structures, authority and responsibility are clearly defined, which leads to efficiency and simplicity of relationships. The organization chart in Figure 12.1 is a line-and-staff structure.

These formal designs have some disadvantages. They often produce monotony, alienate workers, and make adjusting rapidly to altered circumstances difficult. Another problem with line and line-and-staff structures is their adherence to chain of command communication, which restricts upward communication. Good leaders encourage upward communication to compensate for this disadvantage. However, when line positions are clearly defined, going outside the chain of command for upward communication is usually inappropriate.

Ad Hoc Design The ad hoc design is a modification of the bureaucratic structure and is sometimes used on a temporary basis to facilitate completion of a project within a formal line organization. The ad hoc structure is a means of overcoming the inflexibility of line structure and serves as a way for professionals to handle the increasingly large amounts of available information. Ad hoc structures use a project team or task approach and are usually disbanded after a project is completed. This

structure’s disadvantages are decreased strength in the formal chain of command and decreased employee loyalty to the parent organization.

Matrix Structure A matrix organization structure is designed to focus on both product and function. Function is described as all the tasks required to produce the product, and the product is the end result of the function. For example, good patient outcomes are the product, and staff education and adequate staffing may be the functions necessary to produce the outcome.

The matrix organization structure has a formal vertical and horizontal chain of command. Figure 12.2 depicts a matrix organizational structure and shows that the manager of Nursing Women’s Services care could report both to a vice president for Maternal and Women’s Services (product manager) and a vice president for Nursing Services (functional manager). Although there are less formal rules and fewer levels in the hierarchy, a matrix structure is not without disadvantages. For example, in this structure, decision making can be slow because of the necessity of information sharing, and it can produce confusion and frustration for workers because of its dual-authority hierarchical design. The primary advantage of centralizing expertise is frequently outweighed by the complexity of the communication required in the design.

FIGURE 12.2 Matrix organizational structure. (Copyright © 2006 Lippincott Williams & Wilkins. Instructor’s Resource CD-ROM to Accompany Leadership Roles and Management Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.)

Service Line Organization Like the matrix design is service line organization, which can be used in some large institutions to address the shortcomings that are endemic to traditional large bureaucratic organizations. Service lines, sometimes called care-centered organizations, are smaller in scale than a large bureaucratic system. For example, in this organizational design, the overall goals would be determined by the larger organization, but the service line would decide on the processes to be used to achieve the goals.

Flat Designs

Flat organizational designs are an effort to remove hierarchical layers by flattening the chain of command and decentralizing the organization. Thus, a single manager or supervisor would oversee a large number of subordinates and have a wide span of control (Juneja, 1996–2019). In good times, when organizations are financially well off, it is easy to add layers to the organization in order to get the work done, but when the organization begins to feel a financial pinch, they often look at their hierarchy to see where they can cut positions.

In flattened organizations, there continues to be line authority, but because the organizational structure is flattened, more authority and decision making can occur where the work is being carried out. Figure 12.3 shows a flattened organizational structure. Many managers have difficulty letting go of control, and even very flattened types of structure organizations often retain many characteristics of a bureaucracy.

FIGURE 12.3 Flattened organizational structure. (Copyright © 2006 Lippincott Williams & Wilkins. Instructor’s Resource CD-ROM to Accompany Leadership Roles and Management Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.)

Decision Making Within the Organizational Hierarchy The decision-making hierarchy, or pyramid, is often referred to as a scalar chain. By reviewing the organization chart in Figure 12.1, it is possible to determine where decisions are made within the organizational hierarchy. Although every manager has some decision- making authority, its type and level are determined by the manager’s position on the chart.

In organizations with centralized decision making, a few managers at the top of the hierarchy make the decisions and the emphasis is on top- down control. In other words, the vision or thinking of one or a few individuals in the organization guides the organization’s goals and how those goals are accomplished. Execution of decision making in centralized organizations is fairly rapid because role conflict is minimized and role expectations are clarified.

Decentralized decision making diffuses decision making throughout the organization and allows problems to be solved by the lowest practical managerial level. Often, this means that problems can be solved at the level at which they occur, although some delays may occur in decision making if the problem must be transmitted through several levels to reach the appropriate individual to solve the problem. As a rule, however, larger organizations benefit from decentralized decision making.

This occurs because the complex questions that must be answered can best be addressed by a variety of people with distinct areas of expertise. Leaving such decisions in a large organization to a few managers burdens those managers tremendously and could result in devastating delays in decision making.

In general, the larger the organization, the greater the need to decentralize decision making.

Stakeholders Stakeholders are those entities in an organization’s environment that play a role in the organization’s health and performance or that are affected by the organization. Stakeholders may be both internal and external, they may include individuals and large groups, and they may have shared goals or diverse goals. Internal stakeholders, for example, may include the nurse in a hospital or the dietitian in a nursing home. Examples of external stakeholders for an acute care hospital might be the local school of nursing, home health agencies, and managed care

providers who contract with consumers in the area. Even the Chamber of Commerce in a city could be considered a stakeholder for a health- care organization.

Every organization should be viewed as being part of a greater community of stakeholders.

Stakeholders have interests in what the organization does but may or may not have the power to influence the organization to protect their interests. Stakeholders’ interests are varied, however, and their interests may coincide on some issues and not others. Organizations do not generally choose their own stakeholders; rather, the stakeholders choose to have a stake in the organizations’ decisions. Stakeholders may have a supportive or threatening influence on organizational decision making. For many decisions an organization makes, it may face a diverse set of stakeholders with varied and conflicting interest and goals.

As a part of planned change, discussed in Chapter 8, and decision making, discussed in Chapter 1, a stakeholder analysis is an important aspect of the management process. Such an analysis should be performed when there is a need to clarify the consequences of decisions and changes. In addition to identifying stakeholders who will be impacted by a change, it is necessary to prioritize them and determine their influence. Astute leaders must always be cognizant of who their stakeholders are and the impact they may have on an organization. A depiction of some possible stakeholders for a local community hospital appears in Table 12.2.

TABLE 12.2 EXAMPLES OF STAKEHOLDERS IN A COMMUNITY HOSPITAL

External Stakeholders Internal Stakeholders

Local businesses Hospital employees Area colleges and universities Physicians Insurance companies and HMOs Patients Community leaders Patients’ families Unions Union shop stewards Professional organizations Board of directors

HMO, health maintenance organization.

Organizational Culture Organizational culture is the total of an organization’s values, language, traditions, customs, and sacred cows—those few things present in an institution that are not open to discussion or change. For example, the hospital logo that had been designed by the original board of trustees is an item that may not be considered for updating or change.

Similarly, BusinessDictionary.com (2019) defines organizational culture as the values and behaviors that contribute to the unique social and psychological environment of an organization. The organizational culture includes an organization’s expectations, experiences, philosophy, and values that hold it together and is expressed in its self- image, inner workings, interactions with the outside world, and future expectations. It is based on shared attitudes, beliefs, customs, and written and unwritten rules that have been developed over time and are considered valid. Both definitions impart a sense of the complexity and importance of organizational culture.

Organizational culture is a system of symbols and interactions unique to each organization. It is the ways of thinking, behaving, and believing that members of a unit have in common.

Although assessing unit culture is a management function, building a constructive culture, particularly if a negative culture is in place, requires the interpersonal and communication skills of a leader. The leader must take an active role in creating the kind of organizational culture that will ensure success. Groysberg, Lee, Price, and Cheng (2018) agree, noting that although most leaders understand the fundamentals of strategy as a lever in their quest to maintain organizational viability and effectiveness, culture is more elusive because much of it is anchored in unspoken behaviors, mindsets, and social patterns. Groysberg et al. argue, however, that for better or for worse, culture and leadership are inextricably linked. “Founders and influential leaders often set new cultures in motion and imprint values and assumptions that persist for decades. Over time an organization’s leaders can also shape culture, through both conscious and unconscious actions (sometimes with unintended consequences). The best leaders we have observed are fully aware of the multiple cultures within which they are embedded, can sense when change is required, and can deftly influence the process” (Groysberg et al., 2018, para. 3).

It should be noted, however, that the more entrenched the culture and pattern of actions, the more challenging the change process is for the leader. Given such entrenchment of culture, success in building a new culture sometimes requires new leadership and/or the assistance of outside leadership. Groysberg et al. (2018) agree, noting that cultural change is daunting for any organization and often requires new leadership development and team coaching programs.

Organizations, if large enough, also have many different and competing value systems that create subcultures. These subcultures shape perceptions, attitudes, and beliefs and influence how their

members approach and execute their roles and responsibilities. A critical challenge then for the nurse-leader is to recognize these subcultures and to do whatever is necessary to create shared norms and priorities. Managers must be able to assess their unit’s culture and choose management strategies that encourage a shared culture. Such transformation requires both management assessment and leadership direction.

In addition, much of an organization’s culture is not available to staff in a retrievable source and must be related by others. For example, feelings about collective bargaining, nursing education levels, nursing autonomy, and nurse–physician relationships differ from one organization to another. These beliefs and values, however, are rarely written down or appear in a philosophy. Therefore, in addition to creating a constructive culture, a major leadership role is to assist subordinates in understanding the organization’s culture. Display 12.3 identifies questions that leaders and followers should ask when assessing organizational culture.

DISPLAY 12.3 ASSESSING THE ORGANIZATIONAL CULTURE

What Is the Organization’s Physical Environment? 1. Is the environment attractive? 2. Does it appear that there is adequate maintenance? 3. Are nursing stations crowded or noisy? 4. Is there an appropriate-sized lobby? Are there quiet areas? 5. Is there sufficient seating for families in the dining room? 6. Are there enough conference rooms? A library? A chapel or place

of worship?

What Is the Organization’s Social Environment? 1. Are many friendships maintained beyond the workplace? 2. Is there an annual picnic or holiday party that is well attended by

the employees? 3. Do employees seem to generally like each other? 4. Do all shifts and all departments get along fairly well? 5. Are certain departments disliked or resented? 6. Are employees on a first-name basis with coworkers, doctors,

charge nurses, and supervisors? 7. How do employees treat patients and visitors?

How Supportive Is the Organization? 1. Is educational reimbursement available? 2. Are good, low-cost meals available to employees? 3. Are there adequate employee lounges? 4. Are funds available to send employees to workshops? 5. Are employees recognized for extra effort? 6. Does the organization help pay for the holiday party or other

social functions?

What Is the Organizational Power Structure? 1. Who holds the most power in the organization? 2. Which departments are viewed as powerful? Which are viewed

as powerless? 3. Who gets free meals? Who gets special parking places?

4. Who wears laboratory coats? Who has overhead pages? 5. Who has the biggest office? 6. Who is never called by his or her first name?

How Safe Is the Organization? 1. Is there a well-lighted parking place for employees arriving or

departing when it is dark? 2. Is there an active and involved safety committee? 3. Are security guards needed and visible?

What Is the Communication Environment? 1. Is upward communication usually written or verbal? 2. Is there much informal communication? 3. Is there an active grapevine? Is it reliable? 4. Where is important information exchanged—in the parking lot, the

doctors’ surgical dressing room, the nurses’ station, the coffee shop, or during surgery or during the delivery room?

What Are the Organizational Taboos? Who Are the Heroes? 1. Are there special rules and policies that can never be broken? 2. Are certain subjects or ideas forbidden? 3. Are there relationships that cannot be threatened?

