leadership week 5 discus.
dance2k
leadershiptextbook.pdf
Leading and Managing in Nursing
SEVENTH EDITION
Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN Professor and Dean Emerita, Texas Tech University Health Sciences Center, Lubbock, Texas
2
Table of Contents
Cover image
Title page
Copyright
Dedication
Contributors
Reviewers
Acknowledgments
Preface
Concept and practice combined
Diversity of perspectives
Audience
Organization
Design
Learning strategies
Complete teaching and learning package
Chapter overview Part 1: Overview
1: Leading, Managing, and Following
Introduction
Theory development in leading, managing, and following
Leading, managing, and following—different but related
Traditional and emerging leadership and management roles
Leading, managing, and following in a diverse organization
3
Conclusion
Reflections
The evidence
Tips for leading, managing, and following
2: Clinical Safety: The Core of Leading, Managing, and Following
Introduction
The classic reports and emerging supports
Other key agencies and endeavors
Meaning for leading and managing in nursing
Conclusion
Reflections
The evidence
Tips for clinical safety
3: Legal and Ethical Issues
Introduction
Professional nursing practice: nurse practice acts
Negligence and malpractice
Informed consent
Privacy and confidentiality
Policies and procedures
Employment laws
Professional nursing practice: ethics
Conclusion
Reflections
The evidence
Tips for incorporating legal and ethical issues in practice settings
4: Cultural Diversity and Inclusion in Health Care
Introduction
Concepts and principles
Theory
4
National and global directives
Special issues
Language
Meaning of diversity in the organization
Cultural relevance in the workplace
Individual and societal factors
Dealing effectively with cultural diversity
Implications in the workplace
Conclusion
Reflections
The evidence
Tips for incorporating cultural diversity in health care
Part 2: Know Yourself
5: Gaining Personal Insight: The Beginning of Being a Leader
Introduction
Informal and formal leadership
The core of learning to be a leader
Gaining insight into self
Becoming an authentic leader
Conclusion
Reflections
The evidence
Tips for Gaining Personal Insight
6: Being an Effective Follower
Introduction
Research on followership
Followership theories
Differences between leading and following
Leader–follower relationship
Conclusion
5
Reflections
The evidence
Tips on how to be an effective follower
7: Managing Self: Stress and Time
Introduction
Emotional intelligence
Understanding stress
Definition of stress
Sources of job stress
Dynamics of stress
Management of stress
Burnout
Resolution of stress
Management of time
Conclusion
Reflections
The evidence
Tips for self-management
8: Communication and Conflict
Introduction
Effective communication within healthcare settings
Types of conflict
Stages of conflict
Categories of conflict
Modes of conflict resolution
Differences of conflict-handling styles among nurses
The role of the leader
Managing incivility, lateral violence, and bullying
Conclusion
Reflections
The evidence
6
Tips for effective communication and addressing conflict
9: Power, Politics, and Influence
Introduction
History
Power
Empowerment
Sharing Power
Personal power strategies
Exercising Power and Influence in the Workplace and Other Organizations
Conclusion
Reflections
The evidence
Tips for using influence
Part 3: Know the Organization
10: Healthcare Organizations
Introduction
Characteristics and types of organizations
Integration
Acquisitions and mergers
Forces that influence healthcare organizations
Theoretical Perspectives
Nursing role and function changes
Conclusion
Reflections
The evidence
Tips for healthcare organizations
11: Organizational Structures
Introduction
Mission
Vision
7
Philosophy
Organizational culture
Factors influencing organizational development
Characteristics of organizational structures
Bureaucracy
Types of organizational structures
Emerging fluid relationships
Conclusion
Reflections
The evidence
Tips for understanding organizational structures
12: Care Delivery Strategies
Introduction
Historical methods of organizing nursing care
Leadership during implementation of a model of care
Organizational strategies influencing care delivery
Positive care delivery systems
Transitional care
Interprofessional education and collaboration
Conclusion
Reflections
The evidence
Tips for selecting a care delivery model
13: Staffing and Scheduling
Introduction
The staffing process
Evaluation of effective staffing
Factors in staffing that influence patient outcomes
Supplemental (agency or contract) staff and float pools
Organizational factors that affect staffing plans
Developing a staffing budget
8
Scheduling
Evaluating unit staffing and productivity
Conclusion
Reflections
The evidence
Tips for staffing and scheduling
14: Workforce Engagement Through Collective Action and Governance
Introduction
Nurses as knowledge workers
Professional practice responsibility
Workplace advocacy, engagement, and empowerment
Shared governance
Collective action, collective bargaining, and unionization in nursing
Healthy work environments
Conclusion
Reflections
The evidence
Tips for workforce engagement and collective action
Part 4: Use Your Skills
15: Making Decisions and Solving Problems
Introduction
Differentiation of decision making and problem solving
Decision making
Problem solving
Conclusion
Reflections
The evidence
Tips for decision making and problem solving
16: The Impact of Technology
Introduction
9
Types of technologies
Knowledge technology
Information systems
Informatics
Patient safety
Impact of clinical information systems
Safely implementing health information technology
Future trends and professional issues
Professional, ethical nursing practice and new technologies
Conclusion
Reflections
The evidence
Tips for managing information and technology
17: Delegating: Authority, Accountability, and Responsibility in Delegation Decisions
Introduction
Historical perspective
Definitions
Assignment versus delegation
NCSBN model: an organizational framework for delegation
Effective communication: an essential competency for successful delegation
Delegation and the decision-making process in nursing
Organizational and individual accountability
Legal authority to delegate
Learning how to delegate: different strategies for success
Conclusion
Reflections
The evidence
Implications for practice
Tips for delegating
18: Leading Change
Introduction
10
The nature of change
The change process
People and change
Context and change
Leadership and change
Conclusion
Reflections
The evidence
Tips for leading change
19: Building Effective Teams
Introduction
Groups and teams
Creating effective teams
Key concepts of teams
Issues that affect team functioning
Interprofessional teams
The value of team-building
The role of leadership
Conclusion
Reflections
The evidence
Tips for team building
20: Managing Costs and Budgets
Introduction
What escalates healthcare costs
How health care is financed
Healthcare reimbursement
The changing healthcare economic environment
Why profit is necessary
Cost-conscious nursing practices
Budgets
11
Conclusion
Reflections
The evidence
Tips for managing costs and budgets
21: Selecting, Developing, and Evaluating Staff
Introduction
Roles in an organization
Selection of staff
Developing staff
Performance appraisals
Coaching
Conclusion
Reflections
The evidence
Tips for selecting, developing, and evaluating staff
22: Person-Centered Care
Introduction
Person-centered care—why now?
Initiatives to deliver person-centered care
Challenges in the delivery of person-centered care
Patient engagement
Nurses in the delivery of person-centered care
Synthesis and application
Conclusion
Reflections
The evidence
Tips for competent person-centered care
23: Managing Quality and Risk
Introduction
Quality management in health care
12
Benefits of quality management
Planning for quality management
Evolution of quality management
Quality management principles
Customers
The quality improvement process
Quality assurance
Risk management
Conclusion
Reflections
The evidence
Tips for quality management
24: Translating Research Into Practice
Introduction
From using research to evidence-based practice
Development of evidence-based practice
Comparative effectiveness research
Practice-based evidence
Participatory action research
Quality improvement
Evaluating evidence
Organizational strategies to embed evidence-based practice into organizations
Issues for nurse leaders and managers
Conclusion
Reflections
The evidence
Tips for developing skill in using evidence and translating research into practice
25: Managing Personal and Personnel Problems
Introduction
Personal/personnel problems
Documentation
13
Progressive discipline
Termination
Conclusion
Reflections
The evidence
Tips in the documentation of problems
Part 5: Prepare for the Future
26: Role Transition
Introduction
Types of roles
Roles: The ABCs of understanding roles
Role transition process
Strategies to promote role transition
Conclusion
Reflections
The evidence
Tips for role transition
27: Managing Your Career
Introduction
A career framework
Career theory
Professional development
Contributing through scholarly activities and research
Career marketing strategies
Conclusion
Reflections
The evidence
Tips for a successful career
28: Developing the Role of Leader
Introduction
14
What is a leader?
The practice of leadership
Leadership development
Leadership development model
Surviving and thriving as a leader
The nurse as leader
Conclusion
Reflections
The evidence
Tips for becoming a leader
29: Developing the Role of Manager
Introduction
The definition of management
Nurse manager as change leader
Nurse manager role and the intergenerational workforce
The nurse manager and interprofessional collaboration
Building a positive work environment
Consuming research
Organizational culture
Mentoring
Day-to-day management challenges
Managing resources
Technology and informatics
Dashboards and decision support tools
Budgets and finance
Quality indicators
Professionalism
Conclusion
Reflections
The evidence
Tips for implementing the role of nurse manager
15
30: The Strategic Planning Process
Introduction
Strategic planning
Reasons for strategic planning
Phases of the strategic planning process
Conclusion
Reflections
The evidence
Tips for developing and executing a strategic plan for nursing
31: Thriving for the Future
Introduction
Leadership demands for the future
Leadership strengths for the future
Visioning, forecasting, and innovation
The wise forecast model©
Shared vision
Projections for the future
Conclusion
Reflections
Tips for the Thriving in the future
The evidence
Index
16
Copyright
3251 Riverport Lane St. Louis, Missouri 63043
LEADING AND MANAGING IN NURSING, SEVENTH EDITION ISBN: 978-0-323-44913-7
Copyright © 2019 by Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Previous editions copyrighted 2015, 2011, 2007, 2003, 1999, 1995. International Standard Book Number: 978-0-323-44913-7
Senior Content Strategist: Yvonne Alexopoulos Content Development Manager: Lisa P. Newton Senior Content Development Specialist: Tina Kaemmerer Publishing Services Manager: Julie Eddy Senior Project Manager: Jodi M. Willard Design Direction: Brian Salisbury
17
Printed in Canada. Last digit is the print number: 9 8 7 6 5 4 3 2 1
18
Dedication
This book is dedicated to the families and friends who supported all of us who created it, to the faculty who use this book to develop tomorrow’s emerging leaders and managers, and to the
learners who have the vision and insight to grasp today’s reality and mold it into the future of dynamic nursing leadership.
Lead on! ¡Adelante!