LEARNING EXERCISE 12.3

Cultures and Hierarchies

Having been with the county health department for 6 months, you are very impressed with the physician who is the county health administrator. She seems to have a genuine concern for patient welfare. She has a tea for new employees each month to discuss the department’s

philosophy and her own management style. She says that she has an open-door policy, so employees are always welcome to visit her.

Because you have been assigned to the evening immunization clinic as charge nurse, you have become concerned with a persistent problem. The housekeeping staff often spend part of the evening sleeping on duty or socializing for long periods. You have reported your concerns to your health department supervisor twice. Last evening, you found the housekeeping staff having another get-together. This mainly upsets you because the clinic is chronically in need of cleaning. Sometimes, the public bathrooms get so untidy that they embarrass you and your staff. You frequently remind the housekeepers to empty overflowing wastepaper baskets. You believe that this environment is demeaning to patients. This also upsets you because you and your staff work hard all evening and rarely have a chance to sit down. You believe it is unfair to everyone that the housekeeping staff is not doing their share.

ASSIGNMENT:

Note: Attempt to solve this problem before referring to a possible solution posted in the Appendix.

On your way to the parking lot this evening, the health administrator stops to chat and asks you how things are going. Should you tell her about the problem with the housekeeping staff? Is this following an appropriate chain of command? Do you believe that there is a conflict between the housekeeping unit’s culture and the nursing unit’s culture? What should you do? List choices and alternatives. Decide what you should do and explain your rationale.

Finally, Display 12.4 identifies eight distinct culture types, based on two primary dimensions: people interactions (independence or interdependence) and response to change (flexibility or stability). Groysberg et al. (2018) suggest that each style has advantages and disadvantages, and no style is inherently better than another. An organizational culture can, however, be defined by the absolute and relative strengths of each of the eight and by the degree of employee agreement about which styles characterize the organization. This framework, which differentiates it from other models, can also be used to define individuals’ styles and the values of leaders and employees.

DISPLAY 12.4 EIGHT DISTINCT ORGANIZATION CULTURE STYLES

1. Caring: focuses on relationships and mutual trust. Work environments are warm, collaborative, and welcoming places where people help and support one another. Employees are united by loyalty; leaders emphasize sincerity, teamwork, and positive relationships.

2. Purpose: exemplified by idealism and altruism. Work environments are tolerant, compassionate places where people try to do good for the long-term future of the world. Employees are united by a focus on sustainability and global communities; leaders emphasize shared ideals and contributing to a greater cause.

3. Learning: characterized by exploration, expansiveness, and creativity. Work environments are inventive and open-minded places where people spark new ideas and explore alternatives. Employees are united by curiosity; leaders emphasize innovation, knowledge, and adventure.

4. Enjoyment: expressed through fun and excitement. Work environments are lighthearted places where people tend to do what makes them happy. Employees are united by playfulness and stimulation; leaders emphasize spontaneity and a sense of humor.

5. Results: characterized by achievement and winning. Work environments are outcome-oriented and merit-based places where people aspire to achieve top performance. Employees are united by a drive for capability and success; leaders emphasize goal accomplishment.

6. Authority: defined by strength, decisiveness, and boldness. Work environments are competitive places where people strive to gain personal advantage. Employees are united by strong control; leaders emphasize confidence and dominance.

7. Safety: defined by planning, caution, and preparedness. Work environments are predictable places where people are risk- conscious and think things through carefully. Employees are united by a desire to feel protected and anticipate change; leaders emphasize being realistic and planning ahead.

8. Order: focused on respect, structure, and shared norms. Work environments are methodical places where people tend to play by the rules and want to fit in. Employees are united by cooperation; leaders emphasize shared procedures and time-honored customs.

Source: Extracted from Groysberg, B., Lee, J., Price, J., & Cheng, J. Y.-J. (2018). The leader’s guide to corporate culture. Retrieved September 13, 2018, from https://hbr.org/2018/01/the-culture-factor

Finally, organizational culture should not be confused with organizational climate—how employees perceive an organization. For example, an employee might perceive an organization as fair, friendly, and informal or as formal and very structured. The perception may be accurate or inaccurate, and people in the same organization may have different perceptions about the same organization. Therefore, because the organizational climate is the view of the organization by individuals, the organization’s climate and its culture may differ.

In terms of importance, more people rank “workplace well- being” over monetary or “material benefits”—and that well- being is created through a positive organizational culture (Thiefels, 2018).

Shared Governance: Organizational Design for the 21st Century Shared governance, one of the most innovative and empowering organization structures, was developed in the mid-1980s as an

alternative to the traditional bureaucratic organizational structure. A flat type of organizational structure is often used to describe shared governance but differs somewhat, as shown in Figure 12.4. In shared governance, the organization’s governance is shared among board members, nurses, physicians, and management. Thus, decision making and communication channels are altered. Group structures, in the form of joint practice committees, are developed to assume the power and accountability for decision making, and professional communication takes on an egalitarian structure.

FIGURE 12.4 Shared governance model. (Copyright © 2006 Lippincott Williams & Wilkins. Instructor’s Resource CD-ROM to Accompany Leadership Roles and Management Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.)

In health-care organizations, shared governance empowers decision makers, and this empowerment is directed at increasing nurses’ authority and control over nursing practice. Shared governance thus gives nurses more control over their nursing practice by being an accountability-based governance system for professional workers. In addition, shared governance can be used to improve communication

and joint decision making between nursing and other members of the interprofessional health-care team.

The stated aim of shared governance is the empowerment of employees within the decision-making system.

Although participatory management lays the foundation for shared governance, they are not the same. Participatory management implies that others can participate in decision making over which someone has control. Thus, the act of “allowing” participation identifies the real and final authority for the participant.

There is no single model of shared governance, although all models emphasize the empowerment of staff nurses. Generally, issues related to nursing practice are the responsibility of nurses, not managers, and nursing councils are used to organize governance. These nursing councils, elected at the organization and unit levels, use a congressional format organized like a representative form of government, with a president and cabinet.

Typical governance councils include a nursing practice council, a research council, professional development and/or education council, a nursing performance improvement or quality council, and a leadership council. Sometimes, organizations will have a retention council as well. The councils participate in decision making and coordination of the department of nursing and provide input through the shared governance process in all other areas where nursing care is delivered.

The number of health-care organizations using shared governance models is continuing to increase. However, a major impediment to the implementation of shared governance has been the reluctance of managers to change their roles. The nurse-manager’s role becomes one of consulting, teaching, collaborating, and creating an environment with the structures and resources needed for the practice of nursing and shared decision making between nurses and the organization. This new role is foreign to many managers and difficult to accept. In

addition, consensus decision making takes more time than autocratic decision making, and not all nurses want to share decisions and accountability. Although many positive outcomes have been attributed to implementation of shared governance, the expense of introducing and maintaining this model also must be considered because it calls for a conscientious commitment both on the part of the workers and the organization.

Magnet Designation and Pathway to Excellence During the early 1980s, the American Academy of Nursing began conducting research to identify the characteristics of hospitals that were able to successfully recruit and retain nurses. What they found were high-performing hospitals with well-qualified nurse executives in a decentralized environment, with organizational structures that emphasized open, participatory management.

A desire to formally recognize these high-performing hospitals was accomplished when the American Nurses Association (ANA) established the American Nurses Credentialing Center (ANCC) in 1990. Later the same year, the ANA Board of Directors approved the establishment of the Magnet Hospital Recognition Program for Excellence in Nursing Services. The term Magnet was used to denote organizations that were able to attract and retain professional nurses. “Magnet status is not a prize or an award. Rather, it is a credential of organizational recognition of nursing excellence” (ANCC, n.d.-d, para. 2).

A driving force to achieve Magnet status is the clear link between this designation and improved patient outcomes. The ANCC (n.d.-g) notes that Magnet-recognized organizations exhibit higher adoption of National Quality Forum safe practices, lower overall missed nursing care, higher support for evidence-based practice implementation, higher nurse-perceived quality of care, and higher patient ratings of their hospital experience. In addition, research has shown that Magnet organizations have lower mortality rates, lower failure-to-rescue rates,

lower patient fall rates, lower nosocomial infections, lower hospital- acquired pressure ulcer rates, and lower central line–associated bloodstream infection rates (ANCC, n.d.-g).

Magnet status is also associated with superior physician performance. A study by Bekelis, Missios, and MacKenzie (2018) of physicians performing neurosurgical procedures in New York found that Magnet hospital recognition was associated with a higher quality of physicians performing neurosurgical procedures (see Examining the Evidence 12.1).

EXAMINING THE EVIDENCE 12.1 Source: Bekelis, K., Missios, S., & MacKenzie, T. A. (2018). Correlation of hospital Magnet status with the quality of physicians performing neurosurgical procedures in New York State. British Journal of Neurosurgery, 32(1), 13–17. Retrieved August 25, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC597002 9/

Magnet Designation and Physician Quality This study investigated whether Magnet hospital recognition was associated with higher quality of physicians performing neurosurgical procedures. The researchers performed a cohort study of patients undergoing neurosurgical procedures from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. During the study period, 185,277 patients underwent neurosurgical procedures and met the inclusion criteria. Of these, 66,607 (35.6%) were hospitalized in Magnet hospitals, and 118,670 (64.4%) in non-Magnet institutions.

Research findings demonstrated that undergoing neurosurgical operations in Magnet hospitals was associated with a 13.6% higher chance of being treated by a physician with superior performance in terms of mortality (95% confidence interval [CI] [13.2, 14.1]) and a 4.3% higher chance of being treated by a physician with superior performance in terms of length of stay (95% CI [3.8, 4.7]) in comparison to non- Magnet institutions. The researchers noted that it

was unclear whether centers of excellence attract physicians of higher quality or if the opposite is true. It is likely that the presence of highly performing physicians in these institutions was multifactorial.

Earning a Magnet designation, however, is not easy. Currently, only about 8% (n = 477) of all registered hospitals in the United States have achieved ANCC Magnet Recognition status (ANCC, n.d.-b, n.d.-d). To achieve designation as an organization, the organization must create and promote a comprehensive professional practice culture. Then it must apply to ANCC, submit comprehensive documentation that demonstrates its compliance with standards in the ANA Scope and Standards for Nurse Administrators, and undergo a multiday onsite evaluation to verify the information in the documentation submitted and to assess the presence of five model components within the organization (ANCC, n.d.-a) (Display 12.5).

DISPLAY 12.5 FIVE MODEL COMPONENTS REQUIRED FOR MAGNET STATUS

1. Transformational leadership 2. Structural empowerment 3. Exemplary professional practice 4. New knowledge, innovation, and improvements 5. Empirical quality results

Source: American Nurses Credentialing Center. (n.d.-e). Magnet model. Retrieved September 9, 2018, from https://www.nursingworld.org/organizational- programs/magnet/magnet-model/

These five model components grew out of the original 14 Forces of Magnetism identified by ANCC in a 1983 research study that described characteristics of hospitals best able to recruit and retain nurses. The new, simpler model (introduced in 2008) configured these 14 Forces of

Magnetism into five model components, reflecting a greater focus on measuring outcomes and allowing for more streamlined documentation (ANCC, n.d.-e). The 14 Forces are retained, however, as foundational to the program because they are attributes or results that exemplify nursing excellence (ANCC, n.d.-c) (Display 12.6). Magnet status is awarded for a 4-year period, after which the organization must reapply.

DISPLAY 12.6 14 FOUNDATIONAL FORCES OF MAGNETISM FOR MAGNET HOSPITAL STATUS (ANCC, 2018C)

1. Quality of nursing leadership 2. Organizational structure 3. Management style 4. Personnel policies and programs 5. Professional models of care 6. Quality of care 7. Quality improvement 8. Consultation and resources 9. Autonomy 10. Community and the hospital 11. Nurses as teachers 12. Image of nursing 13. Interdisciplinary relationships 14. Professional development

Currently, Magnet recognition is awarded to both individual organizations (not just hospitals) and systems. To achieve designation as a system, the system must not only retain the 14 Forces of Magnetism required for individual organizations but must also demonstrate empirical modeling of five key components: transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovation, and improvements; and empirical quality results.

In addition, ANCC established the Pathway to Excellence program in 2003, based on findings from the Texas Nurse-Friendly Program for Small/Rural Hospitals. Although Magnet recognizes health-care organizations for quality outcomes, patient care and nursing excellence, and innovations in professional practice, the Pathway to Excellence program emphasizes supportive practice environments, including an established shared-governance structure that values nurses’ contributions in everyday decisions, especially those that affect their clinical practice and well-being (Pabico & Graystone, 2018). Thus, the Pathway to Excellence designation recognizes health-care organizations and long-term care institutions for positive practice environments where nurses excel (ANCC, n.d.-f).

To earn the Pathway to Excellence designation, organizations must undergo a thorough review process that meets 12 practice standards essential to an ideal nursing practice environment. “Applicants complete a review process to fully document the integration of those standards in the organization’s practices, policies, and culture. Pathway designation can only be achieved if an organization’s nurses validate the data and other evidence submitted, via an independent, confidential survey. This critical element exemplifies the theme of empowering and giving nurses a voice” (ANCC, n.d.-f, para. 2). Nurses are empowered in the Pathway to Excellence application process itself because frontline staff must validate that their experience with the organization meets the Pathway standards—before designation can be achieved (ANCC, n.d.-f).

LEARNING EXERCISE 12.4

Why Work for Them?

A list of current Magnet-recognized organizations and their contact information can be found at the ANCC (n.d.-b) website: https://www.nursingworld.org/organizational- programs/magnet/find-a-magnet-facility/.

ASSIGNMENT:

Select one of the current organizations and prepare a one-page written report about how that organization demonstrates the excellence exemplified by Magnet status. Speak to at least five of the “forces of magnetism.” Would you want to work for this particular organization?

Committee Structure in an Organization Managers are also responsible for designing and implementing appropriate committee structures. Poorly structured committees can be nonproductive for the organization and frustrating for committee members. However, there are many benefits to and justifications for well-structured committees. To compensate for some of the difficulty in organizational communication created by line and line-and-staff structures, committees are used widely to facilitate upward communication. The nature of formal organizations dictates a need for committees in assisting with management functions. In addition, as organizations seek new ways to revamp old bureaucratic structures, committees may pave the road to increased staff participation in organization governance. Committees may be advisory or may have a coordinating or informal function. They generate ideas and creative thinking to solve operational problems or improve services and often improve the quality and quantity of work accomplished. Committees also can pool specific skills and expertise and help reduce resistance to change.

Because committees communicate upward and downward and encourage the participation of interested or affected employees, they assist the organization in receiving valuable feedback and important information.

However, all of these positive benefits can be achieved only if committees are appropriately organized and led. If not properly used, the committee becomes a liability to the organizing process because it wastes energy, time, and money and can defer decisions and action. One of the leadership roles inherent in organizing work is to ensure that committees are not used to avoid or delay decisions but to facilitate organizational goals. Display 12.7 lists factors to consider when organizing committees.

DISPLAY 12.7 FACTORS TO CONSIDER WHEN ORGANIZING COMMITTEES

The committee should be composed of people who want to contribute in terms of commitment, energy, and time.

The members should have a variety of work experience and educational backgrounds. Composition should, however, ensure expertise sufficient to complete the task.

Committees should have enough members to accomplish assigned tasks but not so many that discussion cannot occur. Six to eight members in a committee are usually ideal.

The tasks and responsibilities, including reporting mechanisms, should be clearly outlined.

Assignments should be given ahead of time, with clear expectations that assigned work will be discussed at the next meeting.

All committees should have written agendas and effective committee chairpersons.

Responsibilities and Opportunities of Committee Work Committees present the leader-manager with many opportunities and responsibilities. Managers need to be well grounded in group dynamics because meetings represent a major time commitment. Managers serve as members of committees and as leaders or chairpersons of committees. Because committees make major decisions, managers should use the opportunities available at meetings to become more visible in the larger organization. The manager has a responsibility to select appropriate power strategies, such as coming to meetings well prepared, and to use skill in the group process to generate influence and gain power at meetings.

Another responsibility is to create an environment at unit committee meetings that leads to shared decision making. Encouraging an interaction free of status and power is important. Likewise, an appropriate seating arrangement, such as a circle, will increase motivation for committee members to speak up. The responsible manager is also aware that staff from different cultures may have different needs in groups, which is why multicultural committees should be the norm. In addition, because gender differences are increasingly being recognized as playing a role in problem solving, communication, and power, efforts should be made to include both men and women on committees.

When assigning members to committees, cultural and gender diversity should always be a goal.

The manager must not rely too heavily on committees or use them as a method to delay decision making. Numerous committee assignments exhaust staff, and committees then become poor tools for accomplishing work. An alternative that will decrease the time commitment for committee work is to make individual assignments and gather the entire committee only to report progress.

In addition, it is important for the manager to be aware of the possibility for groupthink to occur in any group or committee structure. Groupthink occurs when group members fail to take adequate risks by disagreeing, being challenged, or assessing discussion carefully. If the manager is actively involved in the work group or on the committee, groupthink is less likely to occur. The leadership role includes teaching members to avoid groupthink by demonstrating critical thinking and being a role model who allows his or her own ideas to be challenged.

Committees may be chaired by an elected member of the group, appointed by the manager, or led by the department or unit manager. Informal leaders may also emerge from the group process. The opportunity exists for leaders to have significant influence on committee and group effectiveness because leaders keep group work on course. Dynamic leaders also inspire people to work toward shared goals, and this demonstrates their commitment to participatory management.

Finally, leaders should be sure to celebrate committee successes and goal completion. “Beyond the momentary buzz that celebration provides, focus on success aids in a broader goal: enhanced performance. When leaders shine the light on what’s working, it opens up the potential for even bigger gains” (Miller, 2018, para. 3).

Integrating Leadership Roles and Management Functions Associated With Organizational Structure Despite the known difficulties of bureaucracies, it has been difficult for some organizations to move away from the bureaucratic model. However, perhaps because of Magnet hospital research demonstrating both improved patient outcomes and improved recruitment and retention of staff, there has been an increasing effort to redesign and restructure organizations to make them more flexible and decentralized. Still, progress toward these goals continues to be slow.

There is no one “best” way to structure an organization. Variables such as the size of the organization, the capability of its human

resources, and the commitment level of its workers should always be considered. Regardless of what type of organizational structure is used, certain minimal requirements can be identified:

The structure should be clearly defined so that employees know where they belong and where to go for assistance.

The goal should be to build the fewest possible management levels and have the shortest possible chain of command. This eliminates friction, stress, and inertia.

The unit staff need to be able to see where their tasks fit into common tasks of the organization.

The organizational structure should enhance, not impede, communication.

The organizational structure should facilitate decision making that results in the greatest work performance.

Staff should be organized in a manner that encourages informal groups to develop a sense of community and belonging.

Nursing services should be organized to facilitate the development of future leaders.

Integrated leader-managers need to look at organizational structure as the road map that tells them how organizations operate. Without organizational structure, people would work in a chaotic environment. Structure becomes an important tool, then, to facilitate order and enhance productivity.

Astute leader-managers understand both the structure of the organization in which they work and external stakeholders. The integrated leader-manager, however, goes beyond personal understanding of the larger organizational design. The leader-manager takes responsibility for ensuring that subordinates also understand the overall organizational structure and the structure at the unit level. This can be done by being a resource and role model to subordinates. The role modeling includes demonstrating accountability and the appropriate use of authority.

The effective manager recognizes the difficulties inherent in advisory positions and uses leadership skills to support staff in these positions. This is accomplished by granting enough authority to enable advisory staff to carry out the functions of their role.

Leadership requires that problems are pursued through appropriate channels, that upward communication is encouraged, and that unit structure is periodically evaluated to determine if it can be redesigned to enable increased lower level decision making. The integrated leader- manager also facilitates constructive informal group structure. It is important for the manager to be knowledgeable about the organization’s culture and subcultures. It is just as important for the leader to promote the development of a shared constructive culture with subordinates.

It is a management role to evaluate the types of organizational structure and governance and to implement those that will have the most positive impact in the department. It is a leadership skill to role model the shared authority necessary to make newer models of organizational structure and governance possible.

When serving on committees, leaders look for opportunities to gain influence to meet the needs of patients and staff appropriately. In addition, the integrated leader-manager comes to meetings well prepared and contributes thoughtful comments and ideas. The leader’s critical thinking and role-modeling behavior discourages groupthink among work groups or in committees.

Integrated leader-managers also refrain from judging and encourage all members of a committee to participate and contribute. An important management function is to see that appropriate work is accomplished in committees, that they remain productive, and that they are not used to delay decision making. A leadership role is the involvement of staff in organizational decision making, either informally or through more formal models of organizational design, such as shared governance. The integrated leader-manager understands the organization and recognizes what can be molded or shaped and what is constant. Thus, the interaction between the manager and the organization is dynamic.

Key Concepts

■ Many modern health-care organizations continue to be organized around a line or line-and-staff design and have attributes of a bureaucracy; however, there is a movement toward less bureaucratic designs, such as ad hoc, matrix, and care-centered systems.

■ A bureaucracy, as proposed by Max Weber, is characterized by a clear chain of command, rules and regulations, specialization of work, division of labor, and impersonality of relationships.

■ An organization chart depicts formal relationships, channels of communication, and authority through line-and-staff positions, scalar chains, and span of control.

■ Unity of command means that each person should have only one boss so that there is less confusion and greater productivity.

■ Centrality refers to the degree of communication of a management position.

■ In centralized decision making, decisions are made by a few managers at the top of the hierarchy. In decentralized decision making, decision making is diffused throughout the organization, and problems are solved at the lowest practical managerial level.

■ Organizational structure affects how people perceive their roles and the status given to them by other people in the organization.

■ Organizational structure is effective when the design is clearly communicated, there are as few managers as possible to accomplish goals, communication is facilitated, decisions are made at the lowest possible level, informal groups are encouraged, and future leaders are developed.

■ The entities in an organization’s environment that play a role in the organization’s health and performance, or which are affected by the organization, are called stakeholders.

■ Authority, responsibility, and accountability differ in terms of official sanctions, self-directedness, and moral integration.

■ Organizational culture is the total of an organization’s beliefs, history, taboos, formal and informal relationships, and communication patterns.

■ Much of an organization’s culture is not available to staff in a retrievable source and must be related by others.

■ Subunits of large organizations may also have a culture. These subcultures may support or conflict with other cultures in the organization.

■ Informal groups are present in every organization. They are often powerful, although they have no formal authority. Informal groups determine norms and assist members in the socialization process.

■ Shared governance refers to an organizational design that empowers staff nurses by making them an integral part of patient care decision making and providing accountability and responsibility in nursing practice.

■ Magnet designation is conferred by the ANCC to health-care organizations that exemplify five model components: transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovation, and improvements; and empirical quality results.