19
Contributors
Joan Benson, BSN, RN, CPN Manager, Clinical Informatics and Practice, Children's Mercy— Kansas City, Kansas City, Missouri
Kristin K. Benton, BS, BSN, MSN, DNP Director of Nursing, Nursing, Texas Board of Nursing, Austin, Texas
Amy Boothe, DNP, RN Instructor, Traditional Undergraduate Program, Texas Tech University Health Sciences Center, Lubbock, Texas
Elizabeth H. Boyd, MSN, BS Instructor/Site Coordinator, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas
Myra A. Broadway, JD, MS, BSN Formerly, Executive Director, Maine State Board of Nursing, Past President, National Council of State Boards of Nursing, Maine Medical Professionals Health Program Advisory Committee USAFR Nurse Corps (Retired Colonel), Gardiner, Maine
M. Margaret Calacci, MS Director, Simulation and Learning Resources, Arizona State University College of Nursing and Health Innovation, Phoenix, Arizona
Mary Ellen Clyne, PhD President and Chief Executive Officer, Administration, Clara Maass Medical Center, Belleville, New Jersey
Jeannette T. Crenshaw, DNP, RN, LCCE, IBCLC, NEA-BC, FACCE, FAAN Associate Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas
Mary Ann T. Donohue-Ryan, PhD, RN, APN, APRN-MH, NEA-BC Vice President for Patient Care Services and Chief Nursing Officer, Administration, Englewood Hospital and Medical Center, Englewood, New Jersey
Michael L. Evans, PhD, MSN, BSN, BA Dean and Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas
Victoria N. Folse, PhD, APN, PMHCNS-BC, LCPC Director and Professor; Caroline F. Rupert Endowed Chair of Nursing, School of Nursing, Illinois Wesleyan University, Bloomington, Illinois
Jacqueline Gonzalez, DNP, MBA, MSN Senior Vice President/Chief Nursing Officer, Nicklaus Children’s Hospital, Miami, Florida
Debra Hagler, PhD, RN, ACNS-BC, CNE, CHSE, ANEF, FAAN Clinical Professor, College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
Shari Kist, PhD, RN Missouri Quality Initiative (MOQI) Project Supervisor, Sinclair School of Nursing, University of Missouri—Columbia, Columbia, Missouri
Karren Kowalski, BSN, MSN, PhD President & CEO, Colorado Center for Nursing Excellence, Denver, Colorado Professor, Graduate Program, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas
Mary E. Mancini, RN, MSN, PhD Senior Associate Dean for Education Innovation, Undergraduate Nursing, University of Texas at Arlington, Arlington, Texas
20
Maureen Murphy-Ruocco, APN-C, CSN, MSN, EdM, EdD, DPNAP Senior Fellow, National Academies of Practice, Nurse Consultant/Nurse Practitioner New York, New York Professor and Dean Emerita Felician University, Lodi and Rutherford, New Jersey
Karen A. Quintana, PhD, APRN, CPNP-PC Director of Pediatric Nurse Practitioner Studies, Graduate Program, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas
Elaine S. Scott, BSN, MSN, PhD Chair, Nursing Science, East Carolina University, Greenville, North Carolina
Ashley Sediqzad, RN, BSN Manager, Clinical Informatics and Practice, Children's Mercy Kansas City, Kansas City, Missouri
Janis Bloedel Smith, DNP, MSN, BSN Senior Director, Clinical Informatics & Professional Practice, Patient Care Services, Children's Mercy Kansas City, Kansas City, Missouri
Susan Sportsman, PhD Nurse Consultant, Collaborative Momentum Consulting, LLC, St. Louis, Missouri
Sylvain Trepanier, DNP, MSN, BSN, RN, CENP Chief Clinical Executive, Administration, Providence St. Joseph Health, Torrance, California
Diane M. Twedell, DNP, MS Chief Nursing Officer, Mayo Clinic Health System, Southeast Minnesota Region, Austin, Minnesota
Jeffery Watson, DNP, RN-BC, NEA-BC, NE-BC, CRRN Assistant Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas
Jana Wheeler, MSN, RN-BC, CPN Manager, Clinical Informatics & Practice, Children's Mercy Kansas City, Kansas City, Missouri
Crystal J. Wilkinson, DNP, RN, CNS-CH, CPHQ Associate Professor, School of Nursing, Texas Tech University Health Sciences Center, Austin, Texas
Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN Professor and Dean Emerita, Texas Tech University Health Sciences Center, Lubbock, Texas
Margarete Lieb Zalon, PhD, RN, ACNS-BC, FAAN Professor, Nursing, University of Scranton, Scranton, Pennsylvania
21
Reviewers
Karen E. Alexander, PhD, RN, CNOR Program Director RN-BSN, Assistant Professor, Clinical Heath and Applied Science—Nursing, University of Houston—Clear Lake, Houston, Texas
Vicki Bingham, PhD, RN, CPE Dean/Associate Professor of Nursing, Robert E. Smith School of Nursing, Delta State University, Cleveland, Mississippi
Deborah Birk, PhD, RN, MHA, NEA-BC Assistant Professor, Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, Missouri
Barbara B. Blozen, EdD, MA, RN BC, CNL Associate Professor, New Jersey City University, Jersey City, New Jersey
Joseph Boney, MSN, RN, NEA-BC Director of Undergraduate Faculty Development/Instructor, Rutgers School of Nursing, Accelerated BS in Nursing Program, Newark, New Jersey
Mary T. Boylston, RN, MSN, EdD, AHN-BC Professor of Nursing, Nursing, Eastern University, St. Davids, Pennsylvania
Jane Campbell, DNP, RN, NE-BC Professor, School of Nursing, Northern Michigan University, Marquette, Michigan
Holly Johanna Diesel, RN, PhD Associate Professor, Academic Chair for Accelerated and RN to BSN Programs, Department of Nursing, Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri
Jennifer B. Drexler, RN, MSN, PhDc, CCRN Clinical Faculty Educator, College of Nursing, University of New Mexico, Albuquerque, New Mexico
Lynn Renee Dykstra, MS, BSN, HPCN, RN Instructor, Adjunct Faculty, Northern Illinois University, College of Health and Human Sciences, Nursing, DeKalb, Illinois Oakton Community College, Division of Science and Health Careers, Nursing Des Plaines, Illinois
Julie A. Fitzgerald, PhD, RN, CNE Assistant Professor of Nursing, Ramapo College of New Jersey, Mahwah, New Jersey
Kay E. Gaehle, PhD, RN Associate Professor of Nursing, Department of Primary Care and Health Systems, Southern Illinois University—Edwardsville, Edwardsville, Illinois
Maria Gillespie, EdD, MSN, BSN, BS, CNE, RN Assistant Professor, Nursing, University of the Incarnate Word, San Antonio, Texas
Julia Henderson Gist, PhD, RN, CNE Dean, School of Health Sciences, Arkansas State University Mountain Home, Mountain Home, Arkansas
Stephanie A. Gustman, DNP, MSN, BSN, RN Assistant Professor, School of Nursing, Ferris State University, Big Rapids, Michigan
Cam A. Hamilton, PhD, MSN, RN, CNE Assistant Professor, School of Nursing, Auburn University at Montgomery, Montgomery, Alabama
Pamela Gibler Harrison, EdD, RN, CNE Professor of Nursing, Chair, Pre-Licensure Nursing,
22
Indiana Wesleyan University, Marion, Indiana
Karen L. Hoblet, PhD, MSN, RN, CNL Licensed RN, Clinical Nurse Leader, Interim Department Chairperson and Associate Professor, Interim Director Nurse Educator and Clinical Nurse Leader Programs, Advanced Population Care, The University of Toledo College of Nursing, Toledo, Ohio
Janine Dailey Johnson, MSN, RN Assistant Professor, Nursing, Clarkson College, Omaha, Nebraska
Leo-Felix M. Jurado, PhD, RN, APN, NE-BC, CNE, FAAN Associate Professor, College of Science and Health, William Paterson University of New Jersey, Wayne, New Jersey
Barbara J. Keith, RN, MSN, CNE Clinical Lecturer, Vera Z. Dwyer College of Health Sciences, Indiana University School of Nursing, South Bend, Indiana
Donnamarie Lovestrand, RN, MSN, CPAN Faculty, Nursing Programs, Nursing Department, Pennsylvania College of Technology, Williamsport, Pennsylvania
Anne Boulter Lucero, RN, MSN Assistant Director, Instructor Nursing, Nursing Department, Cabrillo College, Aptos, California
Richard C. Meeks, DNP, RN, COI Assistant Professor, Graduate Program Coordinator, School of Nursing, Middle Tennessee State University, Murfreesboro, Tennessee
Kereen Forster Mullenbach, MBA, PhD, RN Associate Professor, Nursing, Radford University School of Nursing, Radford, Virginia
Sue S. Myers, RPN, BSW, MSCTE Faculty, Psychiatric Nursing and Bachelor of Psychiatric Nursing Programs, School of Nursing, Saskatchewan Polytechnic, Parkway Campus, Regina, Saskatchewan
Barbara Pinekenstein, DNP, RN- BC, CPHIMS Clinical Professor, Richard E. Sinaiko Professor in Health Care Leadership, School of Nursing, University of Wisconsin—Madison, Madison, Wisconsin
Dawn M. Pope, MS, RN Assistant Clinical Professor (retired), College of Nursing, University of Wisconsin—Oshkosh, Oshkosh, Wisconsin
Cara L. Rigby, DNP, RN, CMSRN Associate Professor, BSN Program Director, Nursing, The Christ College of Nursing and Health Sciences, Cincinnati, Ohio
Dulce Anne Santacroce, DNP, RN, CCM Nurse Educator, Nursing, Touro University—Nevada, Henderson, Nevada
Ruth Schumacher, DNP, RN, CNL, CPN Assistant Professor, Department of Nursing and Health Sciences, Elmhurst College, Elmhurst, Illinois
Kathy S. Sweeney, MSN, RN Assistant Professor of Nursing, Nursing Education, Kansas Wesleyan University, Salina, Kansas
Denise Robin Zabriskie, DNP, RN, CWOCN, WCC Assistant Professor, School of Nursing, Touro University Nevada, Henderson, Nevada
23
Acknowledgments
Patricia S. Yoder-Wise, RN, EdD, NEA-BC,ANEF, FAAN, Professor and Dean Emerita, Texas Tech University Health Sciences Center, Lubbock, Texas
As with any publication endeavor, many people other than those whose names appear on the cover make the actual publication possible, including the contributors and the Challenge/Solution authors. These behind-the-scenes people also include the reviewers and the publishing team at Elsevier.
We thank each of the contributors who worked diligently to meet deadlines and content expectations. Their names are listed with the chapters they produced. Without them, this book would be a lot thinner! The nurses who told their fabulous stories related to the various chapters always illustrate the real-world meaning of the importance of the chapter content; their names appear with their stories. Without all of them, this book would be much less interesting! What a fabulous group to work with.
We are indebted to our reviewers, who provided valuable feedback that helped refine the book. Receiving peer review is critical to any successful publication. Now that the book is completed, we know who they are and we thank them!
Jeff Watson took on coordinating the ancillaries, and Shelley Burson coordinated and managed an enormous number of details. Both gently nudged all of us to complete our required tasks in a timely manner.
Special thanks go to our publishing team: Senior Content Strategist Yvonne Alexopoulos, Senior Content Development Specialist Tina Kaemmerer, and Senior Production Manager Jodi Willard.
Even more special thanks go to my husband and best friend, Robert Thomas Wise, who vowed to be minimally disruptive as I sat in my office reading, writing, typing, and talking. He is a man of his word!
This book is designed to stimulate thinking and to encourage continued professional development in the area of leading and managing. When the Institute of Medicine released the report, The Future of Nursing, the idea of leadership was clearly a concern for the profession. This book continues its tradition of providing the information that nurses need to assume greater leadership practices and even new management roles. All contributors attempted to provide their best thinking on a given topic so that learners could integrate concepts to form the basis for their contribution to health care. Both the thinking and the complexities will continue to change…and so, hopefully, will you! The passion of nursing and leadership await!
24
Preface
The first edition of Leading and Managing in Nursing began in a hotel room in New Orleans, Louisiana in January of 1990. Darlene Como, the founding publisher of Leading and Managing, and I conceptualized a new way of presenting content about leadership and management: one that might engage learners in valuing the importance of roles that support clinical practice. This new approach included personal stories (The Challenge and The Solution), Literature Perspectives, Research Perspectives, synopses, exercises, and boxes of key information. If you saw that first edition and compared the number of words then compared with the number of words in this edition, you would know the field has grown and become far more complex. Nursing has also grown the field of leadership and management research, and so we have many more citations we can share to make this content both theoretical and practical.
We continue to include everything today’s nurses need to know about the basics of leading and managing. The changes with each revision of Leading and Managing reflect the intensity with which we know how leading and managing influence nurses in direct and indirect caregiving roles, as well as in other aspects of being a professional nurse in a complex, ever-changing, dynamic healthcare environment.
Nurses throughout the profession serve in various leadership roles. Leading and managing are two essential expectations of all professional nurses and become increasingly important throughout one’s career. To lead, manage, and follow successfully, nurses must possess not only knowledge and skills but also a caring and compassionate attitude.
This book results from our continued strong belief in the need for a text that focuses in a distinctive way on the nursing leadership and management issues— both today and in the future. We continue to find that we are not alone in this belief. This edition incorporates reviewers from both service and education to ensure that the text conveys important and timely information to users as they focus on the critical roles of leading, managing, and following. In addition, we took seriously the various comments offered by both educators and learners as I met them in person or heard from them by e-mail.
25
Concept and practice combined Innovative in both content and presentation, Leading and Managing in Nursing merges theory, research, and practical application in key leadership and management areas. Our overriding concern in this edition remains to create a text that, while well-grounded in theory and concept, presents the content in a way that is real. Wherever possible, we use real-world examples from the continuum of today’s healthcare settings to illustrate the concepts. Because each chapter contributor synthesizes the designated focus, you will find no lengthy quotations in these chapters. We have made every effort to make the content as engaging, inviting, and interesting as possible. Reflecting our view of the real world of nursing leadership and management today, the following themes pervade the text:
• Every role within nursing has the basic concern for safe, effective care for the people for whom we exist—our clients and patients.
• The focus of health care continues to shift from the hospital to the community at a rapid rate.
• Healthcare consumers and the healthcare workforce are increasingly culturally diverse.
• Today virtually every professional nurse leads, manages, and follows, regardless of title or position.
• Consumer relationships play a central role in the delivery of nursing and health care.
• Communication, collaboration, team-building, and other interpersonal skills form the foundation of effective nursing leadership and management.
• Change continues at a rapid pace in health care and society in general. • Change must derive from evidence-based practices wherever possible and from
thoughtful innovation when no or limited evidence exists. • Healthcare delivery is highly dependent on the effectiveness of nurses across roles
and settings.
26
Diversity of perspectives Contributors are recruited from diverse settings, roles, and geographic areas, enabling us to offer a broad perspective on the critical elements of nursing leadership and management roles. To help bridge the gap often found between nursing education and nursing practice, some contributors were recruited from academia, and others were recruited from practice settings. This blend not only contributes to the richness of this text but also conveys a sense of oneness in nursing. The historical “gap” between education and service must become a sense of a continuum, not a chasm.
27
Audience This book is designed for undergraduate learners in nursing leadership and management courses, including those in BSN-completion courses and second-degree programs. In addition, we know that practicing nurses—who had not anticipated formal leadership and management roles in their careers—use this text to capitalize on their own real-life experiences as a way to develop greater understanding about leading and managing and the important role of following. Numerous examples and The Challenge/The Solution in each chapter provide relevance to the real world of nursing.
28
Organization We have organized this text around issues that are key to the success of professional nurses in today’s constantly changing healthcare environment. The content flows from the core concepts (leading, managing, and following; clinical safety; legal considerations; and culture), to knowing yourself (being an effective follower, self-management, conflicts, and power), to knowing the organization (care delivery strategies, staffing), to using your personal and professional skills (technology, delegation, change, and quality), to preparing for the future (personal role transition, self and career management and strategic planning).
Because repetition plays a crucial role in how well learners learn and retain new content, some topics appear in more than one chapter and in more than one section. For example, because problem behavior is so disruptive, it is addressed in several chapters that focus on conflict, personal/personnel problems, incivility, and self-management. Rather than referring learners to another portion of the text, the key information is provided within the specific chapter.
We also made an effort to express a variety of different views on some topics, as is true in the real world of nursing. This diversity of views in the real world presents a constant challenge to leaders, managers, and followers, who address the critical tasks of creating positive workplaces so that those who provide direct care thrive and continuously improve the patient experience.
29
Design The functional full-color design, still distinctive to this text, is used to emphasize and identify the text’s many learning strategies, which are featured to enhance learning. Full-color photographs not only add visual interest but also provide visual reinforcement of concepts, such as body language and the changes occurring in contemporary healthcare settings. Figures expand and clarify concepts and activities described in the text graphically.