■ Magnet-designated organizations demonstrate improved patient outcomes and higher staff nurse satisfaction than organizations that do not have Magnet status.

■ The Pathway to Excellence designation, also conferred by the ANCC, recognizes health-care organizations and long-term care institutions with foundational quality initiatives in creating a positive work environment, as defined by nurses and supported by research.

■ Too many committees in an organization is a sign of a poorly designed organizational structure.

■ Committees should have an appropriate number of members, prepared agendas, clearly outlined tasks, and effective leadership if they are to be productive.

■ Groupthink occurs when there is too much conformity to group norms.

Additional Learning Exercises and Applications

LEARNING EXERCISE 12.5

Restructuring—In Depth

You are the supervisor at a home health agency. There are 22 registered nurses in your span of control. In a meeting today, John Dao, the chief nurse officer (CNO), tells you that your span of control needs adjustment to be effective. Therefore, the CNO has decided to flatten the organization and decentralize the department. To accomplish this, he plans to designate three of your staff as shift coordinators. These shift coordinators will “schedule patient visits for all the staff on their shift and be accountable for the staff that they supervise.” The CNO believes that this restructuring will give you more time for implementing a continuous quality improvement program and promoting staff development.

Although you are glad to have the opportunity to begin these new projects, you are somewhat unclear about the role expectations of the new shift coordinators and how this will change your job description. In fact, you worry that this is just a precursor to the elimination of your position. Will

these shift coordinators report to you? If so, will you have direct line authority or staff authority? Who should be responsible for evaluating the performance of the staff nurses now? Who will handle employee disciplinary problems? How involved should the shift coordinators be in strategic planning or determining next year’s budget? What types of management training will be needed by the shift coordinators to prepare for their new role? Are you the most appropriate person to train them?

ASSIGNMENT:

There is great potential for conflict here. In small groups, make a list of 10 questions (not including the ones listed in the Learning Exercise) that you would want to ask the CNO at your next meeting to clarify role expectations. Discuss tools and skills that you have learned in the preceding units that could make this role change less traumatic for all involved.

LEARNING EXERCISE 12.6

Problem Solving: Working Toward Shared Governance You are the supervisor of a surgical services department in a nonunion hospital. The staff on your unit have become increasingly frustrated with hospital policies regarding staffing ratios, on-call pay, and verbal medical orders but feel that they have limited opportunities for providing feedback to change the current system. You would like to

explore the possibility of moving toward a shared governance model of decision making to resolve this issue and others like it but are not quite sure where to start.

ASSIGNMENT:

Assume that you are the supervisor in this case. Answer the following questions: 1. Who do I need to involve in this discussion and at

what point? 2. How might I determine if the overarching

organizational structure supports shared governance? How would I determine if external stakeholders would be impacted? How would I determine if organizational culture and subculture would support a shared governance model?

3. What types of nursing councils might be created to provide a framework for operation?

4. Who would be the members on these nursing councils?

5. What support mechanisms would need to be in place to ensure success of this project?

6. What would be my role as a supervisor in identifying and resolving employee concerns in a shared governance model?

LEARNING EXERCISE 12.7

Finding Direction

You are a new graduate working on the 3:00 PM to 11:00 PM shift in a large, metropolitan hospital on the pediatrics unit. You feel frustrated because you had many preceptors while you were being oriented, and each told you slightly different variations of the unit routine. In addition, the regular charge nurse has just been promoted and moved to another unit, and the charge nurse position on your unit is being filled by two part-time nurses.

You feel inadequately prepared for the job and do not know where to turn or to whom you should direct your questions. If your organization chart resembles the one in Figure 12.1, outline a plan of action that would be appropriate to take. Share your plan with a larger group.

LEARNING EXERCISE 12.8

Thinking About Committee Work

As a writing exercise, choose one of the following to examine in depth:

1. What has contributed to the productivity of the committees on which you have served?

2. Have you ever served on a committee that made recommendations on which higher authority never acted? What was the effect on the group?

LEARNING EXERCISE 12.9

Participation and Productivity

You are a 3:00 PM to 11:00 PM charge nurse on a surgical unit. You have been selected to chair the unit’s safety committee. Each month, you have a short committee meeting with the other committee members. Your committee’s main responsibility is to report upward any safety issues that have been identified. Lately, you have found an increase in needle-stick incidents, and the committee has been addressing this problem.

The committee is made up of two nursing assistants, one unit clerk, two staff registered nurses, and two licensed

practical nurses/licensed vocational nurses. All shifts and staff cultures are represented. Lately, you have found that the meetings are not going well because one member of the group, Mary, has begun to monopolize the meeting time. She is especially outspoken about the danger of HIV and seems more interested in pointing blame regarding the needle sticks than in finding a solution to the problem.

You have privately spoken to Mary about her frequent disruption of the committee business; although she apologized, the behavior has continued. You feel that some members of the committee are becoming bored and restless, and you believe that the committee is making little progress.

ASSIGNMENT:

Using your knowledge of committee structure and effectiveness, outline steps that you would take to facilitate more group participation and make the committee more productive. Be specific and explain exactly what you would do at the next meeting to prevent Mary from taking over the meeting.

LEARNING EXERCISE 12.10

Finding an Organizational Culture That Fits

Joanie Smith is a 32-year-old single mother of two who will graduate in 3 months from a local associate degree nursing program. Joanie has accrued some debts in completing her nursing education. She has been offered two jobs upon

graduation: one is at a local medium-sized hospital (Community Center Hospital) and one is in a larger city some distance away (Metropolitan City Hospital). Both job offers are in the obstetrical unit, which is Joanie’s desired place of work because some day, she hopes to return to school to become a nurse midwife.

Research on the two hospitals shows that both are accredited and have good medical staffs, and Joanie has received positive feedback on both from people whose judgment she trusts.

ASSIGNMENT:

Pretend you are this nurse. What additional type of information should you gather to be able to decide which of these organizations is a better fit? What particular assessment of organizational culture can you do that would help you make a better decision? Are there particular culture styles (see Display 12.4) that are a better fit for you than others?

R E F E R E N C E S American Nurses Credentialing Center. (n.d.-a). ANCC Magnet

Recognition Program®. Retrieved September 10, 2018, from https://www.nursingworld.org/organizational-programs/magnet/

American Nurses Credentialing Center. (n.d.-b). Find a Magnet facility. Retrieved September 10, 2018, from https://www.nursingworld.org/organizational-programs/magnet/find- a-magnet-facility/

American Nurses Credentialing Center. (n.d.-c). Forces of magnetism. Retrieved September 10, 2018, from

https://www.nursingworld.org/organizational- programs/magnet/history/forces-of-magnetism/

American Nurses Credentialing Center. (n.d.-d). Growth. Retrieved September 9, 2018, from https://www.nursingworld.org/organizational- programs/magnet/history/growth/

American Nurses Credentialing Center. (n.d.-e). Magnet model. Retrieved September 9, 2018, from https://www.nursingworld.org/organizational- programs/magnet/magnet-model/

American Nurses Credentialing Center. (n.d.-f). ANCC Pathway to Excellence® program. Retrieved August 25, 2019, from https://www.nursingworld.org/organizational-programs/pathway/

American Nurses Credentialing Center. (n.d.-g). Why become Magnet? Retrieved December 3, 2018, from https://www.nursingworld.org/organizational-programs/magnet/why- become-magnet/

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13

Organizational, Political, and Personal Power

. . . nearly all men can stand adversity, but if you want to test a man’s character, give him power.—Abraham Lincoln

. . . Being powerful is like being a lady. If you have to tell people you are, you aren’t.—M. Thatcher

. . . Power should not be concentrated in the hands of so few, and powerlessness in the hands of so many.— Maggie Kuhn

CROSSWALK

This chapter addresses:

BSN Essential II: Basic organizational and systems leadership for quality care and patient safety

BSN Essential V: Health-care policy, finance, and regulatory environments

BSN Essential VI: Interprofessional communication and collaboration for improving patient health outcomes

BSN Essential VIII: Professionalism and professional values MSN Essential II: Organizational and systems leadership MSN Essential VI: Health policy and advocacy

MSN Essential VII: Interprofessional collaboration for improving patient and population health outcomes

AONL Nurse Executive Competency I: Communication and relationship building

AONL Nurse Executive Competency II: A knowledge of the health-care environment

AONL Nurse Executive Competency III: Leadership AONL Nurse Executive Competency IV: Professionalism AONL Nurse Executive Competency V: Business skills ANA Standard of Professional Performance 7: Ethics ANA Standard of Professional Performance 9: Communication

ANA Standard of Professional Performance 10: Collaboration

ANA Standard of Professional Performance 11: Leadership ANA Standard of Professional Performance 16: Resource utilization

QSEN Competency: Teamwork and collaboration

LEARNING OBJECTIVES

The learner will:

assess how power dynamics in the family unit as a child may affect an adult’s perception of power as well as the ability to use it appropriately

explore the influence of gender in how an individual may view power and politics

differentiate among legitimate, reward, coercive, expert, referent, charismatic, self, and information power

recognize the need to create and maintain a small authority– power gap

identify and use appropriate strategies to increase his or her personal power base

use power on behalf of other people rather than over them empower subordinates and followers by providing them with opportunities for success

describe how to access and build political alliances and coalitions through networking

use appropriate political strategies in resolving unit problems use cooperation rather than competition and avoid overt displays of power and authority whenever possible

explore factors that historically led to nursing’s limited power as a profession

identify driving forces in place as well as specific strategies to increase the nursing profession’s power base

identify political strategies the novice manager could use to minimize the negative effects of organizational politics

serve as a role model of an empowered nurse

Introduction Chapter 12 reviewed organizational structure and introduced status, authority, and responsibility at different levels of the organizational hierarchy. In this chapter, the organization is examined further, with emphasis on the management functions and leadership roles inherent in effective use of authority, establishment of a personal power base, empowerment of others, and the impact of organizational politics on power. In addition, factors that have historically contributed to nursing’s limited power as a profession are presented as well as the driving forces in place to change this phenomenon. Finally, this chapter introduces strategies the individual and the nursing profession could use to increase their power base.

The word power is derived from the Latin verb potere (to be able); thus, power may be appropriately defined as that which enables one to accomplish goals. Power can also be defined as the capacity to act or the strength and potency to accomplish something. It is almost impossible to achieve organizational or personal goals without an adequate power base. It is even more difficult to help subordinates, patients, or clients achieve their goals when powerless because having access to and control over resources is often related to the degree of power one holds.

Having power gives one the potential to change the attitudes and behaviors of individual people and groups.

Authority, or the right to command, accompanies any management position and is a source of legitimate power, although components of management, authority, and power are also necessary, to a degree, for successful leadership. The manager who is knowledgeable about the wise use of authority, power, and political strategy is more effective at meeting personal, unit, and organizational goals. Likewise, powerful leaders can raise morale because they delegate more and build with a team effort. Thus, their followers become part of the growth and excitement of the organization as their own status is enhanced. The leadership roles and management functions inherent in the use of authority and power are shown in Display 13.1.

DISPLAY 13.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH ORGANIZATIONAL, POLITICAL, AND PERSONAL POWER

Leadership Roles 1. Creates a climate that promotes followership in response to

authority 2. Recognizes the impact of power on relationships that exist

within an organization 3. Uses a powerful persona and referent power to increase

respect and decrease fear in subordinates 4. Recognizes when it is appropriate to have authority

questioned or to question authority 5. Is personally comfortable with power in the political arena 6. Empowers others whenever possible 7. Assists others in using appropriate political strategies 8. Serves as a role model of the empowered nurse 9. Strives to eliminate a perception of powerlessness among

others 10. Uses power judiciously and mindfully 11. Role models political skill in developing consensus, inclusion,

and follower involvement 12. Builds alliances and coalitions inside and outside of nursing

Management Functions 1. Uses authority to ensure that organizational goals are met 2. Uses political strategies that are complementary to the unit

and organization’s functioning 3. Builds a power base appropriate for the assigned

management role 4. Creates and maintains a small authority–power gap

5. Is knowledgeable about the essence and appropriate use of power

6. Maintains personal credibility with subordinates 7. Avoids using power over others rather than on behalf of

others whenever possible 8. Demonstrates reasoned risk taking in decision making with

political implications 9. Uses reward power, coercive power, legitimate power, and

expert power when appropriate to positively influence the achievement of organizational goals

10. Limits visible displays of legitimate power and avoids overusing commands

11. Understands the organizational structure in which he or she works, functions effectively within that structure, and deals effectively with the institution’s inherent politics

12. Promotes subordinate identification and recognition

Understanding Power How individuals view power varies greatly. Indeed, power may be feared, worshipped, or mistrusted, and it is frequently misunderstood. Our first experience with power usually occurs in the family unit. Because children’s roles are likened to later subordinate roles and the parental power position is like management, adult views of the management–subordinate relationship are often influenced by how power was used in the family unit and the often- unacknowledged impact of gender on power in family dynamics. A positive or negative familial power experience may greatly affect a person’s ability to deal with power systems in adulthood.

Gender and Power

Successful leaders are attentive to the influence of gender on power as well. Many women (and thus nurses) have historically demonstrated ambivalence toward the concept of power, and some have even eschewed the pursuit of power. This likely occurred because some women have been socialized to view power, believing that women do not inherently possess power (formal or informal) or authority (Huston, 2020). In addition, rather than feeling capable of achieving and managing power, some women feel that power manages them.

These gender-based perceptions are changing; yet, many women still need to learn how to use power as a tool for personal and professional success. In contemporary society, people are finding new ways for leaders, regardless of gender, to acquire and manage power. These changes are taking place within women, in women’s view of other women holding power, in organizational hierarchies, and among male subordinates and male colleagues (Huston, 2020). Indeed, skills that have often been linked to female characteristics such as political skill in developing consensus, inclusion, and involvement are now viewed as strengths in the corporate world. These attributes are certainly not limited to women, but it is notable that the same attributes that once closed corporate doors and created the barrier popularly called the glass ceiling are now generally welcomed in the boardroom.

Power and Powerlessness In determining whether power is desirable, it may be helpful to look at its opposite: powerlessness. Most people agree that they dislike being powerless. Everyone needs to have some control in his or her life, and when that is not the case, the result is typically a bossy and rules-oriented individual, desperate to have some degree of power or control. Leader-managers who feel powerless often create an ineffective, petty, dictatorial, and rule-minded management style.

They may become oppressive leaders, punitive and rigid in decision making, or withhold information from others, and they become difficult to work with. This suggests that although the adage that power corrupts might be true for some, it is also likely correct to say that powerlessness holds at least as much potential for corruption.

Power is likely to bring more power in an ascending cycle, whereas powerlessness will only generate more powerlessness.

LEARNING EXERCISE 13.1

Is Power Different for Men and Women?

Research studies suggest differences in how men and women view power and how others view men and women in positions of authority. Do you think that there are gender differences in how power is perceived? Who did you feel was most powerful in your family while growing up? Why do you think that person was powerful? If you are using group work, how many in your group named powerful male figures; how many named powerful female figures? Discuss this in a group and then go to the library or use Internet sources to see if you can find recent studies that support your views.

In contrast, truly powerful individuals know they are powerful and do not need to display this overtly. Instead, their power is evident in the respect and cooperation of their followers. Because the powerful have credibility to support their actions, they have greater capacity to get things accomplished and can enhance their base.

Apparently, then, power has a negative and a positive face. The negative face of power is the “I win, you lose” aspect of dominance versus submission. The positive face of power occurs when someone exerts influence on behalf of—rather than over—someone or something. Power, therefore, is not good or evil; it is how it is used and for what purpose that matters.

Types of Power For leadership to be effective, some measure of power must often support it. This is true for the informal social group and the formal work group. The Mind Tools Editorial Team (1996–2019) describes French and Raven’s classical work regarding the bases or sources of power: reward power, punishment or coercive power, legitimate power, expert power, and referent power.

Reward power is obtained by the ability to grant favors or reward others with whatever they value. The arsenal of rewards that a manager can dispense to get employees to work toward meeting organizational goals is very broad. Positive leadership through rewards tends to develop a great deal of loyalty and devotion toward leaders.

Punishment or coercive power, the opposite of reward power, is based on fear of punishment if the manager’s expectations are not met. The manager may obtain compliance through threats (often implied) of transfer, layoff, demotion, or dismissal. The manager who shuns or ignores an employee is exercising power through punishment, as is the manager who berates or belittles an employee.

Legitimate power is position power. Authority is also called legitimate power. It is the power gained by a title or official position within an organization. Legitimate power has inherent in it the ability to create feelings of obligation or responsibility. The socialization and culture of subordinate employees will influence to some degree how much power a manager has due to his or her position.

Expert power is gained through knowledge, expertise, or experience. Having critical knowledge allows a manager to gain power over others who need that knowledge. This type of power is limited to a specialized area. For example, someone with vast expertise in music would be powerful only in that area, not in another specialization. When Florence Nightingale used research to quantify the need for nurses in the Crimea (by showing that when nurses were present, fewer soldiers died), she was using her research to demonstrate expertise in the health needs of the wounded.

Referent power is power that a person has because others identify with that leader or with what that leader symbolizes. Referent power also occurs when one gives another person feelings of personal acceptance or approval. It may be obtained through association with the powerful. People may also develop referent power because others perceive them as powerful. This perception could be based

on personal charisma, the way the leader talks or acts, the organizations to which he or she belongs, or the people with whom he or she associates. People who others accept as role models or leaders enjoy referent power. Physicians use referent power very effectively; society, as a whole, views physicians as powerful, and physicians carefully maintain this image.

Although correlated with referent power, charismatic power is distinguished by some from referent power. Referent power is gained only through association with powerful others, whereas charisma is a more personal type of power.

Another type of power, which is often added to the French and Raven power source is informational power. This source of power is obtained when people have information that others must have to accomplish their goals. The various sources of power are summarized in Table 13.1.

TABLE 13.1 SOURCES OF POWER

Type Source

Referent Association with powerful others Legitimate Position Coercive Fear Reward Ability to grant favors Expert Knowledge and skill Charismatic Personal Informational The need for information

The Authority–Power Gap If authority is the right to command, then a logical question is “Why do workers sometimes not follow orders?” Sometimes, it is because they believe management does not understand their point of view or

that they are insensitive to worker needs. When followers feel that their needs and wants don’t matter and that the person in charge does not care, their innate motivation to be a good follower declines.

Clearly then, the right to command does not ensure that employees will follow orders. The gap that sometimes exists between a position of authority and subordinate response is called the authority–power gap. The term manager power may explain subordinates’ response to the manager’s authority. The more power subordinates perceive a manager to have, the smaller the gap between the right to expect certain things and the resulting fulfillment of those expectations by others.

The negative effect of a wide authority–power gap is that organizational chaos may develop. There would be little productivity if every order was questioned. The organization should rightfully expect that its goals will be accomplished. One of the core dynamics of civilization is that there will always be a few authority figures pushing the many for a certain standard of performance.

People in the United States are socialized very early to respond to authority figures. In many cases, children are conditioned to accept the directives of their parents, teachers, and community leaders. The traditional nurse-educator has been portrayed as an authoritarian who demands unconditional obedience. Educators who maintain a very narrow authority–power gap reinforce dependency and obedience by emphasizing extreme consequences, including the death of the patient. Thus, nursing students may be socialized to be overly cautious and to hesitate when making independent nursing judgments.

Because of these types of early socialization, the gap between the manager’s authority and the worker’s response to that authority tends to be relatively small. In other countries, it may be larger or smaller, depending on how people are socialized to respond to authority. This authority dependence that begins with our parents

and is later transferred to our employers may be an important resource to managers.

Although the authority–power gap continues to be narrow, it has grown in the last 50 years. Both the women’s movement and the student unrest of the 1960s contributed to a widening of the authority–power gap in the United States. This widening gap was evident when a 1970s college student asked her mother why she did not protest as a college student; the mother replied, “I didn’t know I could.”

At times, however, authority should be questioned by either the leader or the subordinates. This is demonstrated in health care by the increased questioning of the authority of physicians—many of whom feel they have the authority to command—by nurses and consumers. Figure 13.1 shows the dynamics of the relationships in the organizational authority–power response.

FIGURE 13.1 Interdependency of response to authority. (Copyright © 2006 Lippincott Williams & Wilkins. Instructor’s Resource CD-ROM to Accompany Leadership Roles and Management Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.)

Bridging the Authority–Power Gap For an organization to be successful, mutual trust must be present between managers and employees. This means that managers need to trust their employees, employees need to trust their managers, and employees need to trust each other.

There are many things that can lead to a loss of trust between managers and subordinates. Sometimes, subordinates lose trust when they continually experience visible exercises of authority (these should be used sparingly). Because overusing commands can stifle cooperation, outright naked commands should be used only infrequently. In addition, Overland (2015) notes that managers need to be careful not to belittle, ignore, or avoid conversations with subordinates who seem disillusioned with their leader. They need

direction and support to help them move forward and to reestablish a more appropriate authority–power gap. The manager will have bridged the authority–power gap if followers (a) perceive that the manager is doing a good job, (b) believe that the organization has their best interests in mind, and (c) do not feel controlled by authority.

Overt displays of authority should be used as a last resort.

One way for the leader to bridge the gap is to make a genuine effort to know and care about each subordinate as a unique individual. This is especially important because each person has a limited tolerance of authority, and subordinates are better able to tolerate authority if they believe that the leader cares about them as individuals. Bradberry (2015) notes that more than half of people who leave their jobs do so because of their relationship with their boss. Managers who celebrate worker’s achievements and empathize with those going through hard times are more likely to be perceivable as deserving of employee trust.

LEARNING EXERCISE 13.2

Power and Authority

Think back to your childhood. Did you grow up with a very narrow authority–power gap? Have your views regarding authority and power changed since you were a child? Do you believe that children today have an

authority–power gap similar to what you had as a child? Support your answers with examples.

In addition, the manager needs to provide enough information about organizational and unit goals to subordinates for them to understand how their efforts and those of their manager are contributing to goal attainment. Clear agreements and a detailed description of targets help learners visualize a positive outcome (Overland, 2015). Managers must show employees what a good job looks like and use examples and templates to keep people on the right track (Overland, 2015).

Finally, the manager must be credible for the authority–power gap not to widen. All managers begin their appointment with subordinates ready to believe them. This, again, is due to the socialization process that causes people to believe that those in power say what is true. However, the deference to authority will erode if managers handle employees carelessly, are dishonest, or seem incapable of carrying out their duties. Managers must create an environment where employees can express their opinions or concerns without fear of repercussions. In addition, managers should admit when they have made a mistake and their motivations should be transparent. When a manager loses credibility, the power inherent in his or her authority decreases. It is important then for those in power to answer followers honestly when they do not have all the answers.