30
Learning strategies The numerous strategies featured in this text are designed both to stimulate learners’ interest and to provide constant reinforcement throughout the learning process. Color is used consistently throughout the text to help the reader identify the various chapter elements described in the following sections.
Chapter Opener Elements
• Objectives articulate the chapter’s learning intent, typically at the application level or higher.
• Terms to know are listed and appear in color type in each chapter. • The Challenge presents a contemporary nurse’s real-world concern related to the chapter’s
focus. It is designed to allow us to “hear” a real-life situation. The Challenge ends with a question about what you might do in such a situation.
Elements Within the Chapters
• Exercises stimulate learners to reason critically about how to apply concepts to the workplace and other real-world situations. They provide experiential reinforcement of key leading, managing, and following skills. Exercises are highlighted within a full-color box and are numbered sequentially within each chapter to facilitate their use as assignments or activities. Each chapter is numbered separately so that learners can focus on the concepts inherent in a specific area and educators can readily use chapters to fit their own sequence of presenting information.
• Research Perspectives and Literature Perspectives illustrate the relevance and applicability of current scholarship to practice. Theory Boxes provide a brief description of relevant theory and key concepts.
• Numbered boxes contain lists, tools such as forms and worksheets, and other information relevant to the chapter.
• The vivid full-color chapter opener photographs and other photographs throughout the text help convey each chapter’s key message. Figures and tables also expand concepts presented to facilitate a greater grasp of important materials.
End-of-Chapter Elements
• The Solution provides an effective method to handle the real-life situations set forth in The Challenge. It reflects the response of The Challenge author and ends with a question about how that solution would fit for you.
• The Evidence contains either one example of evidence related to the chapter’s content or contains a summary of what the literature shows to be evidence related to the topic.
• Reflections provide the learner with the opportunity to reflect on something they’ve encountered in practice.
• Tips offer practical guidelines for learners to follow in applying some aspect of the information presented in each chapter.
• References provide the learner with a list of key sources for further reading on topics found in the chapter.
31
Complete teaching and learning package In addition to the text Leading and Managing in Nursing, educator resources are provided online through Evolve (http://evolve.elsevier.com/Yoder-Wise/). These resources are designed to help educators present the material in this text and include the following assets:
• Updated PowerPoint Slides, with lecture notes where applicable, are provided for each chapter.
• An updated ExamView Test Bank includes answers and a rationale. • An updated TEACH for Nurses ties together the chapter resources for the most
effective class presentations, with sections dedicated to objectives, instructor and student chapter resources, teaching strategies, application activities and answers, an in-class case study discussion, and answers to the text Exercise boxes.
Student Resources Learning Resources can also be found online through Evolve (http://evolve.elsevier.com/Yoder- Wise/). These resources provide learners with additional tools for learning and include the following assets:
• NCLEX Review Questions • Sample Resumes
32
Chapter overview
1 Leading, Managing, and Following, 1 The changing landscape of health care provides opportunities for nurses to be actively involved in leading at many levels, from direct patient care to national policy development. Skills related to leading, managing, and following can serve nurses, our patients, and health care well. Nurses must use these skills while incorporating numerous other skills, especially emotional intelligence, to deliver high-quality care to individuals, families, and communities. This chapter provides an overview of theories related to leading and managing as well as complexity science, which can be useful in understanding our evolving healthcare system and profession.
2 Clinical Safety: The Core of Leading, Managing, and Following, 20 Every registered nurse has a legal obligation as a leader—someone who has the opportunity and authority to make changes for his or her patients or for the staff who provide direct care. Despite years of focusing on improving safety, patient safety issues have risen to become the third leading cause of death in the United States. Functioning safely in the clinical area is the complex work of the healthcare team, and the greatest numbers of providers are derived from nursing. This chapter provides an overview of some major patient safety efforts as the basis for nursing’s leadership work. In addition, this chapter addresses staff safety, which is another obligation of nurses to improve the workplace so that safe care can be rendered without harm to providers.
3 Legal and Ethical Issues, 32 This chapter highlights and explains key legal and ethical issues pertinent to managing and leading. Nurse practice acts, negligence and malpractice, informed consent, types of liability, selected federal and state employment laws, ethical principles, and related concepts are discussed. This chapter provides specific guidelines for preventing legal liability and guides the reader in applying ethical decision-making models in everyday practice settings.
4 Cultural Diversity and Inclusion in Health Care, 62 This chapter focuses on the importance of cultural considerations for patients and staff. Although it does not address comprehensive details about any specific culture, it does provide guidelines for actively incorporating cultural aspects into the roles of leading and managing. Diverse workforces are discussed, as well as how to capitalize on their diverse traits and how to support differences to work more effectively. The chapter presents concepts and principles of transculturalism, describes techniques for managing a culturally diverse workforce, emphasizes the importance of respecting different lifestyles, and discusses the effects of diversity on staff performance.
5 Gaining Personal Insight: The Beginning of Being a Leader, 77 Being clinically competent is the goal of every registered nurse, and competence is the foundation of who we are as nurses. In addition, every registered nurse has a legal obligation as a leader. The opportunity to execute this role begins with developing a personal insight about one’s values, strengths, resources, and connections and continues throughout life. Those insights are developed over time and capitalize on past knowledge and experiences and how others react to the demonstration of knowledge, skills, and attitudes in various situations. This chapter provides an overview of some initial strategies to strengthen the skill of leading. These strategies often build on prior experiences and now take on a different perspective of nurse as leader.
33
6 Being an Effective Follower, 89 Almost every formal organization has a multilayered hierarchy. The role of the leader has been explicated in the literature for decades. Less well understood, and certainly less well documented, is the role of the follower. This chapter is designed to discuss the role and responsibilities of the follower in the team.
7 Managing Self: Stress and Time, 99 This chapter recalls our understanding of stress and applies it to nursing. Almost every point made about what nurses experience could be applied or modified for other groups of professionals. This is important to remember, because any group has the tendency to think of itself as different from others. This chapter also examines the concept of self-management—developing behaviors that enhance rather than duplicate organizational cultures, social contexts, and occupational expectations as a professional nurse. Positive outcomes of effective self-management include better organization of your day, a higher degree of engagement and positivity, and respect for one’s needs for daily renewal. Three components of self-management are explored: emotional intelligence, time management, and overall stress management. Methods for managing stress and organizing your time are included. Practical exercises and suggestions for stress management and day-to-day time management are presented so they may be applied to personal and professional situations. Personal and professional growth is a life-long journey, and developing healthy habits can serve you well over your entire career.
8 Communication and Conflict, 123 Effective communication and appropriate conflict-handling strategies are essential in professional nursing practice to ensure positive patient outcomes. This chapter focuses on maximizing the ability of nurse leaders to promote a practice environment characterized by effective interprofessional communication and strategies for conflict resolution.
9 Power, Politics, and Influence, 141 The focus of this chapter is the impact of power and politics on the roles of leaders, managers, and followers and the ways in which leaders and managers use power and politics to be influential. Contemporary concepts of power, empowerment, and types of power exercised by nurses are considered. Key factors important to develop a powerful image and personal and organizational strategies for exercising power are recommended. Finally, the power of nurses to shape health policy by taking action in the arena of legislative politics is explored. Each of these concepts will help the nurse manager effectively engage in the politics of the workplace and, ultimately, use these skills in the broader healthcare environment.
10 Healthcare Organizations, 159 This chapter presents an overview of healthcare organizations, their characteristics, and their designs. Economic, social, and demographic factors that influence organizational development are discussed. An emphasis is placed on management and leadership responses that professional nurses must consider in planning the delivery of nursing care in the changing environment. Leaders, managers, and followers must be engaged and aware of the changing dynamics if they are to be effective healthcare professionals and advocate for patients, families, and community.
11 Organizational Structures, 176 The key concepts related to organizational structures and information on designing effective structures that reflect the organization’s mission, vision, philosophy, and values are the focus of this chapter. This information can be used to help nurse managers and others function in an organization and to design structures that support work processes. An underlying theme is designing organizational structures that will respond to continuous changes in the healthcare environment.
34
12 Care Delivery Strategies, 193 Nursing care delivery models used to organize care in a variety of healthcare organizations are explored in this chapter. Several historical methods of organizing nursing care—functional nursing, team nursing, and primary nursing (including hybrid forms of these approaches)—are presented. The chapter summarizes an overview of key concepts associated with each care delivery model, including the benefits and disadvantages, with an explanation of the nurse manager’s and direct care nurse’s role. Also discussed are strategies that influence care delivery, such as differentiated practice, the use of rapid cycle change at the bedside, and transitions models to help patients move through various levels of care. Approaches to case management by nurses are also considered.
13 Staffing and Scheduling, 215 This chapter explores research regarding the relationship between nurse staffing and various nurse and patient outcomes and discusses the interrelationship between the personnel budget and the staffing plan. Measures for evaluating unit productivity and the impact of various staffing and scheduling strategies on overall nursing satisfaction and continuity of patient care are discussed. These key points are critical to nurse managers’ ability to deliver safe and effective care in their areas of responsibility while maintaining a high degree of employee satisfaction on the units. Understanding the impact of nurse-sensitive indicators on patient outcomes helps nurse managers control the unit’s labor expenses while ensuring safe and effective care. The nurse manager’s ability to use this information and communicate about staffing to employees is critical to effectively managing productive services and being a valuable member of the leadership team.
14 Workforce Engagement Through Collective Action and Governance, 237 In the healthcare industry today, organizations must empower and retain highly qualified, knowledgeable nurses to provide their services. The ongoing and projected shortage of qualified nurses provides incentives for healthcare organizations to create work environments that attract and engage the most qualified nursing workforce. Work environments that empower and engage nurses promote nurses having a voice in decisions that impact their professional practice, impact patient outcomes, and increase job satisfaction. Empowerment through shared decision making can also provide leverage for nurses to negotiate pay commensurate with their education and expertise and helps create a healthy work environment. This chapter provides information on how to assess work environments through assessing organizational and governance characteristics, nurse empowerment/engagement strategies, and a variety of collective action and bargaining strategies that can shape nurses’ practice.
15 Making Decisions and Solving Problems, 257 This chapter explores the stages of the decision-making and problem-solving processes and describes the analytical tools used in the application of these processes. Strategies for both individual and group (intraprofessional) decision making are addressed.
16 The Impact of Technology, 274 This chapter describes recent technology that allows nurses to effectively and efficiently use data gathered at the point of care. It discusses nurses as knowledge workers who use biomedical and information technology to care for patients. It includes sections on biomedical, information, and knowledge technology with subsections that discuss informatics competencies, information systems hardware, the science of informatics, and patient care safety and quality. Nurses build knowledge for practice by comparing and contrasting not only current patient data with previous data for the same patient but also data across patients with the same diagnosis. Information tools and skills are essential for these decision-making processes now and in the future.
17 Delegating: Authority, Accountability, and Responsibility in
35
Delegation Decisions, 298 Delegation, a multifaceted decision-making process, is a learned nursing leadership behavior achieved by understanding the art of delegation, developing critical thinking and diagnostic reasoning skills, and applying critical judgment to effectively delegate to others in clinical practice. The overall purpose of delegation is to achieve nursing goals and improve person-centered care. This chapter discusses different aspects of delegation including the five rights of delegation, organizational and individual accountability, challenges and barriers to delegation, implementation of effective delegation strategies, and the legal parameters of delegation in professional nursing practice. The emphasis is on the role of registered nurses as delegators.
18 Leading Change, 320 This chapter highlights the increasing changes in health care and describes how all nurses must be change agents. The nature of change and the elements of the change process are reviewed. The theories, conceptual frameworks, and human responses to change are considered in an effort to understand the magnitude of managing the change experience. The roles of both the direct care nurse and the nurse manager in navigating change in the healthcare system are explored. Direct care nurses support change by remaining open to and engaging in new models of care, evidence- based practices, and requirements for ensuring safe and effective patient care. Nurse leaders must anticipate, prepare for, facilitate, oversee, and sustain change to achieve improved outcomes and professional and organizational goals. Avenues for promoting staff empowerment and engagement are examined as proactive change management strategies leaders can use to facilitate rapid, efficient, and almost continuous change.
19 Building Effective Teams, 336 This chapter explains major concepts and presents tools with which to create and maintain a smoothly functioning team. Many important group and team efforts occur in the work setting. Effective teamwork requires that we work together in a smooth and efficient manner, communicate clearly, and develop relationships that produce partnerships. Great team members use behaviors such as establishing a clear purpose, active listening, honesty, compassion, and flexibility. Each individual member of the team commits to participate in conflict resolution and cooperates in order to meet the agreed-upon goals. Leaders who understand the value of building an effective team use skills such as debriefing, acknowledgment, and group agreements to manage issues that can impact team functioning. They support the collaboration of interprofessional team members to provide safe and high-quality care.
20 Managing Costs and Budgets, 358 This chapter focuses on methods of financing health care and specific strategies for managing costs and budgets in healthcare settings—something that has become increasingly important as healthcare delivery evolves. Factors that escalate healthcare costs; sources of healthcare financing; reimbursement methods; cost-containment; promotion of growth, access, and revenues; value- based purchasing (as part of The Patient Protection and Affordable Care Act); and implications for nursing practice are discussed. Various budgets and the budgeting process are explained. In addition to clinical competency and caring practices, understanding the cost and revenue in healthcare delivery and the ethical implications of financial decisions is essential for nurses to contribute fully to the health of patients and populations.