Another dimension of credibility that influences the authority– power relationship is future promising. It is best to underpromise if promises must be made. Bradberry (2015) notes that making promises to people places you on a fine line between making them very happy and watching them walk out the door. Upholding commitments makes a manager trustworthy and honorable; not doing so comes across as uncaring and disrespectful.

Managers should never guarantee future rewards unless they have control of all possible variables. If managers revoke future rewards, they lose credibility in the eyes of their subordinates. However, managers should dispense present rewards to buy patronage, making the manager more believable and building greater power into his or her legitimate authority. A scenario that illustrates the difference in dispensing future and present awards follows.

A registered nurse (RN) requests a day off to attend a wedding, and you can replace her. You use the power of your position to reward her and give her the day off. The RN is grateful to you, and this increases your power. Another RN requests 3 months in advance to have every Thursday off in the summer to take a class. Although you promise this to her, on the first day of June, three nurses resign, rendering you unable to fulfill your promise. This nurse is very upset, and you have lost much credibility and, therefore, power. It would have been wiser for you to say that you could not grant her original request (underpromising) or to make it contingent on several factors. If the situation had remained the same and the nurses had not resigned, you could have granted the request. Less trust is lost between the manager and the subordinate when underpromising occurs than when a granted request is rescinded, as long as the subordinate believes that the manager will make a genuine effort to meet his or her request.

LEARNING EXERCISE 13.3

Authority–Power Gap in the Student Role

You are a senior nursing student completing your final leadership practicum. Your assignment today is to assume leadership of a small team composed of the registered nurse (RN), one licensed vocational nurse/licensed practical nurse, and one certified nursing assistant (CNA). The RN preceptor has agreed to let you take on this leadership role in her place, although she will shadow your efforts and provide support throughout the day.

Almost immediately after handoff report, a patient puts on the call light and tells you that she needs to have her sheets changed as she was incontinent in the bed. Because you are just beginning your 8:00 AM med pass and are already behind, you ask the CNA if she has time to do this task. She immediately responds, “I’m busy and you’re the student. Do it yourself! It would be a good learning experience for you.” When you try to explain your leadership role for the day, she walks away, saying that she does not have time anyway.

A few minutes after that, a physician enters the unit. He wants to talk to the nurse about his patient. When you inform him that you are the student nurse caring for his patient that day, he responds, “No—I want to talk to the real nurse.”

You feel frustrated with this emerging authority–power gap and seek out the RN to formulate a plan to make this gap smaller.

ASSIGNMENT:

Identify at least four strategies you might use to reduce the size of this authority–power gap. Would you involve the RN in your plan? Do you anticipate having similar authority–power gaps in the new graduate role?

Empowering Subordinates The empowerment of staff is a hallmark of transformational leadership. To empower means to enable, develop, or allow. Empowerment, as discussed in Chapter 2, can be defined as decentralization of power. Empowerment occurs when leaders communicate their vision; employees are given the opportunity to make the most of their talents; and learning, creativity, and exploration are encouraged.

Empowerment is not the relinquishing of rightful power inherent in a position. Nor is it a delegation of authority or its commensurate responsibility and accountability. Instead, the actions of empowered staff are freely chosen, owned, and committed to on behalf of the organization without any requests or requirements to do so. Empowerment plants seeds of leadership, collegiality, self-respect, and professionalism.

Empowerment can also be as simple as assuring that all individuals in the organization are treated with dignity. Empowerment, however, is not an easy one-step process. Instead, it is a complex process that consists of responsibility for the individual desiring empowerment as well as the organization and its leadership. Individually, all practitioners must have professional traits, including responsibility for continuing education, participation in professional organizations, political activism, and most importantly, a sense of value about their work. In addition, the nurse must work in

an environment that encourages empowerment, and the empowerment process must include an effective leadership style.

One way that leaders empower subordinates is when they delegate assignments to provide learning opportunities and allow employees to share in the satisfaction derived from achievement. The complexity, however, of determining when delegation and new learning can result in employee empowerment was evident in research conducted by Lee, Willis, and Wei Tian (2018) (see Examining the Evidence 13.1). Lee et al. found that empowering leadership can motivate employees and fuel creativity, but it can also create additional burdens and stress that may hurt routine performance. Managers then must understand that empowering leadership has its limits and that factors like trust and experience affect how their behaviors are perceived.

EXAMINING THE EVIDENCE 13.1 Source: Lee, A., Willis, S., & Wei Tian, A. (2018). When empowering employees works, and when it doesn’t. Retrieved September 13, 2018, from https://hbr.org/2018/03/when-empowering- employees-works-and-when-it-doesnt

Empowering Employees Many leaders attempt to empower employees by delegating authority and decision making, sharing information, and asking for their input. To determine what type of leadership is best for empowering employees, the researchers conducted a meta-analysis of all available field experiments on leaders empowering subordinates—examining the results of 105 studies, which included data from more than 30,000 employees from 30 countries. The researchers examined whether an empowering leadership style was linked to improved job performance and whether this was true of different types of performance, such as routine task performance, organizational citizenship behavior, and creativity. They also tested several mechanisms that might explain how this type of leadership would improve job performance—for example, were these effects caused by increased feelings of empowerment or by increased trust in one’s leader? Finally, the researchers explored whether leaders who focused on empowering employees influenced employee job performance equally across

different national cultures, industries, and levels of employee experience.

The researchers found that empowering leaders are much more effective at influencing employee creativity and citizenship behavior (i.e., behavior that is not formally recognized or rewarded like helping coworkers or attending work functions that aren’t mandatory) than routine task performance. Second, by empowering their employees, these leaders are also more likely to be trusted by their subordinates, compared to leaders who do not empower their employees. Third, leaders who empowered employees were more effective at influencing employee performance in Eastern, compared to Western, cultures, and they had a more positive impact on employees who had less experience working in their organizations.

They also found that empowering leaders were linked to good employee performance on routine, core job tasks—but they weren’t much different from nonempowering leaders. Sometimes, employees felt burdened and stressed when their leaders tried to empower them with additional responsibility and challenges at work. In addition, some employees responded to empowering leadership more than others.

The researchers concluded that empowering leadership can motivate employees and fuel creativity, but it can also create additional burdens and stress that may hurt routine performance. It is crucial for managers to

understand that empowering leadership has its limits and that factors like trust and experience affect how their behaviors are perceived.

LEARNING EXERCISE 13.4

Cultural Diversity and Empowerment

Do you think that cultural diversity might be a challenge when empowering nurses? Think of ways that various cultures may view power and empowerment differently. If you know people from other cultures, ask them how powerful people or those in authority positions are viewed in their culture and compare that with your own culture.

Empowerment creates and sustains a work environment that speaks to values, such as facilitating the employee’s choice to invest in and own personal actions and behaviors that result in positive contributions to the organization’s mission.

Not having a commitment to empowerment though is a barrier to creating an environment for empowerment in an organization. Other barriers would include a rigid organizational belief about authority and status. A manager’s personal feelings regarding empowerment’s potential effect on the manager’s own power can also impede the empowering process.

Once organizational barriers have been minimized or eliminated, the leader should develop strategies at the unit level to empower staff. The easiest strategy is to be a role model of an empowered nurse. Another strategy would be to assist staff in building their own personal power base. This can be accomplished by showing subordinates how their personal, expert, and referent power can be expanded. Empowerment also occurs when workers are involved in planning and implementing change and when workers believe that they have some input in what is about to happen to them and some control over the environment in which they will work in the future.

Mobilizing the Power of the Nursing Profession Until the nursing profession has a seat at the health-care policy- making table, individual nurses and leader-managers will be limited in how much personal power they will hold. Huston (2020) suggests that nursing has not been the force it could be in the policy arena, stating that nurses have often been reactive rather than proactive in addressing policy decisions and legislation after the fact rather than taking part in drafting and sponsoring legislation. However, she cites several driving forces that should increase nursing’s power base (Display 13.2)

DISPLAY 13.2 SIX DRIVING FORCES TO INCREASE NURSING’S POWER BASE

1. The timing is right 2. The size of the nursing profession 3. Nursing’s referent power 4. Increasing knowledge base and education for nurses 5. Nursing’s unique perspective 6. Desire of consumers and providers for change

Source: Huston, C. (2020). The nursing profession’s historic struggle to increase its power base. In C. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 318–333). Philadelphia, PA: Wolters Kluwer.

The timing is right. The errors reported in our medical system, the numbers of uninsured, and the shortcomings of our current health-care system are all reasons that consumers and legislators are willing to listen to nurses as an attempt is made to fix the health-care crisis. Clearly, the public wants a better health-care system, and nurses want to be able to provide high- quality nursing care. Both are powerful elements for change, and new nurses are entering the profession at a time when their energy and expertise will be more valued than ever.

The passage and implementation of the Patient Protection and Affordable Care Act only escalated public awareness and debate about flaws in publicly funded or subsidized health care in the United States. Furthermore, because of publications such as To Err Is Human, consumers, health-care providers, and legislators are more aware than ever of the shortcomings of the current health-care system, and the clamor for action has never been louder.

Size of the nursing profession. Numbers are very important in politics, and the nursing profession’s size is its greatest asset. The United States had 2,951,960 active RNs as of May 2018

(U.S. Department of Labor, 2019), which represents an impressive potential voting bloc.

Nursing’s referent power. The nursing profession has a great deal of referent power because of the high degree of trust and credibility the public places in them. Indeed, nurses have placed first almost every year in the Gallup Organization’s annual poll on professional honesty and ethical standards since nurses were first included in the survey in 1999.

Increasing knowledge base and education for nurses. There are more nurses being awarded master’s and doctoral degrees than ever before. One of the greatest areas of growth is in the number of Doctor of Nursing Practice (DNP) students. As of 2019, DNP programs were available in all 50 states plus the District of Columbia, and from 2017 to 2018, the number of students enrolled in DNP programs increased from 29,093 to 32,678. During that same period, the number of DNP graduates increased from 6,090 to 7,039 (American Association of Colleges of Nursing, 2019).

In addition, more nurses are stepping into advanced practice roles as nurse practitioners, clinical nurse specialists, certified nurse midwives, RN anesthetists, or clinical nurse-leaders. If knowledge is power, then those having knowledge can influence others, gain credibility, and gain power.

Furthermore, leadership, management, and political theory are increasingly a part of baccalaureate nursing education, although most nurses still do not hold baccalaureate degrees. These are learned skills, and collectively, the nursing profession’s knowledge of leadership, politics, negotiation, and finance is increasing. This can only increase the nursing profession’s influence outside the field (Huston, 2020).

Nursing’s unique perspective. Professionals have power over the practice of their discipline. This is referred to as professional autonomy. Nursing has long been recognized as having a strong

caring component. Combine that with nursing’s recent surge in scientific knowledge and critical thinking, and there is a blend of art and science that brings a unique perspective to the health- care arena.

Desire of consumers and providers for change. Limited consumer choice, hospital restructuring, the downsizing of registered nursing, and the Institute of Medicine (IOM) medical error reports were the sparks needed to mobilize nurses, as well as consumers, to act. Nurses began speaking out about how downsizing and restructuring were affecting the care they were providing, and the public began demanding accountability. The public does care who is caring for them and how that affects the quality of their care. The flaws of the health-care system are no longer secret, and nursing can use its expertise and influence to help create a better health-care system for the future.