21 Selecting, Developing, and Evaluating Staff, 377 One of the most important roles of a nurse leader is that of interviewing, hiring, and developing employees for an organization. Hiring the right employees is an important part of building a highly functioning team that provides safe and high-quality patient care and staff and patient satisfaction. The role of the nurse leader as a coach who empowers employees to grow as followers and develop their leadership skills in a learning environment is explored. Nursing staff in a patient care area are followers who play an important role in interviewing potential candidates and need to be clear
36
about various role expectations. The nurse leader also plays an important role in staff development and ongoing feedback of an individuals’ performance.
22 Person-Centered Care, 385 This chapter provides an overview of concepts related to person-centered care and strategies for its effective delivery. Specifically, the role of nurses in the delivery of person-centered care, factors in the healthcare delivery system driving the development of person-centered care approaches, and strategies that can be used by nurse leaders and followers to enhance the delivery of person- centered care are examined.
23 Managing Quality and Risk, 407 The key concepts and strategies related to quality and risk management are explained in this chapter. All healthcare professionals, including nurses, must be actively involved in the continuous improvement of patient care.
24 Translating Research Into Practice, 428 The importance of research in the development of the scientific basis for nursing practice is described in this chapter. The role of the nurse as a follower, manager, and leader of a healthcare organization in applying research to practice is delineated in the context of demands for the provision of health care based on the best available scientific evidence. This chapter also describes the practical aspects of appraising research, the development of evidence-based practice and practice-based evidence, and the use of large data sets to develop evidence in nursing. Strategies for translating research into practice that can be used by the individual nurse as a follower, leader, and manager in the context of the organization are outlined.
25 Managing Personal and Personnel Problems, 451 The purpose of this chapter is to discuss various personal and personnel problems that a leader must face in all nursing settings. Some specific tips and tools are provided as ways to intervene, coach, correct, and document problem behaviors such as absenteeism, uncooperative employees, emotional problems, or substance abuse. Supportive communication applications are also discussed. The problems and issues discussed are not only the responsibility of nursing leadership but also the responsibility of the entire team, including newly licensed registered nurses. Working on these issues from the perspective of newly licensed registered nurses provides a significant learning experience as these nurses transition into the workplace.
26 Role Transition, 465 As individuals progress through life, they transition through many roles at home, at work, and in relation to other individuals. This chapter focuses on role transition—the process of moving from one role to another. An example of this could be a nurse whose primary role is providing direct patient care (direct care nurse) transitioning to a nurse leader role. Role expectations need to be clearly articulated and determined for successful role transition to occur. The process of role transition and the different phases of this are reviewed.
27 Managing Your Career, 476 Successful people actively manage their careers rather than wait for “lucky breaks.” Although trusted others may guide or influence career development, individuals manage their own reputations and careers. Continuous lifelong learning and the ability to demonstrate and document competence are critical elements in effective career management. This chapter provides guidance for creating a successful career in nursing through academic progression, continuing education, certification, and service in professional organizations. In addition, this chapter includes the process of documenting qualifications and accomplishments for use in employment and career transitions.
37
28 Developing the Role of Leader, 495 The role of leader is vitally important in all healthcare settings. Nurses are present in virtually all settings, and developing the role of leader is very important to quality, safety, and staff productivity. This chapter focuses on leadership and its value in advancing the profession of nursing. Leadership development is explained with examples of how to survive and thrive in a leadership position. The differences between emerging and entrenched workforce generations are explored, and the desired characteristics of a leader for the emerging workforce are described. Leadership in a variety of situations, such as clinical settings, community venues, organizations, and political situations, is described. In addition, this chapter provides an introduction to the opportunities, challenges, and satisfaction of leadership.
29 Developing the Role of Manager, 510 The nurse manager serves as the catalyst for change by exhibiting a multitude of critical skills. Finding a mentor(s) is key in building and learning new skills as a nurse manager. Mentors serve as guides and coaches and share the lessons they have learned, including acute observation, proactivity, and risk-tasking. This chapter provides an overview of important elements that can assist in optimizing the knowledge and competency of the nurse manager. In addition, this chapter addresses items such as the evolution of management theories, managing the complexities of an intergenerational workforce, ensuring a positive workplace culture, mentoring, and the manager’s role in handling resources. The importance of the nurse manager’s use of dashboards and key performance indicators is demonstrated to ensure positive patient outcomes.
30 The Strategic Planning Process, 530 Today’s healthcare landscape is in a state of evolution with a concentrated focus on quality outcomes, patient safety, improved operational efficiencies, new reimbursement models, and demonstrated cost savings. Healthcare organizations must be resilient while navigating this new paradigm. The strategic planning process is one way in which a healthcare organization can chart its course for future success, and nurses are poised to be an integral part of the strategic planning process. The strategic planning process incorporates the same scientific process as the nursing process by: (1) assessing the current state of the organization; (2) conducting a gap analysis to establish a baseline of where the organization needs to be; (3) examining the organization’s mission, vision, and values; (4) implementing a plan with benchmark data; and (5) evaluating and continuing to monitor the outcomes of the plan and to revise the plan as needed. Nursing has the ability to create its own strategic plan that aligns with the mission, vision, values, and goals of the organization and that can serve as the basis for a division-, service-, or unit-level strategic plan. Unless all elements in an organization can envision how they fit within the overall strategic plan, it is likely it will not be achieved. This chapter provides an overview of strategic planning and the strategic planning process. Specifically, this chapter will demonstrate how nursing is integral in this strategic journey.
31 Thriving for the Future, 540 As everyone in health care knows, health care is changing so rapidly that keeping up-to-date is an increasing challenge. To be current, we really need to think about the future and what the nature of various changes will do to and for our practice. How we think about the future and the actions we take now shape what health care will be like and what our practice might be. This chapter explores the potential for the future and how the changes we face can be maximized to our benefit— organizationally and personally. The key leadership skills of visioning, forecasting, and innovating are presented. Projections for the future and their implication for nursing are included.
38
PA R T 1 Overview
39
Leading, Managing, and Following Shari Kist
LEARNING OUTCOMES
• Describe the evolution of the theoretical basis for leadership and management. • Evaluate leadership and management theories for appropriateness in health care today. • Apply concepts of complexity science to healthcare delivery and the evolution of nursing. • Compare and contrast the actions associated with leading, managing, and following.
KEY TERMS advanced practice registered nurse (APRN) clinical process complexity science emotional intelligence followership leadership
40
leadership theory managing management theory motivation process of care quadruple aim social networking values vision
T h e C h a l l e n g e JoAnn Franklin, DNP, RN, GNP-BC, FNP-BC, MHNP, FAANP Missouri Quality Initiative (MOQI), University of Missouri-Columbia, Columbia, MO APRN at National Health Care Desloge, Desloge, MO
Angelita Pritchett, MSW, LMSW MOQI Care Transitions Coach, University of Missouri-Columbia, Columbia, MO
The acuity of residents in long-term care [LTC] facilities has increased over time. Today’s nursing home residents are similar to hospitalized medical-surgical patients of the past. However, the processes of care in these facilities have not changed to meet the demand. The minimum requirement for physician visits is a 10- to 30-minute visit every other month. A change in the resident’s condition generally results in either an emergency department visit or hospitalization— thus the mantra, “when in doubt, send them out.” However, hospitalization puts an older person at risk for further decline unrelated to the primary admission diagnoses.
At a particular LTC facility, no systems were in place to prevent transfers. It was not uncommon for multiple residents to be sent to the hospital every week. The solution to any symptom was to add more medications to the resident’s drug regimen, often resulting in polypharmacy. Clinical skills of nursing staff were limited, and management was accustomed to “putting out fires” as opposed to being proactive in having preventive care/conversations with residents and their families. Communication among staff was limited and no active staff education program, beyond new employee education and mandatory in-service classes, was in place. Those in management positions did not make rounds on the nursing units. Additionally, residents and their family members were not having open, honest conversations about the residents’ goals for care. In many instances, transfers occurred because goals of care, particularly for end-of-life care, had not been addressed.
What would you do if you were this nurse?
41
Introduction The nursing profession constitutes the backbone of the healthcare system, both in numbers and in span of influence. All too often nurses, especially new graduates, desire to focus on direct patient care, with limited attention to the the healthcare spectrum. However, our complex work environments should stimulate us to look more broadly at the systems affecting how we practice. The skills of leading, managing, and following can be used whether the nurse is providing direct patient care or collaborating with stakeholders of a large healthcare system.
Beyond the expectation to lead, manage, and follow, nurses are also expected to help fulfill health care’s quadruple aim. Initially known as the triple aim by the Institute for Healthcare Improvement (IHI), the quadruple aim relates to improving access to care, quality of care, cost of care, and work life of the healthcare team (Bodenheimer & Sinsky, 2014) (Fig. 1.1). Nurses who practice in expanded roles, such as advanced practice registered nurses, help improve healthcare access beyond traditional hospitals and ambulatory centers.
FIG. 1.1 Quadruple aim.
Nurses must be vigilant in delivering care that is scientific, state of the art, and sensitive to patients’ needs, collectively creating an accessible and cost-effective experience that leaves care
42
providers satisfied with their contributions. Patients want their values and beliefs respected as they partner with the care team. Patients also demand a safe clinical experience, free from medical error and catastrophic events, up to and including death.
Access to care and cost of care must be considered by patients, providers, and payers. Technology, institutional care, supplies, and human resource requirements carry a staggering cost burden. How to provide quality care at a reasonable cost is an ongoing discussion at many levels, ranging from the family dinner table to board rooms and Congress.
Providing access to quality, reasonably priced care creates a new level of stress for all members of the healthcare team. Healthcare team members must learn to identify professional burnout and implement strategies that will achieve work–life balance. The expectations of the quadruple aim require that all members of the team function at the highest level possible both as a team member and as an individual. As a discipline, we are called upon to develop expanded roles congruent with societal needs; we influence policy development, and we design and carry out clinical processes to provide safe and high-quality patient- and family-centered experiences in a wide range of settings.
The practice of nursing can be both physically and emotionally demanding. Consistent with the quadruple aim, nurses should actively care for their own physical and emotional well-being and lead initiatives that promote health. Self-care actions for balanced lives with early recognition of burnout can lead to a healthier personal and professional life.
This chapter starts to frame your professional journey, and the chapters that follow add to your professional formation. In this chapter and in subsequent chapters, various perspectives on the concepts of leading (leadership), managing (management), and following (followership) are presented. Leading, managing, and following are not institutionally role-bound concepts—the nurse must lead, manage, and follow within any nursing role, from direct care nurse to chief executive nurse, and do so with fluidity among those roles. In the end, nurses with leadership, management, and followership abilities will make better clinical decisions, consider the organizational and societal context of decisions, act as advocates for individuals receiving care, and influence the impact of these decisions on families, the organization, and the society.
43
Theory development in leading, managing, and following Theory has several important functions for the nursing profession. First, theory can be used to guide how the nurse approaches a particular situation. Second, theory can be used to frame a research question and guide a research study. Third, theory directs and sharpens the ability to predict or guide clinical and organizational problem solving and outcomes. Because nursing is a practice discipline, it is possible to focus more effort on the doing rather than the theoretical perspective. However, having a theory-based approach can enhance performance and strengthen the value of the theory.
The theoretical basis for understanding leading, managing, and following originates from multiple disciplines. Early researchers in organizational science noted the differences in the ways some organizations operated. The focus was on traits of individual leaders rather than characteristics or functioning of the organization. Studies of individual leaders resulted in awareness that some individuals possessed traits that seemed to produce better organizational outcomes. Trait theory, developed from these studies, is still examined as a leadership factor today, even though it holds less influence than some other theories.
Closely tied to this appreciation of traits as one leadership ingredient were observations that a leader could be successful in one environment yet not necessarily in another. The situation at hand and the work environment itself were variables that mattered. Activities being performed were yet another variable that was studied. When the setting required reproducible and repetitive tasks, a charismatic leader may be less effective than in an unpredictable or unstructured situation where the tasks required on-the-spot innovation. Study of these variables advanced knowledge about leading, managing, and following and promoted the development of other theories. These include situational/contingency theory, which examines variables in the external and internal environment, including the nature of the work itself, worker behaviors (individual or group), the predictability or unpredictability of work, and the risk associated with work. Management theories, which address planning, organizing, directing, and controlling aspects of work design, were also included and sometimes were cited as leadership theories. These theories, originating from the mid-1950s, are still relevant today. They continue to evolve and often are combined with other theories to guide professionals into evidence-based organizational practices.
Terms such as leadership theory, transformational leadership, servant leadership, authentic leadership management theory, motivational theory, and even attempts at followership theories are interrelated and cannot be categorized in a mutually exclusive manner. The theories that leaders, managers, and followers use are drawn from yet another set of theories, some of which are addressed later in this book and include change, conflict, economic, clinical, individual and group interactions, communication, and social networking. The Theory Box on p. 9 is organized as an overview to highlight sets of theoretical works that are commonly referenced for the purpose of demonstrating the variety, approach, and constant evolution of theory development in organizational studies. The complex factors associated with clinical care and organizational functioning explain why no single theory fully addresses the totality of leading, managing, and following.
Using Complex Adaptive Science to Understand Health Care Today Too often, theories are thought to have evolved from circumstances that do not reflect current practices and are too narrow in scope to be useful. Typically, theory development has been based on assumptions that by reducing something into its component parts, its functioning could be better understood. For example, departments of a healthcare organization, such as laboratory, pharmacy, and dietary, all have leaders and managers. Although they have both responsibility and authority within a department, very often a decision made within the department will have a complex ripple effect on the rest of the organization, and most commonly the nursing department is affected by each of those other departments.