DISPLAY 13.3 ACTION PLAN FOR INCREASING THE POWER OF THE NURSING PROFESSION

1. Place more nurses in positions of influence. 2. Recognize and highlight the potential nurses have to make a

difference. 3. Nurses must become better informed about all health-care

policy efforts. 4. Coalition building must occur within and outside of nursing. 5. More research must be done to strengthen evidence-based

practice. 6. Nursing leaders must be supported. 7. Attention must be paid to mentoring future nurse-leaders and

leadership succession.

Source: Huston, C. J. (2020). The nursing profession’s historic struggle to increase its power base. In C. J. Huston (Ed.), Professional issues in nursing: Challenges and opportunities (5th ed., pp. 318–333). Philadelphia, PA: Wolters Kluwer.

An Action Plan for Increasing Professional Power in Nursing Huston (2020) also developed an action plan for the nursing profession to build its power base (Display 13.3 shows a summary of these actions). This action plan includes the following strategies:

Place more nurses in positions of influence. The IOM (2011) suggested that for health-care reform to work, nurses must be a part of decision-making processes in the health-care system. This means placing nurses on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care (IOM, 2011). Unfortunately, although nurses typically represent the greatest percentage of the workforce in hospitals, inadequate numbers of nurses serve on hospital boards or hold positions of significant power.

Progress, however, is being made. Beverly Malone, chief executive officer of the National League for Nursing, noted that in 2018, nurses were increasingly taking seats at the table. “We will see more nurses on boards across the country—more than we’ve ever seen before in healthcare” (Stokowski, 2018, para. 2). Bob Dent, senior vice president, chief operating officer, and chief nursing officer, Midland Memorial Hospital, and president, American Organization of Nurse Executives, agreed, noting that “nurses at the point of service are continually stepping up in patient care settings and across other healthcare settings” (Stokowski, 2018, para. 3).

Running for and holding elected office is, however, the ultimate in political activism and involvement. Only two nurses were serving in Congress as of mid-2019 (American Nurses Association, 2019). Many more nurses hold elected office in state legislatures. Huston (2020) argues that nurses are uniquely qualified to hold public office because they have the

greatest firsthand experience of problems faced by patients in today’s health-care system as well as an uncanny ability to translate the health-care experience to the public. As a result, more nurses need to seek out this role. In addition, because the public respects and trusts nurses, nurses who choose to run for public office are often elected. The problem then is not that nurses are not elected; the problem is that not enough nurses are running for office.

Recognize and highlight the potential nurses have, to make a difference. Huston (2020) suggests it is critical that nurses never lose sight of their potential to make a difference. In addition, some legislators and employers have argued that all nurses are interchangeable. This is shortsighted. Nurses can be whatever they want to be in nursing, and they can achieve that goal at whatever level of quality they choose. The bottom line, however, is that the profession will only be as smart, as motivated, and as directed as its weakest link. If the nursing profession is to be the powerful force it can be, it needs to be filled with bright, highly motivated people who want to make a difference in the lives of the clients with whom they work as well as in the health-care system itself.

“Have you ever heard or said,” “I am just a nurse . . . ?” Perhaps something said in the face of a conflict or a problem? My response to that is, “No, especially a nurse. I am especially a nurse.” (Payne, 2016, p. 13)

Become better informed about all health-care policy efforts. This means becoming involved with grassroots knowledge building and becoming better informed consumers and providers of health care with a commitment to collective strength. This is difficult because no one can do this but nurses. Cardillo (2019)

argues that every nurse can and should learn the ABCs of politics and power as a first step to personal and professional empowerment. She suggests that nurses should develop relationships with their legislators and contact their assemblypersons, congresspersons, and senators by phone or e-mail. These nurses should also introduce themselves as constituents in their district and offer to be a resource on nursing and health-care issues. Cardillo goes on to suggest that every step an RN takes toward political awareness and activism benefits the entire profession. It is also one more way to impact the greater good and advocate for better health care for all.

Build coalitions inside and outside of nursing. Health policy takes place in a virtual network of participants, professions, and organizations, both locally and nationally. Nurses have not always done well in building political coalitions with other interdisciplinary professionals with similar challenges. In addition to belonging to nursing professional organizations, nurses need to reach out to other nonnursing groups with the same concerns and goals. This interdependence and strength in numbers is what will ultimately help the profession achieve its goals.

Conduct more research to strengthen evidence-based practice. Great strides have been made in researching what it is that nurses do that makes a difference in patient outcomes (research on nursing sensitivity), but more needs to be done. Nurses must use research to present the case that nursing skills are vital to competent health care. In addition, building and sustaining evidence-based practice in nursing will require far greater numbers of master’s- and doctorally prepared nurses as well as entry into practice at an educational level similar to other professions (Huston, 2020).

Support nursing leaders. Rather than supporting their leaders’ efforts to lead, nurses have sometimes viewed their leaders as deviants, and this has occurred at a high personal cost to the

innovator. In addition, nurses often resist change from their leaders and instead look to leaders in medicine or other health- related disciplines. Thus, the division in nursing often comes from within the profession itself (Huston, 2020).

Mentor future nurse-leaders and plan for leadership succession. Female-dominated professions such as nursing often exemplify the queen bee syndrome. The queen bee is a woman who has struggled to become successful, but once successful, she refuses to help other women reach the same success. This leads to inadequate empowering of new leaders by the older, more established leaders. Increased and adequate empowering of others, mentoring the young, and ensuring leadership succession are clearly needed to advance nursing leadership. Remember that the profession is responsible for ensuring leadership succession and is morally bound to do it with the brightest, most highly qualified individuals (Huston, 2020).

Changing nurse’s view of both power and politics is perhaps the most significant key to proactive rather than reactive participation in policy setting.

Strategies for Building a Personal Power Base In addition to assisting with empowering the profession, nurse- leaders and nurse-managers must build a personal power base to further organizational goals, fulfill the leadership role, carry out management functions, and meet personal goals. Even a novice manager or newly graduated nurse can begin to build a power base in many ways. Habitual behaviors resulting from early lessons, passivity, and focusing on wrong targets can be replaced with new power-gaining behaviors. The following are suggested strategies for enhancing power.

Maintain Personal Energy Power and energy go hand in hand. To take care of others, you must first take care of yourself. Effective leaders take enough time to unwind, reflect, rest, and have fun when they feel tired. Leader- managers who do not take care of themselves begin to make mistakes in judgment that may result in terrible political consequences. Taking time for significant relationships and developing outside interests are important so that other resources are available for sustenance when political forces in the organization drain energy.

You must take care of yourself before you can take care of others.

Present a Powerful Picture to Others How people look, act, and talk influence whether others view them as powerful or powerless. The nurse who stands tall and is poised, assertive, articulate, and well-groomed presents a picture of personal control and power. The manager who looks like a victim will undoubtedly become one. When individuals take the time for self- care, they exude confidence. This is apparent in not only how they dress and act but also how they interact with others.

Work Hard and Be a Team Player Newcomers who stand out and appear powerful are those who do more, work harder, and contribute to the organization. They attend meetings and in-service opportunities; they do committee work and take their share of night shifts and weekend and holiday assignments without complaining. A power base is not achieved by slick, easy, or quick maneuvers but through hard work. It is also

important to be a team player. Showing a genuine interest in others, being considerate of other people’s needs and wants, and offering others support whenever possible are all part of a successful team building. These interpersonal skills are part of emotional intelligence.

Determine the Powerful in the Organization Understanding and working successfully within both formal and informal power structures are important strategies for building a personal power base. Individuals must be cognizant of their limitations and seek counsel appropriately. One should know the names and faces of those with both formal power and informal power. The powerful people in the informal structure are often more difficult to identify than those in the formal structure. When working with powerful people, look for similarities and shared values and avoid focusing on differences.

Learn the Language and Symbols of the Organization Each organization has its own culture and value system. New members must understand this culture and be socialized into the organization if they are to build a power base. Being unaware of institutional taboos often results in embarrassment for the newcomer.

Learn How to Use the Organization’s Priorities Every group has its own goals and priorities for achieving those goals. Those seeking to build a power base must be cognizant of organizational goals and use those priorities and goals to meet management needs. For example, a need for a new manager in a community health service might be to develop educational programs on chemotherapy because some of the new patient caseload includes this nursing function. If fiscal management is a high priority,

the manager needs to show superiors how the cost of these educational programs will be offset by additional revenues. If public relations with physicians and patients are a priority, the manager would justify the same request in terms of additional services to patients and physicians.

Increase Professional Skills and Knowledge Because employees are expected to perform their jobs well, one’s performance must be extraordinary to enhance power. One method of being extraordinary is to increase professional skills and knowledge to an expert level. Having knowledge and skill that others lack greatly augments a person’s power base. Excellence that reflects knowledge and demonstrates skill enhances a nurse’s credibility and determines how others view him or her.

Individuals may be born average, but staying average is a choice.

Maintain a Broad Vision Vision is one of the most powerful tools that a leader has in his or her toolbox. Because workers are assigned to a unit or department, they often develop a narrow view of the total organization. Power builders always look upward and outward. The successful leader recognizes not only how the individual unit fits within the larger organization but also how the institution as a whole fits into the scheme of the total community. People without vision rarely become very powerful.

Use Experts and Seek Counsel

Newcomers should seek out role models. Role models are experienced, competent individuals an individual wants to emulate. Even though there may be no significant interpersonal relationship, one can learn a great deal about successful leadership, management, and decision making by observing and imitating positive role models. By looking to others for advice and counsel, people demonstrate that they are willing to be team players, that they are cautious and want expert opinion before proceeding, and that they are not rash newcomers who think they have all the answers. Aligning oneself with appropriate veterans in the organization is excellent for building power.

Be Flexible Great leaders understand the power of flexibility. Anyone wishing to acquire power should develop a reputation as someone who can compromise. The rigid, uncompromising newcomer is viewed as being insensitive to the organization’s needs.

Develop Visibility and a Voice in the Organization Newcomers to an organization must become active in committees or groups that are recognized by the organization as having clout. When working in groups, the newcomer must not monopolize committee time. In addition, novice leaders and managers must develop observational, listening, and verbal skills. Their spoken contributions to the committee should be valuable and articulated well.

Experienced leader-managers must strive for visibility and voice as well. Managers who are too far removed from workers in the organization hierarchy can have a view that is cloudy or distorted. If workers do not know their managers, they will not trust them.

Learn to Accept Compliments Accepting compliments is an art. One should be gracious but certainly not passive when praised for extraordinary effort. In addition, people should let others know when some special professional recognition has been achieved. This should be done in a manner that is not bragging but reflects the self-respect of one who is talented and unique.

Maintain a Sense of Humor Appropriate humor is very effective. The ability to laugh at oneself and not take oneself too seriously is a most important power builder. Humor allows the leader to relax so that he or she can step away from the challenge and look at the circumstance in a different perspective.

Empower Others Leaders need to empower others, and followers must empower their leaders. When nurses empower each other, they gain referent power. Individual nurses and the profession as a whole do not gain their share of power because they allow others to divide them and weaken them. Nurses can empower other nurses by sharing knowledge, maintaining cohesiveness, valuing the profession, and supporting each other. Power-building and political strategies are summarized in Table 13.2.

TABLE 13.2 LEADERSHIP STRATEGIES: DEVELOPING POWER AND POLITICAL SAVVY

Power-Building Strategies Political Strategies

Maintain personal energy Develop information acquisition skills

Present a powerful persona Communicate astutely Work hard Become a proactive decision

maker Be a team player Assume authority Determine the powerful Engage in networking Learn the organizational culture Expand personal resources Use organizational priorities Maintain maneuverability Increase skills and knowledge Develop political alliances and

coalitions Have a broad vision Remain sensitive to people,

timing, and situations Use experts and seek counsel Promote subordinate

identification Be flexible Meet organizational needs Be visible and have a voice Minimize ego-driven reactions Accept compliments graciously Maintain a sense of humor Empower others

LEARNING EXERCISE 13.5

Building Power as the New Nurse

You have been a registered nurse for 3 years. Six months ago, you left your position as a day charge nurse at one of the local hospitals to accept a position at the public health agency. You really miss your friends at the hospital and find most of the public health nurses older and aloof. However, you love working with your patients and have decided that this is where you want to build a lifetime career. Although you believe that you have some good ideas, you are aware that because you are new, your ability to act as a change agent will be limited. Eventually, you would like to be promoted to agency supervisor and become a powerful force for stimulating growth within the agency. You decide that you can do a few things to build a power base. You spend a weekend designing a personal power-building plan.

ASSIGNMENT:

Make a power-building plan. Give 6 to 10 specific examples of things you would do to build a power base in the new organization. Provide rationale for each selection. (Do not merely select from the general lists in the text. Outline specific actions that you would take.) It might be helpful to consider your own community and personal strengths when solving this learning exercise.

The Politics of Power Politics is the art of using legitimate power wisely. It requires clear decision making, assertiveness, accountability, and the willingness to express one’s own views. It also requires being proactive rather than

reactive and demands decisiveness. Leader-managers in power positions in today’s health-care settings are more likely to recognize their innate abilities that support the effective use of power.

It is important for managers to understand politics within the context of their employing organization. After the employee has built a power base through hard work, increased personal power, and knowledge of the organization, developing skills in the politics of power is necessary. After all, power may not be gained indefinitely; it may be fleeting. For example, people often lose hard-earned power in an organization because they make political mistakes. Even seasoned leaders occasionally blunder in this arena.

Although power is a universally available resource, it does not have a finite quality and can be lost as well as gained.

It is useless to argue the ethics or value of politics in an organization because politics exists in every organization. Thus, nurses waste energy and remain powerless when they refuse to learn the art and skill of political maneuvers. Politics becomes divisive only whenever gossip, rumor, or unethical strategies occur.

Much attention is given to improving competence, but little time is spent in learning the intricacies of political behavior. The most important strategy is to learn to “read the environment” (e.g., understand relationships within the organization) through observation, listening, reading, detachment, and analysis.

Because power implies interdependence, nurses must not only understand the organizational structure in which they work but also be able to function effectively within that structure, including dealing effectively with the institution’s inherent politics. Only when managers understand power and politics will they be capable of recognizing limitations and potential for change.

Understanding one’s own power can be frightening, especially when one considers that “attacks” (or opposition) from various fronts may reduce that power. When these attacks occur, people who hold powerful positions may undermine themselves by regressing rather than progressing and by being reactive rather than proactive. The following political strategies will help the novice manager to negate the negative effects of organizational politics:

Become an expert handler of information and communication. Beware that facts can be presented seductively and out of context. Be cautious in accepting facts as presented because information is often changed to fit others’ needs. Managers must become artful at acquiring information and questioning others. Delay decisions until adequate and accurate information has been gathered and reviewed. Failing to do the necessary homework may lead to decisions with damaging political consequences.

Managers must not trap themselves by discussing something about which they know very little. Political astuteness in communication is a skill to be mastered, and the politically astute manager says, “I don’t know” when adequate information is unavailable. Grave consequences can result from sharing the wrong information with the wrong people at the wrong time. Determining who should know, how much they should know, and when they should know requires great finesse.

One of the most politically serious errors that one can make is lying to others within the organization. Unlike withholding and refusing to divulge information, which may be good political strategies, lying destroys trust, and leaders must never underestimate the power of trust.

Be a proactive decision maker. Nurses have had such a long history of being reactive that they have had little time to learn how to be proactive. Although being reactive is better than being

passive, being proactive means getting the job done better, faster, and more efficiently. Proactive leaders prepare for the future instead of waiting for it. Seeing changes approaching in the health-care system, they prepare to meet them, not fight them.

Assuming authority is one way that nurses can become proactive. Part of power is the image of power; a powerful political strategy also involves image. Instead of asking, “May I?” leaders assume that they may. When people ask permission, they are really asking someone to take responsibility for them. If something is not expressly prohibited in an organization or a job description, the powerful leader assumes that it may be done. Politically astute nurses have been known to create new positions or new roles within a position simply by gradually assuming that they could do things that no one else was doing. In other words, they saw a need in the organization and started meeting it. The organization, by default, allowed expansion of the role. People need to be aware, however, that if they assume authority and something goes wrong, they will be held accountable, so this strategy is not without risk.

Expand personal resources. Because organizations are dynamic and the future is impossible to predict, the proactive nurse prepares for the future by expanding personal resources. Personal resources include economic stability, higher education, and a broadened skill base. Some call this the political strategy of “having maneuverability,” that is, the person avoids having limited options. People with “money in the bank and gas in the tank” have a political freedom of maneuverability that others do not. People lose power if others within the organization know that they cannot afford to make a job change or lack the necessary skills to do so. Those who become economically dependent on a position lose political clout. Likewise, the nurse who has not developed additional skills or sought further

education loses the political strength that comes from being able to find quality employment elsewhere.

Develop political alliances and coalitions. Nurses often can increase their power and influence by forming coalitions and alliances (networking) with other groups, be they peers, sponsors, or subordinates, especially when these alliances are with peers outside the organization. In this manner, the manager keeps abreast of current happenings and consults others for advice and counsel. Although networking works among many groups, for the nurse-manager, few groups are as valuable as local and state nursing associations. More power and political clout result from working together rather than alone. When a person faces political opposition from others in the organization, group power is very useful.

Nurses must be represented in mass, in some way, before they will be able to significantly impact the decisions that directly influence their own profession.

Be sensitive to timing. Successful leaders are sensitive to the appropriateness and timing of their actions. The person who presents a request to attend an expensive nursing conference on the same afternoon that his or her supervisor just had extensive dental work typifies someone who is insensitive to timing. Besides being able to choose the right moment, the effective manager should develop skill in other areas of timing, such as knowing when it is appropriate to do nothing. For example, in the case of a problem employee who is 3 months from retirement, time itself will resolve the situation. The sensitive manager also learns when to stop requesting something. That time is before your boss issues a firm “no,” at which point continuing to press the issue is politically unwise.

Promote subordinate identification. A manager can promote the identification of subordinates in many ways. A simple “thank you” for a job well done works well when spoken in front of someone else. Calling attention to the extra efforts of subordinates says in effect, “Look what a good job we are capable of doing.” Sending subordinates sincere notes of appreciation is another way of praising and promoting. Rewarding excellence is an effective political strategy.

View personal and unit goals in terms of the organization. Even extraordinary and visible activities will not result in desired power unless those activities are used to meet organizational goals. Hard work purely for personal gain will become a political liability. Frequently, novice managers think only in terms of their needs and their problems rather than seeing the large picture. Moreover, people often look upward for solutions rather than attempting to find answers themselves. When problems are identified, it is more politically astute to take the problem and a proposed solution upward rather than just presenting the problem to the superior. Although the superior may not accept the solution, the effort to problem solve will be appreciated.

Minimize ego-driven reactions. Although political actions can be negative, you should make an effort not to take political attacks personally because you may well be a bystander hit in a crossfire. Likewise, be careful about accepting credit for all political successes because you may just have been in the right place at the right time. Be prepared as a manager to make political errors. The key to success is how quickly you rebound.

LEARNING EXERCISE 13.6

A Shifting of Power

The following is based on a real event. The cast includes Sally Jones, the chief nursing officer; Jane Smith, the hospital administrator and chief executive officer; and Bob Black, the assistant hospital administrator. Sally has been in her position at Memorial Hospital for 2 years. She has made many improvements in the nursing department and is generally respected by the hospital administrator, the nursing staff, and the physicians.

The present situation involves the newly hired Bob Black. Previously too small to have an assistant administrator, the hospital has grown, and this position was created. One of the departments assigned to Bob is the personnel and payroll department. Until now, nursing, which comprises 45% of all personnel, has done its own recruiting, interviewing, and selecting. Since Bob has been hired, he has shown obvious signs that he would like to increase his power and authority. Now, Bob has proposed that he hire an additional clerk who will do much of the personnel work for the nursing department, although nursing administration will be able to make the final selections in hiring. Bob proposes that his department should do the initial screening of applicants, seeking references, and so on. Sally has grown increasingly frustrated in dealing with the encroachment of Bob. Having just received Bob’s latest proposal, she has requested to meet with Jane Smith and Bob to discuss the plan.

ASSIGNMENT:

What danger, if any, is there for Sally Jones in Bob Black’s proposal? Explain two political strategies that you believe Sally could use in the upcoming meeting. Is it possible to facilitate a win–win solution to this conflict? If so, how? If there is not a win–win solution, how much can Sally win?

Note: Attempt to solve this case before reading the solution presented in the Appendix.

Integrating Leadership Roles and Management Functions When Using Authority and Power in Organizations A manager’s ability to gain and wisely use power is critical to his or her success. Nurses will never be assured of adequate resources until they gain the power to manipulate the needed resources legitimately. To do this, managers must be able to bridge the authority–power gap, build a personal power base, and minimize the negative politics of the organization.

One of the most critical leadership roles in the use of power and authority is the empowerment of subordinates. The leader recognizes that some degree of power is held by all in the organization, including subordinates, peers, and higher administrators.

The key then to establishing and keeping authority and power in an organization is for the leader-manager to be able to accomplish four separate tasks:

Maintain a small authority–power gap. Empower subordinates whenever possible.

Use authority in such a manner that subordinates view what happens in the organization as necessary.

When needed, implement political strategies to maintain power and authority.

Integrating the leadership role and the functions of management reduces the risk that power will be misused. Power and authority will be used to increase respect for the position and for nursing as a whole. The leader comfortable with power ensures that the goal of political maneuvers is cooperation, not personal gain. The successful manager who has integrated the role of leadership will not seek to have power over others but instead will empower others. It is imperative for leader-managers to become skillful in the art of politics and the use of political strategy if they are to survive in the corporate world of the health-care industry. It is with the use of such strategies that organizational resources are obtained and goals are achieved.

Key Concepts

■ Power and authority are necessary components of leadership and management.

■ A person’s response to authority is influenced early through authority figures, experiences in the family unit, and gender role identification.

■ The gap that sometimes exists between a position of authority and subordinate response is called the authority– power gap.

■ The empowerment of staff is a hallmark of transformational leadership. Empowerment means to enable, develop, or allow.

■ Power has both a positive and a negative face.

■ Traditionally, women have been socialized to view power differently than men do. However, recent studies show that gender differences regarding power are slowly changing.

■ Reward power is obtained by the ability to grant rewards to others.

■ Coercive power is based on fear and punishment. ■ Legitimate power is the power inherent in one’s position. ■ Expert power is gained through knowledge or skill. ■ Referent power is obtained through association with others. ■ Charismatic power results from a dynamic and powerful

persona. ■ Information power is gained when someone has information

that another needs. ■ Female-dominated professions such as nursing often

exemplify the queen bee syndrome. The queen bee is a woman who has struggled to become successful, but once successful, she refuses to help other women reach the same success.