Complexity theory is a nontraditional theory that has emerged over time from the works of physical and social sciences. Complex adaptive science can help us understand health care as it is
44
delivered to patients and families, as well as healthcare systems in general. Complexity science does not refer to the complexity of the decision to be made or to the work environment, but rather to examining how systems adapt and function—where co-creation of ideas and actions unfold in a nonprescriptive manner. Complexity theory can be used by those in leadership and management roles for understanding an organization as well as in planning and executing changes within an organization.
Complexity science promotes the idea that the world is full of patterns that interact and adapt through relationships. These interactive patterns may be missed when one focuses solely on a single part. Complexity scientists pay keen attention to what naturally occurs as patterns in the universe and how these patterns create adaptive change rather than how people create planned or forced change. Stated in nursing terms, nurses care for individual patients who each present a unique challenge. With experience, nurses recognize that patterns of patient behaviors emerge and learn that certain nursing actions lead to effectively managing pain, engaging family members in end-of- life planning discussions, and addressing a host of other issues. Most healthcare team members are very focused on problems and predictable solutions that appear to be linear in nature, which is described as technical work. However, if we look more deeply at both disease processes and health care, we realize that both are an interconnected web of physiologic processes and services. Thus a linear solution may not be feasible, and solutions require adaptations that account for a multitude of factors. The application of complexity science is reflected in the elements of evidence-based nursing practice, which includes patient preferences, along with assessment data, research findings, and clinical expertise. Although much work in health care has focused on acute care organizations, complexity science is applicable in other settings, including long-term care, as illustrated in the Research Perspective.
R e s e a r c h Pe r s p e c t i ve Resource: Colon-Emeric, C., Toles, M., Cary M. P., Batchelor-Murphy, M., Yap, T., Song, Y., Hall, R., Anderson, A., Burd, A., & Anderson, R. A. (2016). Sustaining complex interventions in long- term-care: A qualitative study of direct care staff and managers. Implementation Science, 11, 94.
The aim of this qualitative study was to understand perspectives related to the sustainability of an intervention being tested in a long-term care facility. Complexity science served as the theoretical basis for the intervention portion of the study and thus guided the qualitative study being described here. Fifteen focus groups with 83 participants were conducted. Participants included both managers and direct care staff to get a wide variety of perspectives.
The findings identified that all participants believed the intervention was useful because it would ultimately improve the care of residents. The intervention tested was complex. Some participants, especially those with less education, struggled to grasp the intent and how it could affect their roles in the long-term care facility. Although participants valued the training they received, they expressed concern that sustaining change would be difficult because of staff turnover, lack of leadership support, and lack of culture change.
Implications for Practice By using the lens of complexity science for this study, nurses can begin to appreciate the numerous factors that come into play when planning, implementing, and evaluating a change in a care process. Being able to sustain a change in behaviors requires that those in administrative roles are supportive, while maintaining a level of accountability for all staff.
In complex adaptive leadership, the goal in responding to patient and organizational problems is to examine a problem through multiple lenses. An adaptive leader understands that systems are ecological—they restore themselves—and that change can happen equally from the bottom up or from the top down. Questioning, observing patterns, and generating new patterns through being involved is how change unfolds. Adaptive leaders appreciate that they have influence and can help shape overall outcomes, with no sense that absolute control is either necessary or possible.
In complexity science, information is not a commodity to be controlled by those in charge. Instead, it is intended to be shared with and interpreted by a wide audience, to provide varying interpretations of the same scenario. Diverse thinking leads to creative problem solving in which
45
multiple individuals are actively engaged, using diverse skills to be part of the solution. Relationships and communication are central factors in complex adaptive leadership. Poor team
communication has been directly linked to preventable medical errors, high staff turnover rates, and low morale. On the other hand, team members who communicate effectively with each other and feel that their voices are heard are likely to provide safe high-quality care, be active team members, and stay with the organization for a period of time. In complexity science, every voice counts and every encounter with patients and families merges to co-create a desired outcome. Co- creation, the idea that a change doesn’t belong to one person or group, is critical to moving quality of care and innovation forward.
One of the early references in complexity science and leading and managing identified four concepts:
• Managers must be aware that employees will self-manage themselves into work groups. Rather than exerting control, effective managers stimulate creative problem solving. These groups may start as having a single purpose but may be sustained through achieving positive outcomes.
• Managers must be skillful in providing context. While keeping a clear vision of the objective to be accomplished, employees can be encouraged to explore and develop solutions to complex problems. Concepts of shared governance and adaptive leadership blend well with the overall aim of safe and effective patient care.
• Managers must adapt to the changing environment and use influence where they can have the most impact. Health care is often procedure driven, yet managers must remain cognizant of the communication and relationships necessary to carry out procedures that create positive outcomes.
• Managers must address sources of tension and contradiction. Disagreement and tension may be the result of creative problem solving by the group and are expected when working with diverse groups. Seeking insight and encouraging creativity and communication allow the manager to capitalize on tension for a positive benefit. By addressing this tension, new alliances may be created that contribute to high-quality outcomes (Morgan, 2003).
The ability to do “systems thinking” is a central concept in adaptive leadership because of the broad perspectives needed to understand a situation. The principles of systems thinking theory that we use today were characterized classically by Anderson and Johnson (1997) as:
• Thinking of the “Big Picture”: The nurse who looks past an individual assignment and comprehends the needs of all units of the hospital, or who can focus on the needs of all the residents in a long-term care facility, or who can think through the complications of urban emergency department overcrowding is seeing the big picture. Such nurses have the ability to envision the context of their work beyond the immediate tasks.
• Balancing Short-Term and Long-Term Objectives: The nurse who recognizes the long-term consequences of actions on the organization or patient, such as the decision of a patient to terminate clinical treatment, can guide thinking about how to balance decision making for quality outcomes.
• Recognizing the Dynamic, Complex, and Interdependent Nature of Systems: All things are connected. Patients are connected to families and friends. Together, they are connected to communities and cultures. Communities and cultures make up the fabric of society. The cost of health care is linked to local economies, and local businesses are connected to global industries. Identifying and understanding these relationships helps solve problems with full recognition that small decisions can have a large impact.
• Using Measurable versus Nonmeasurable Data Systems: This thinking triggers a “tendency to ‘see’ only what we measure.” If we focus our measuring on morale, working relationships, and teamwork, we might miss the important signals that only objective statistics can show us. On the other hand, if we consider only numbers (e.g., number of patients seen), we might miss a perspective such as lack of engagement in the workplace.
46
E x e r c i s e 1 . 1 Identify a clinical scenario in which a complex problem needs to be addressed. For example, consider how nurses can ensure that drug levels are drawn before and after a medication or how nurses ensure that equipment shared among patients is adequately cleaned and maintained. Who would you include in a team to engage in creative problem solving? How would you go about linking to other key stakeholders if the problem were “bigger than” your immediate contacts? Concentrate on the power of these influencing individuals. What role would the patient and family and community play in co-creating the resolution strategies? How would you encourage nonhierarchical interaction among nurses, patients, families, and others involved in this situation?
47
Leading, managing, and following—different but related Each of these terms—leading, managing, and following—represents a distinct aspect of a nurse’s role. Yet the fluidity of a situation may require a change in roles, such as the quietest follower moving into a leadership role when that person’s talents are best suited to the situation. Nurses need to appreciate the complexity of the work situation and be prepared to assume different roles and to do so in a fluid manner rather than in only a defined time, role, or situation.
Leading Leadership can be defined as the use of individual traits and abilities in relationship with others and the ability (often rapidly) to interpret the environment/context where a situation is emerging and enter that situation without the use of a predesigned plan. Leadership is required when the unknown presents itself, necessitating the use of principles to improvise solutions and help others cope, thrive, and function in the situation. Concepts related to leadership are present in nearly all professional disciplines; they are not distinct to nursing and health care. In fact, many of the concepts discussed here originated with other professions and have been adapted for the healthcare environment.
Key traits that leaders possess include (1) articulating a vision for the desired future state; (2) seeing possibilities in the midst of challenging, complex, uncharted, or even dire circumstances; (3) communicating effectively, sometimes powerfully, with others; (4) adapting to new situations and environments; and (5) using experience and knowledge to judge reasonable risks.
Nurses face the unknown every day. New diseases emerge. Natural disasters, such as hurricanes and tornadoes, create havoc, which leaves many people in need of immediate health care. Clinical procedures have to be adapted to a patient’s physical and emotional challenges. Each of these requires stepping into the unknown, using principles, showing a commanding presence, and taking risks. Interprofessional educational experiences focus on understanding and communicating with other members of the healthcare team and provide opportunities for the development of leadership skills that can be readily applied in the clinical setting.
Gardner (1990) described tasks of leadership in his seminal book, On Leadership. These are still applicable today.
Gardner’s Tasks of Leadership Gardner’s leadership tasks are presented in Table 1.1 to demonstrate that leading, managing, and following are relevant for nurses who hold clinical positions, formal management positions, and executive leadership positions. Note that each role represents the interests of the organization, although the focus of attention is different.
Table 1.1
Gardner’s Tasks of Leading/Managing Applied to Practice, Management, and Executive Positions
48
Envisioning Goals Leading requires envisioning goals in partnership with others. At the point of care, leading helps patients envision their life journey when health outcomes are unknown. It might help a patient envision walking again, participating in family events, or changing a lifestyle pattern. In the case of leading peers, the leader envisions an aim while keeping it within the broad purpose of the organization. An effective leader strives to engage those within the organization to embrace a shared vision of a high-performing unit and the process to reach that goal.
Affirming Values Values are the connecting thoughts and inner driving forces that give purpose, direction, and precedence to life priorities. An organization, through its members, shares collective values that are expressed through its mission, philosophy, and practices. Leaders influence priority setting and decision making as a means to express organizational values. Other individuals also use their values to achieve their goals, which are then manifested through behavior.
The word value connotes something of worth; intentional actions reflect our values. A leader continuously clarifies and acknowledges the values that draw attention to a problem and develops the resources in human and material terms to solve the problem. Values are powerful forces that promote acceptance of change and drive achievement toward a goal.
Motivating When values drive our actions, they become a source of motivation. Motivation energizes what we value, personally and professionally, and stimulates growth and movement toward the vision. One task of leadership is communicating organizational values and vision to enhance motivation. Motivators are the reinforcers that keep positive actions alive and sustained, fueling the desire to
49
engage in change. Theories of motivation identify and describe the forces that motivate people. Examples of motivation theory are presented in the Theory Box.
Managing The ability to manage is an important aspect of organizational functioning, because management requires determining routines and practices that offer structure and stability to others. This is especially true in certain positions of influence within a clinical setting, such as a nurse manager, clinical nurse specialist, or clinical nurse leader, all of whom share responsibility for creating effective structures that support clinical and organizational outcomes. Being effective as a manager requires behaviors different from those associated with effective leadership, and vice versa. Ideally, those charged with managing are also good leaders and followers, because no organizational position is limited to one exclusive set of behaviors over another. Leaders, managers, and followers who are effective use all three roles to accomplish their goals.
Achieving Workable Unity Another challenging leadership task is to achieve workable unity between and among the parties being affected by change and to avoid, diminish, or resolve conflict so that vision can be achieved (see Chapters 8 and 18). Conflict resolution skills are essential for leaders. When a dispute occurs because of conflicting values or interests, following the principles of communication and conflict resolution can help facilitate a mutually satisfying resolution.
Developing Trust A hallmark task of leadership is to behave with consistency so that others believe in and can count on the leader’s intentions and direction. Trust develops when leaders establish clear goals and objectives with associated employee behaviors. Inherent in this concept is the behavior of truth telling. Although leaders cannot always share all information, it is unwise to misdirect others in their thinking and actions. Trust, according to Lencioni’s (2002) classic work, is the key component of a team. Without trust, the team is dysfunctional. Trustworthiness is reflected in both actions and communications.
Explaining Leading, managing, and following require a willingness to communicate and explain—again and again. Many of the skills related to patient-centered communication are transferrable to those in leadership roles.
T h e o r y B o x Leadership Theories
50
51
The importance of clear and repeated communication cannot be emphasized enough. If instructions are not clear, employees are left to interpret them using their viewpoints. That viewpoint might be consistent with the intended message of the leader, but it may not be. When it is not, both the leader and employee experience frustration, and patient outcomes may be affected. Chapter 8 provides more information on communication. Many organizations offer courses on communicating effectively as a leader; online resources can help hone your explaining and communication skills.
Serving as a Symbol Every leader has the opportunity to be an ambassador for those he or she represents. Nurses may be symbolically present for patients and families, represent their department at an organizational event, or be involved in community public relations events. Serving as a symbol reflects unity and collective identity.
Representing the Group More than being present symbolically, many opportunities exist for leaders to represent the group through active participation. Progressive organizations create opportunities for employees to participate in and foster organizational innovation. Nurses may participate in numerous committees and work groups related to human resources, patient safety, and quality improvement. When nurses offer their “voices” in each of these leadership opportunities, they are representing a group and are thinking beyond personal needs. When decision making is decentralized and layers of management compressed, nurses must demonstrate leadership accountability. A leader treats these newfound opportunities with respect and represents the group’s interests with openness and integrity. Ultimately, leaders must understand the organization’s objectives and contribute to its mission and purpose. As an example, nurses who speak on behalf of a group should represent an organizational perspective rather than a personal one.
Renewing Leaders can generate energy within and among others. A true leader attends to the group’s energy and does not allow it to lose focus. When changes are made based on a shared vision, they can be made with renewed spirit and purpose. Taking time to celebrate individual accomplishments or creating a “Hall of Honor” to post photos, letters, and other forms of positive feedback renews the spirit of workers. As identified in the quadruple aim, self-care and avoiding burnout are central to providing high-quality safe care. Leaders must be proponents of self-care for themselves and those they lead. A balanced diet, adequate sleep and exercise, and other wellness-oriented activities are necessary to maintain the perspective, focus, and energy of an effective leader. Gardner (1990) states, “The consideration leaders must never forget is that the key for renewal is the release of human energy and talent” (p. 136). This requires focused energy and personal well-being. The American Nurses’ Association has acknowledged this idea of renewal and supports self-care
52
through the Healthy Nurse Healthy Nation Grand Challenge centering around five areas: physical activity, nutrition, rest, quality of life, and safety.
Concepts of complexity science and leadership have been combined into what is known as generative leadership. Generative leaders are not satisfied with the status quo; instead they are creative and curious individuals who seek new solutions to old problems (Disch, 2009). Creative solutions evolve from new ways of thinking. Disch (2009) identified three ways to approach developing new solutions: (1) Embrace paradox. Health care is full of paradoxes, that through confronting rather than ignoring a situation, solutions can be developed. (2) Seek ambiguity. By obtaining input from others and accepting that multiple perspectives of any situation exist, leaders can begin to identify broad solutions. (3) Reframe situations. By taking a new perspective on a problem, the solution often becomes more evident.
As you can see, a successful leader must possess the capacity to monitor multiple projects while keeping an eye to the future.
Managing Managing is the ability to plan, direct, control, and evaluate others in situations where the outcomes are known or preestablished, where one or more ways of performing have been agreed on based on evidence, where feedback and communication is shared to improve clinical processes and outcomes, and where sustained relationships advance consistency of purpose. Traits needed for effective managers include (1) the ability to identify recurring problems and design evidence-based routines to create structure and improve work efficiency, (2) persistent and vigilant behavior in self and others, and (3) communication that maintains esprit de corps in the face of repetitive work tasks. In the workplace, management is needed to provide structure, a sense of purpose, and safety.
Bleich’s Tasks of Management The ability to manage is very much aligned with how an organization structures its key systems and processes to deliver service. A care delivery system is composed of multiple processes necessary to achieve effective patient care. Some of the key processes relate to medication procurement, ordering, and administration; patient safety practices; patient education; and discharge planning and care coordination. A process of care specifies the desired sequence of steps to achieve clinical standardization, safety, and outcomes. Effective management depends on knowing, adhering to, and improving processes for efficiency and effectiveness. Each person must respect and act on a prescribed role in a process of care. Data-driven outcome measurements provide feedback on the process. Feedback reports provide a basis for improvement programs, which may include coaching and mentoring employees. Rewards for individual and team effectiveness reinforce desired behaviors. Box 1.1 lists Bleich’s tasks of management that are essential to effective functioning.
Box 1.1
B l e i c h ’ s Ta s k s o f M a n a g e m e n t
1. Identify systems and processes that require responsibility and accountability, and specify who owns the process.
2. Verify minimum and optimum standards/specifications, and identify roles and individuals responsible to adhere to them.
3. Validate the knowledge, skills, and abilities of available staff engaged in the process; capitalize on strengths; and strengthen areas in need of development.
4. Devise and communicate a comprehensive big-picture plan for the division of work, honoring the complexity and variety of assignments made at an individual level.
5. Eliminate barriers/obstacles to work effectiveness. 6. Measure the equity of workload, and use data to support judgments about efficiency and
effectiveness. 7. Offer rewards and recognition to individuals and teams. 8. Recommend ways to improve systems and processes.
53
9. Use a social network to engage others in decision making and for feedback, when appropriate or relevant.
New nurses typically think of management as it relates to either direct patient care or nursing unit management. You may also be involved in project management. Many efforts in health care are complex and develop over time. Because nurses are often the end users in the rollout of new care processes, it is important that they are involved in the planning and implementation as well. An example of a situation where nurses can contribute greatly to overall project success is planning for implementation of a new electronic health record.
E x e r c i s e 1 . 2 Examine one structured process in the delivery of patient care from start to finish (e.g., diagnostic laboratory studies). How is the process organized? Describe what steps are involved. How many steps does the process take? Who is responsible for each step in the process? Who has the responsibility and authority for managing the process? What outcome data are available to determine how well the process is working? Are outcomes reviewed on a regular basis?
The tasks of management are designed to enact Gardner’s tasks of leadership. For example, although the leader may create a culture of trust, the manager offers rewards that reinforce that value. A professional nurse must have abilities to both lead and manage. Nurses are on the front line when dealing with new and unknown health experiences, which require leadership, and implementing care routines, which must be managed.
Following Following is a term that can be misinterpreted. Images associated with followers portray passive, uninspired workers waiting for direction. Although that may be accurate for some organizations, following in a high-functioning team is an active, creative role that influences leaders and managers. A healthy definition of followership is that each group member contributes optimally in tandem with other group members to achieve clinical or organizational outcomes. All team members are expected to fully participate, using their knowledge, skills, and experience to help deal with complex clinical and organizational issues. In essence, maximal functioning as a team member exemplifies followership. When in the following role, teamwork is palpable. Each person acts together with purpose and in a rhythm that addresses the aim at hand.
Nurses may demonstrate followership by serving on committees. Even simple activities such as completing readings and reviewing minutes from previous meetings are essential for an organization’s success. Traits of followers include acting synergistically with others, being enthusiastic and responsible, speaking and acting with principle and integrity, adding value to the work being accomplished, and questioning decisions and directions that are not congruent with the purpose or values of the group. The effective follower is willing to be led, to share time and talents, to create and innovate solutions, to take direction from the manager and to role model confidence and professionalism. Simultaneously, followers must perform their assigned structured duties, which require critical thinking and decision making. Bleich’s tasks associated with followership can be found in Box 1.2.
Box 1.2
B l e i c h ’ s Ta s k s o f F o l l o we r s h i p
1. Demonstrate individual accountability while working within the context of organizational systems and processes; do not alter the process for personal gain or shortcuts.
2. Honor and implement care to the standards and specifications required for safe and acceptable care/service.
54
3. Offer knowledge, skills, and abilities to accomplish the task at hand. 4. Collaborate with leaders and managers; avoid passive-aggressive or nonassertive responses
to work assignment. 5. Include evidence-based feedback as part of daily work activities as a self-guide to efficiency
and effectiveness and to contribute to outcome measurement. 6. Demonstrate accountability to the team effort. 7. Take reasonable risks as an antidote for fearing change or unknown circumstances. 8. Evaluate the efficiency and effectiveness of systems and processes that affect outcomes of
care/service; advocate for well-designed work. 9. Give and receive feedback to others to promote a nurturing and generative culture.
Followers complement leaders and managers with their skills. Together they work to fill gaps and to build on each other’s cognitive, technical, interpersonal, and emotional capabilities. Followers, showing sensitivity to other roles, may offer respite in times of stress. Followers need feedback from others to stay on course. The follower may acquiesce to the skills and abilities of the leader or manager to promote teamwork but is prepared to lead or manage when circumstances demand it.
Leading, Managing, and Following in Action The relationship between and among followers and leaders and managers is complex. In any given work shift, a nurse may assume all three roles. At the beginning of the shift the nurse may function as a manager to ensure that patient care assignments are distributed, report received, and adequate supplies are ordered. Later, the nurse may lead by inspiring a colleague to discuss end-of-life care with a particularly anxious family. During a facility-wide committee meeting, the nurse may show followership as the group plans to implement a new fall risk assessment.
During a shift, critical clinical events (e.g., cardiac arrest) arise that require a temporary adjustment to maximize the talents and skills of team members. Those team members who are able to nimbly respond to changing situations and roles with little or no fanfare have what is often referred to as emotional intelligence.
E x e r c i s e 1 . 3 Using the definitions for leading, managing, and following noted previously, observe how work is organized on a clinical unit. What situations occurred that could not be predicted at the onset of the shift? What work followed a routine nature or was driven by protocol? Identify an activity that was driven by principles rather than by formal evidence. Identify an activity that was driven by evidence-based practice or evidence-based organizational practice. Then, notice team functioning. Who led? Who managed? Who followed? Did this happen seamlessly, or were there times when there was tension in efforts?
Emotional Intelligence to Lead, Manage, and Follow Emotional intelligence is necessary to carry out the expectations of leading, managing, and following. In his classic work, Goleman (2000) refers to emotional intelligence as being characterized by self-awareness, self-regulation, empathy, and social skills that help people harmonize to increase their value in the workplace. Self-awareness and self-regulation are personal skills, whereas empathy and social skills are abilities to manage relationships (Hemens, 2014). These characteristics are essential for direct care nurses as well as those in designated leadership positions (Fig. 1.2). Emotionally intelligent leaders are a common topic of research studies in today’s healthcare environment and are critical as our profession adapts to constant change. Delmatoff and Lazarus (2014) described an emotionally and behaviorally intelligent style of leadership. This means that the leader not only possesses emotional intelligence but behaves in an emotionally intelligent manner. Although that may seem obvious, leaders sometimes do not demonstrate emotional intelligence. This is particularly true with those new to leading and managing. A new manager may identify with a leader who does not demonstrate emotional intelligence, so the new manager begins
55
to adopt similar ineffective behaviors. In this instance the new nurse manager fails to demonstrate the very characteristics that likely led to earning the management position.
FIG. 1.2 Being empathetic and showing sensitivity to the experiences of others helps nurse leaders develop their emotional intelligence. (© Thinkstock images/iStock/Thinkstock)
Emotionally intelligent nurses are credible as leaders, managers, and followers because they possess awareness of the individual, family, or community that is the locus of caregiving, have enhanced organizational skills because they have invested in relationships, and are able to collaborate, show insight into others, and commit to self-growth. When coupled with performing clinical
56
L i t e r a t u r e Pe r s p e c t i ve Resource: Bisognano, M. (2016). Nursing leadership: New ways to see, Nurse Leader, 14(6), 422-426.
The author describes five “lessons” that have occurred in health care over time. The first is new ways to see health care as a system. Hiring the right staff is more than intelligence and competence. It also includes having emotional fortitude and curious spirit. The curious spirit can lead to seeking out the perspective of the patient. Narratives of less than optimal patient experiences provide many opportunities to see, solve, and share in a realtime manner rather than lengthy procedure changes. The second is new ways to see the patient and their support systems. The “What Matters to You” campaign to better identify patient wishes is the epitome of patient-centered care. The third lesson addresses how patients move both within and among healthcare organizations and providers. Testing new models of care within healthcare facilities and homes is central to decreasing the stress and strain of navigating the healthcare system. The fourth lesson is looking at new ways to see and build teams. Currently, it is possible to have five distinct generations, each with their own values, working together. Thus it is essential that employees understand the diverse values and beliefs present in today’s workforce. The last lesson is applying new ways to lead. Making decisions based on real-time data allows organizations to nimbly respond to trends. Exnovation is defined as ridding the systems of unnecessary processes, meetings, reports, and other duties that take away from the priorities of patient care. The purpose is to develop more efficient and effective clinical care processes.
Implications for Practice These five lessons provide opportunity for self-reflection on how you can fit into this ever- changing healthcare system.
tasks tied to critical thinking and action, the emotionally intelligent nurse demonstrates the capacity to be a high-performing professional. Employees are tuned in to the emotional intelligence of managers and leaders. The synergy associated with a leader’s credibility and capability fuse for success. Without self-reflective skills, growth in emotional intelligence is stymied, work becomes routine, and asynchrony with others results. The Literature Perspective illustrates the importance of emotional intelligence.
E x e r c i s e 1 . 4 Reflect on the worldview of how family, friends, and others see you. Think about the historical markers that influenced your life perspective. Think about your religious or other belief systems. Review the extent to which others with diverse ideas and beliefs were a part of your life experience. As you journal these thoughts, how do they affect your emotional intelligence? What role can a mentor and continuing education play in advancing your life perspective? Which of the characteristics of emotional intelligence is the most developed and which is the least developed? How might you further enhance your emotional intelligence?
57
Traditional and emerging leadership and management roles The way nurses lead, manage, and follow has changed over time. Formerly, nurses took direction exclusively from physicians or senior nurses such as “head” or “charge” nurses. These formal roles still exist in some places; however, the expectation has shifted from a top-down, order-giving model to one in which shared decision making with collaborative action is the norm. As knowledge expands and the array of treatment interventions available to patients has grown, care delivery has moved far beyond what a command-and-control top-down structure can accommodate in a traditional hierarchical organization. Health care is now delivered in a collaborative and interprofessional manner, such as that reflected in the movement toward primary care or medical homes. In this model of care, providers strive for comprehensive, patient-centered, coordinated, high-quality care (Flieger, 2017). This holistic approach to care delivery requires holistic leadership, emphasizing effective communication and outcomes.
Health care today is an amalgamation of both traditional and dynamic structures. New theories of leadership will emerge to capture the complexity and globalization of health care and changing communication patterns through the influence of the Internet and social media. Professional nurses must be prepared to practice within a system that is both predictable and unpredictable.
Concepts of teamwork and collaborative decision making are critical in a healthcare environment that is dynamic and ever changing. A nurse has great potential to shape those changes. We do not have to have “titles” to be leaders; we just have to be living human beings willing to execute our potentials. In other words, the synchrony of leading, managing, and following is within each of us.
The collective behaviors that reflect leading, managing, and following enhance each other. All interdisciplinary healthcare providers, including professional nurses, experience situations each day in which they must lead, manage, and follow. Some institutional formal positions, such as nurse manager or charge nurse, require an advanced set of attributes and know-how to establish organizational goals and objectives, oversee human resources, provide staff with performance feedback, facilitate change, and manage conflict to meet patient care and organizational requirements.
58
Leading, managing, and following in a diverse organization The healthcare industry is going through unparalleled change from the traditional industrial models of the previous century. The culture in most healthcare organizations today is more ethnically diverse; has an expansive educational chasm (from non–high school graduates to doctorally prepared clinicians); has multiple generations of workers with varying values and expectations of the workplace; involves extensive use of technology to support all aspects of the organization; and challenges workers, patients, families, and communities with antibiotic-resistant microorganisms and emerging diseases.
The complexity of the healthcare system is marred with chronic problems, information imbalance (sometimes too much, sometimes not enough), physically and emotionally intense work with little time for reflection, increased consumer and regulatory demands, and fatigue from too many cues and reminders! Upcoming changes may exacerbate these problems.
These and other variables make leading, managing, and following increasingly challenging. A leader must address the needs of the diverse community. Language variations, cultural barriers, and overused electronic communication create opportunities for misunderstanding that could contribute to errors. Followers and leaders of different generations and values can educate each other on the best ways to communicate.
The outlook for health care is not all doom and gloom. Our understanding of human behavior allows those in administrative positions to understand characteristics of the workforce better than ever before. As a result, workforce development can be tailored. Although both a gift and a curse, options for technology allow for even greater exchange of information among healthcare team members, patients, and families. Box 1.3 identifies attributes of leaders, managers, and followers, including commonalities. These attributes represent hope for the future.
Box 1.3
D e s i r e d At t r i b u t e s o f L e a d e r s , M a n a g e r s , a n d F o l l o we r s
• Use focused energy and stamina to accomplish a vision. • Use critical-thinking skills in decision making. • Trust personal intuition and then back up intuition with facts. • Accept responsibility willingly and follow up on the consequences of actions taken. • Identify the needs of others. • Deal with people skillfully: coach, communicate, counsel. • Demonstrate ease in standard/boundary setting. • Examine multiple options to accomplish the objective at hand flexibly. • Be trustworthy and handle information from various sources with respect for the source. • Motivate others assertively toward the objective at hand. • Demonstrate competence or be capable of rapid learning in the arena in which change is
desired.
The importance of teamwork and collaboration is well understood in the healthcare industry. Collaboration requires a set of special conditions between leaders and followers. Among these conditions are the ideas that each voice will be valued in an equitable manner, that power is evenly distributed among the stakeholders, and that conditions allow for innovation.
59
60
Conclusion Developing skills and abilities for leading, managing, and following encourages professional nurses to adapt to and accept differences as a positive rather than a negative force in daily work life. Building on gender strengths; generational values, gifts, and talents; cultural diversity; varying educational and experiential perspectives; and a mobile and flexible workforce is rewarding for a leader. It is also rewarding to experience the strength of a good manager and to achieve positive outcomes as a follower and team member.
T h e S o l u t i o n JoAnn Franklin; Angelita Pritchett
Complexity science served as the basis for addressing concerns in this LTC setting. A full-time advanced practice registered nurse (APRN) was employed in each nursing home to work with nursing staff about the importance of recognizing a change in condition, completing an assessment, and obtaining treatment in the nursing home, rather than transferring to the hospital. Through early illness recognition, the resident could be treated in a proactive manner at the LTC facility, rather than waiting until a significant physical decline occurred that warranted a transfer to the hospital.
Embedding a full-time APRN in the facility resulted in positive outcomes for the residents. The APRN developed relationships with nearly all nursing home staff, no matter their role, and served as an expert clinician and resource. In addition, she volunteered to be on call 24/7 and provided phone support during nonworking hours. The nursing home was primarily staffed with licensed practical nurses and certified nurse assistants, as is typical of most nursing homes. Education was central to enhancing the clinical skills and decision making of the nursing staff. Both formal and roving ongoing education was provided as new staff members were hired and new clinical challenges arose. Role modeling by the APRN enhanced clinical reasoning skills when a resident exhibited a condition change.
Another key feature in the intervention was the use of the Interventions to Reduce Acute Care Transfers (INTERACT) tools. These standardized tools are designed to improve recognition and communication about changes in resident condition. The two main tools used were (1) Stop and Watch and (2) Situation, Background, Assessment, and Recommendation, or SBAR. (Note: The acronym SBAR is slightly different in the INTERACT model.) The Stop and Watch tool is used to report a subtle change in condition. Any person, including those from dietary, housekeeping, and family members, could fill out a Stop and Watch to alert the nurse of a subtle change in resident condition. This allowed those with the most frequent resident interaction to have a means of communicating what might seem a “bit off” or “different” in a resident. The SBAR tool provided a means for documentation of condition change, as well as guiding critical thinking about a change in status. Nurses completed the SBAR before contacting a provider. Staff reported feeling more confident and empowered in their job performance.
Management of polypharmacy and reduction of antipsychotic medication was led by the APRN in collaboration with staff physicians. Comprehensive, thoughtful medication reviews were conducted on all residents. The original rate of antipsychotic usage of 30.8% was reduced to 3.3%, all of which were for residents with a diagnosis of bipolar disorder. No antipsychotics have been prescribed for residents with only a psychiatric diagnosis of dementia for more than 3 years. Communication regarding medication management as well as condition change has been enhanced through the use of secure, encrypted electronic communication channels.
Site staff have also been active in the education and implementation of advance directives in the facility as well as in the community. Annually, the center hosts advance directive clinics where staff, residents, families, and community members can fill out an advance directive free of charge. Facility representatives also travel to senior centers within the county to provide education and opportunities to enact an advance directive.
Consistent with complexity science, there was no one “magic bullet” that led to the success of the MOQI project at this site. It took a large degree of commitment from staff and providers to be open
61
to a new way of thinking and caring for residents. Care processes and communication channels changed. Monthly quality assurance meetings give actual data demonstrating quality outcomes, which have continued to improve. The change did not occur overnight. It was a gradual change that was nudged and at times pushed by the APRN and the leadership in the home.
Would this be a suitable approach for you? Why?
62
Reflections Ponder the leadership theories presented here. Does one seem to make more sense to you than another? Consider, for example, what you were doing the last time you were in the clinical area. Does one theory suggest that you were using it as you enacted your role? Identify one way you can incorporate a leadership theoretical perspective into a daily clinical routine.
63
The evidence What makes a good leader or a good follower? The roles of leader, manager, and follower are different, and each is needed in a successful organization. In fact, the same individual often plays each of the roles in a successful organization. Studies of identity dynamics help explain who wants to lead and who wants to follow and how individuals enact and develop those roles.
Although much of the prior research on leadership considers the perspective of how others see the leader or follower, it is also important to consider how the individuals in those roles see themselves. A multilevel view of identity development includes reflection on intrapersonal, interpersonal, and group identity. Engaging in reflection and identity work can help more fully develop our roles as leaders and followers (Epitropaki, Kark, Mainemelis, & Lord, 2017). Collaboration requires a set of special conditions between leaders and followers. Among these conditions is the idea that each voice will be valued in an equitable manner, that power is evenly distributed among all of the stakeholders, and that conditions exist for innovation to occur.
Organizations often function with effective leaders and managers who preside over work groups with common, short-term goals. When true teamwork is required the work is longer to allow for team relationships to build.
Complexity science does not refer to the complexity of the decision to be made or to the work environment, but rather to examining how systems adapt and function—where co-creation of ideas and actions unfold in a nonprescriptive manner. Social networking is being recognized as a web of relationships that can be tapped and used for communication, problem solving, support, and real- time information, critical to decision making. It is a real tool for individuals to use when leading, managing, or following.
64
Tips for leading, managing, and following • Use theories of leadership and management to frame complex problems and guide decision
making. • Understand the situation to be more effective as a manager. • Acknowledge that situations not well understood are best approached using leadership
tasks. • Lead, manage, and follow as warranted in any role at appropriate times.
65
References Anderson V., Johnson L. Systems thinking basics: From concepts to causal loops.
Waltham, MA: Pegasus Communications; 1997. Bass B.M. From transactional to transformational leadership: Learning to share the
vision. Organizational Dynamics. 1990;18:19–31. Bennis W.G., Nanus B. Leaders: The strategies for taking charge. 2nd ed. New York:
Harper Business; 2007. Blake R.R., Mouton J.S. The managerial grid III. Houston: Gulf Publishing; 1985. Bodenheimer T., Sinsky C. From triple aim to quadruple aim: Care of the patient
requires care of the provider. Annals of Family Medicine. 2014;12(6):573–576. Delmatoff J., Lazarus I.R. The most effective leadership style for the new landscape
of healthcare. Journal of Healthcare Management. 2014;59(4):245–249. Disch J. Generative leadership. Creative Nursing. 2009;15(4):172–177. Epitropaki O., Kark R., Mainemelis C., Lord R.C. Leadership and followership
identity processes: A multilevel review. The Leadership Quarterly. 2017;28(1):104–129.
Fiedler F.A. A theory of leadership effectiveness. New York: McGraw-Hill; 1967. Flieger S.P. Implementing the patient-centered medical home in complex adaptive
systems: Becoming a relationship-centered patient-centered medical home. Health Care Management Review. 2017;42(2):112–121.
Gardner J.W. On leadership. New York: Free Press; 1990. Goleman D.P. Working with emotional intelligence. New York: Bantam Books;
2000. Hemens M.J. Emotional intelligence: The sine qua non for effective leadership.
Canadian Journal of Medical Laboratory Science, Winter. 2014;2014:14–15. Herzberg F. One more time: How do you motivate employees?. In: Ward M.J., Price
S.A., eds. Issues in nursing administration: Selected readings. St. Louis: Mosby; 1991.
House R.J., Mitchell T.R. Path-goal theory of leadership. Journal of Contemporary Business. 1974, Autumn;3:81–97.
Lencioni P.M. The five dysfunctions of a team: A leadership fable. San Francisco: Jossey-Bass; 2002.
Likert R. New patterns of management. New York: Garland; 1987. Luthans F. Organizational behavior. 12th ed. Burr Ridge, IL: McGraw-Hill; 2011. Maslow A. A theory of human motivation. Psychological Review. 1943;50:370–396. Morgan G. Applying complexity science to health and healthcare. Carlson School of
Management: University of Minnesota; 2003. http://c.ymcdn.com/sites/www.plexusinstitute.org/resource/collection/6528ED29- 9907-4BC7-8D00- 8DC907679FED/11261_Plexus_Summit_report_Health_Healthcare.pdf.
Shartle C.L. Executive performance and leadership. Englewood Cliffs, NJ: Prentice Hall; 1956.
Stogdill R.M. Personal factors associated with leadership: A survey of the literature. Journal of Psychology. 1948;25:35–71.
Stogdill R.M. Manual for the leader behavior description questionnaire, form XII. Columbus: The Ohio State University, Bureau of Business Research; 1963.
Tichy N.M., Devanna M.A. The transformational leader. New York: John Wiley & Sons; 1997.
Vroom V.H. Work and motivation. New York: John Wiley & Sons; 1994. Vroom V.H., Yetton P. Leadership and decision-making. Pittsburgh, PA: University
66
of Pittsburgh Press; 1973.
67
Clinical Safety: The Core of Leading, Managing, and Following Patricia S. Yoder-Wise
LEARNING OUTCOMES
• Differentiate the key organizations leading patient safety movements in the United States. • Value the need for leaders, managers, and followers to focus on clinical safety. • Apply the concepts of today’s expectations for how clinical safety is implemented.
KEY TERMS Agency for Healthcare Research and Quality (AHRQ) Choosing Wisely Det Norske Veritas (DNV) Institute for Healthcare Improvement (IHI) Magnet Recognition Program®
68
National Academy of Medicine (NAM) (formerly the Institute of Medicine [IOM]) National Integrated Accreditation for Healthcare Organizations (NIAHO) National Quality Forum (NQF) Quality and Safety Education for Nurses (QSEN) TeamSTEPPS (an AHRQ strategy to promote patient safety) The Joint Commission (TJC)
T h e c h a l l e n g e Katheren Koehn, RN, MA Executive Director, ANA-Minnesota
Several years ago, embracing the need to move to evidence-based practice, the nursing department of the hospital I was working in selected a model that we would use. The selection process was admirable, using our collaborative governance structure to make the decision. Several models were presented to the Nursing Practice Council, which was made up of primarily direct-care nurses from each unit of the tertiary care hospital. Pros and cons were weighed, and a decision was made. Voila, our practice was now going to be evidence-based!
Moving from model selection to becoming truly evidence-based was much more challenging for the nurses. Changing practice habits and beliefs requires a lot of education and communication. Nurses on each unit practiced differently from each other, and units had customs of practice that differed from other units. Orthopedic spine nurses had practices far different from the neurosurgical spine nurses. However, some nurses on each unit questioned whether we were doing the right thing at the right time. When were practice variations acceptable and when did those variations have the potential of doing harm?
The Nursing Practice Council decided to create a formalized practice of inquiry, the Clinical Question Process. All nurses from all units were invited to submit questions about practice that were of concern to them. Forms were created for the nurses to use for submission of their question. All of the questions would be researched by one of the two clinical nurse specialists on the Council. That person would report her findings at Council meetings, then practice would be clarified and changed, reflecting the most current evidence.
Nurses fairly quickly responded to the request for question submission, creating a list of more than 50 questions. The clinical nurse specialist (CNS) was overwhelmed with how to fit this new investigatory work into her already busy work schedule. She reported out at each Council meeting, but her reports did not result in policy change, because Council members continued to ask for more detail. The CNS became frustrated and the Council became bored. The list of clinical questions continued to grow, with many questions overlapping each other in theme and content. The entire functioning of what had been a vibrant Clinical Council was unraveling.
What would you do if you were this nurse?
69
Introduction This book focuses on the concepts of leading and managing effectively. The question is, however, leading for what? No issue is more prominent in the literature or in healthcare organizations than the concern for patient safety and for employee safety, and that is at the core of leading and managing in nursing. Many factors and individuals have influenced the nursing profession’s and the public’s concern about safety, starting with Florence Nightingale’s work in the Crimean War. In the United States, the seminal work, To Err is Human: Building a Safer Health System (2000), produced by the Institute of Medicine (IOM) (now known as the National Academy of Medicine [NAM]), shaped much of our thinking about patient safety. This focus fits well with the basic patient advocacy role that nurses have supported over decades. This role has evolved over 175 years, as reflected in a review article in the American Journal of Nursing (Kowalski & Anthony, 2017). This is a history befitting nursing, the most trusted profession.
Although less attention has focused on the clinical environment itself, it too has great importance in patient—and provider—safety.
Because the core of concern in any healthcare organization is safety, it also is the core concern for nurses. Safety, and subsequently quality, should drive such aspects of leading and managing as staffing and budgeting decisions, personnel policies and change, information technology, delegation decisions, workplace environment, and personal practices. Another reason to be concerned with preventing patient safety concerns is that at least one study showed that both physicians and nurses who were involved in a patient safety event were more likely to have multiple negative outcomes. Greater risk for burnout, turnover, and “problematic medication use” were three such outcomes (Van Gerven et al., 2016).
Three major driving forces provide the greatest emphasis on quality: the IOM (now NAM), the Agency for Healthcare Research and Quality (AHRQ), and the National Quality Forum (NQF). Many other groups incorporate specific standards and expectations about safety and quality into their respective work. Additionally, specifically focused efforts, such as those of the Quality and Safety Education for Nurses (QSEN) and TeamSTEPPS initiatives, have addressed patient safety issues. No nurse can function today without a focus on patient safety, nor can any nurse leader or manager.
70
The classic reports and emerging supports Several reports are reflective of the efforts to refocus health care to quality, as illustrated in Table 2.1. These reports and the related supporting work form the basis for the continued efforts all healthcare professionals must address to promote safe care.
Table 2.1
Major Forces Influencing Patient Safety
71
72
The Institute of Medicine Reports on Quality This safety-focused work began with the report To Err is Human (IOM, 2000) and rapidly moved to several other reports designed to set aims of health care, to address how professionals were prepared, and to target key areas such as the work environment, mental health and substance use, and medication errors. Crossing the Quality Chasm (IOM, 2001) identified six aims of providing health care, which remain relevant to today’s practice (Box 2.1). Equally relevant to safety issues is how professionals are prepared, and the report “Health Professions Education: A Bridge to Quality” (IOM, 2003) established expected competencies for all health professions (Box 2.2). Basically, the idea of this report was to shrink the chasm between learning and reality. A commitment to this redirection of learning, to approach reality, is critical for “learning organizations,” a term coined by Peter Senge. Thus constant learning is a commitment every healthcare professional and organization must have. Although it is the individual’s accountability to maintain competence and participate in learning, a learning organization values and acknowledges learning as a vital element in being effective.
Box 2.1
T h e A i m s o f P r o v i d i n g H e a l t h C a r e
• Safe • Effective • Patient-centered • Timely • Efficient • Equitable
From Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
Box 2.2
C o m p e t e n c i e s o f H e a l t h P r o f e s s i o n a l s
• Provide patient-centered care. • Work in interdisciplinary teams. • Employ evidence-based practice. • Apply quality improvement. • Utilize informatics.
From Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academy Press.
Many nurses think of “Keeping Patients Safe: Transforming the Work Environment of Nurses”
73
(IOM, 2004) as the major impetus behind many changes designed to improve working conditions for nurses. This report identified lack of trust in organizations, lack of readily available resources (such as clinical leaders), and the presence of unsafe equipment, supplies, and practices as contributions to an unsafe work environment. Regrettably, well over a decade later, many of these issues persist in numerous healthcare settings.
Two other related reports in what is called the Chasm Series also provide guidance to nursing and were focused on specific, pervasive issues: mental health/substance use and medication errors (IOM, 2005, 2006). Both of these reports fit within the IOM’s focus on quality and its attempt to make health care a quality endeavor.
One final report of importance, though it is not focused directly on patient safety, is The Future of Nursing (IOM, 2010). The numerous citations of evidence related to education, scope of practice, and leadership clearly indicate that if the eight recommendations (Box 2.3) were fully implemented, the quality of care, including safety, would be enhanced.
Box 2.3
T h e F u t u r e o f N u r s i n g R e c o m m e n d a t i o n s
1. Remove scope-of-practice barriers. 2. Expand opportunities for nurse to lead and diffuse collaborative improvement efforts. 3. Implement nurse residency programs. 4. Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. 5. Double the number of nurses with a doctorate by 2020. 6. Ensure that nurses engage in lifelong learning. 7. Prepare and enable nurses to lead change to advance health. 8. Build an infrastructure for the collection and analysis of interprofessional healthcare
workforce data.
From Institute of Medicine (IOM). (2010). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press.
Agency for Healthcare Research and Quality The AHRQ is the primary federal agency devoted to improving quality, safety, efficiency, and effectiveness of health care (Agency for Healthcare Research and Quality [AHRQ], 2018). An example of this agency’s work is the detailed curriculum for residents in continuing care retirement communities (CCRCs). This tool is designed to help employees promote healthy practices for CCRC residents.
E x e r c i s e 2 . 1 Go to https://www.ahrq.gov/professionals/education/curriculum-tools/stepmanual/index.html to review the Staying Healthy through Education and Prevention. Note that this site contains an entire curriculum for continuing care retirement communities (CCRCs). Select at least three content areas to determine what healthy older adults should be encouraged to do to stay healthy. After doing that, select one or two local CCRCs and read what they say is available to people who choose to live in those communities. Were you able to determine at least one healthy practice promoted by your local CCRCs?
Most famously, AHRQ’s TeamSTEPPS programs are designed to increase attention to safety within healthcare organizations. More recently, the AHRQ issued a report on evidence-based practices, Making Health Care Safer II (AHRQ, 2016). This work has focused on various aspects of care such as preoperative checklists, bundles to prevent central line–associated bloodstream infections, interventions to reduce urinary catheter care, hand hygiene, “do not use” abbreviations,
74
barrier precautions to prevent healthcare-associated bloodstream infections, interventions to reduce falls, use of rapid response systems, and simulation exercises in patient safety efforts.
E x e r c i s e 2 . 2 Refer to Gardner’s Tasks of Leadership in Chapter 1. Create a 3 × 10 grid. Enter Gardner’s tasks in the left vertical column. Go to the AHRQ website and find the report on Making Health Care Safer II. Select one of the practices and enter one behavior expected of a leader in column two to illustrate each of Gardner’s tasks. Then in the third column, enter one behavior expected of a manager to illustrate each task. Finally, reflect on your latest day in the clinical setting. Did you see evidence of the best practices being employed? What leadership and management behaviors were observable?
The National Quality Forum The National Quality Forum (NQF) is a membership-based organization designed to develop and implement a national strategy for healthcare quality measurement and reporting. Through its consensus process, NQF sets standards and endorses measures, which allow for comparison across settings, states, diagnoses, and so forth. The NQF then advises the Centers for Medicare and Medicaid Services (CMS) about measures that can be used to determine payment. These measures can be altered based on emerging evidence and testing of measures, and they form the basis for comparison of quality. As a result, CMS will not pay for certain conditions that result from what might be termed poor practices or events that should not have occurred while a patient was under the care of a healthcare professional.
E x e r c i s e 2 . 3 The IOM, through its report on The Future of Nursing, advocated for having at least 80% of the registered nurse population prepared at the baccalaureate level. Conduct a brief online search regarding the rationale behind this recommendation. Assume that you work in a facility that does not require all staff to hold a bachelor’s degree and does not provide support (time off, tuition reimbursement, recognition of educational achievement). How could you use the information you found to change workplace policies and practices to benefit patients and nurses who do not hold a baccalaureate degree in nursing?
In 2016, Press Ganey issued a report on workplace safety and its influence on both nursing and patient outcomes. This report included nurse perceptions about both safety itself and the surveillance capacity. The key findings of the analyses performed were lower rates of missed care, higher rates of job enjoyment, higher overall hospital ratings, and fewer hospital-acquired pressure ulcers. These findings make a business case for attention to the work environment (clinical safety being a major focus of that environment). The Literature Perspective indicates the importance of the workplace on overall safety issues. A study in emergency departments supported the idea of absolute numbers being important as well as the skill and experience mix of the staff for staff to perceive that their workplace can provide safe patient care (Wolf, Perhats, Delao, Clark, & Moon, 2016).
L i t e r a t u r e Pe r s p e c t i ve Resource: Press Ganey. (2016). 2016 Nursing Special Report: The role of workplace safety and surveillance capacity in driving nurse and patient outcomes. http://www.pressganey.com/resources/white-papers/the-role-of-workplace-safety-and- surveillance-capacity-in-driving-outcomes.
Press Ganey used an integrated, cross-domain analysis approach to consider workplace safety and surveillance capacity. Those elements were significantly associated with several important factors, such as nurse performance and pay-for-performance outcomes. Workplace safety, an
75
environment in which nurses feel safe (both physically and emotionally), was stronger across outcomes than was nurse surveillance, (the monitoring, evaluating, and acting related to patients’ changes in conditions).
Implications for Practice The fourth component of the Quadruple Aim (http://www.annfammed.org/content/12/6/573.full) was found to have important influence on many factors, including, by extension, reimbursement percentages. Several strategies are recommended for action, including concurrence with the Safe Patient Handling and Mobility Standards (http://www.nursingworld.org/nurses-books/safepatient- handling-and-mobility-interprofessional-national-standards-ac/).
76
Other key agencies and endeavors The Joint Commission (TJC) is a not-for-profit organization that accredits healthcare organizations. It has “deemed” status from the CMS, which means that an organization that meets TJC standards is deemed to have met the standards that the CMS sets.
When TJC changed its focus from process to outcomes, it also emphasized patient safety. As a result, TJC issues, with input, annual patient safety goals that are setting-specific; a list of “do-not- use” terms, symbols, and abbreviations; and sentinel events. All of these efforts are directed toward improving patient safety. In addition, with the NQF, TJC sponsors the Eisenberg Award for patient safety to highlight exemplars of quality.
The Det Norske Veritas (DNV) or National Integrated Accreditation for Healthcare Organizations (NIAHO) is an internationally based organization that provides accreditation in various fields, including health care. The accreditation process is based on a set of international standards known as International Organization for Standardization (ISO). Organizations are surveyed annually and receive extensive reports that can guide work toward higher quality. Because ISO is relevant to many fields, and it is well recognized in Europe and elsewhere, these standards have high acceptability in global work.
The Magnet Recognition Program® is a national designation built on, and evolving through, research. This program is designed to acknowledge nursing excellence. Through the Magnet Model® (www.nursecredentialing.org), organizations must demonstrate how they provide excellence. Five elements comprise the model: transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovation, and improvements; and empirical quality results. From initial designation to redesignation, greater emphasis is placed on empirical quality results. Magnet®, like other organizations mentioned here, focuses on quality care.
The Institute for Healthcare Improvement (IHI), which merged with the National Patient Safety Foundation in May 2017, is dedicated to rapidly improving care through a variety of mechanisms including rapid cycle change projects. (See the Theory Box for the classic view of rapid cycle change.)
Rapid cycle change is evident in today’s intense electronic age. For example, only a few people have the vision and inventiveness that Steve Jobs at Apple did. What makes any product or idea popular is the viral nature with which early adopters grab the product or idea and tell others how valuable this new thing is. As soon as others also adopt the idea or product, it is the new expectation and is already undergoing change so that the “new” idea or product becomes the old one.
Think, for example, how many people worldwide respond when a tragedy occurs. They quickly tweet or
T h e o r y B o x Diffusion Theory
Theory/Contributor Key Idea Application to Practice Rogers (2003) Diffusion is a process of communication about innovation to
share information over time and among a group of people. It allows for nonlinear change. More complex change is less likely to be adopted. Early adopters serve as role models.
Engage key leaders in a change to infuse the energy from early adopters. Using Twitter in the hospital culture to engage employees communicates changes quickly. New changes are altered while they are being adopted because new evidence or a better idea emerges.
post and the community responds, often by expressing greater strength and perseverance than previously shown. On April 15, 2013, the famous Boston Marathon was disrupted by bombs at the finish line. The tweets and postings numbered in the millions, and the community refused to let that event change the view of the importance of Boston, its race, or its theme song, Sweet Caroline.
IHI’s work, Transforming Care at the Bedside (TCAB), has created numerous clinical practice changes for nursing. These small tests of change were designed to be tested quickly so that if failure
77
occurred not many resources nor much time was wasted. Yet the successful ventures spread rapidly to other organizations and became the new practice. The common core of most projects is patient safety. Further, IHI’s Global Trigger Tool is one of the most used ways to determine harm to patients (go to www.ihi.org and search for Trigger Tools).
A project known as Quality and Safety Education for Nurses (QSEN) serves as a repository for resources related to the knowledge, skills, and attitudes that learners need to develop to serve as safe practitioners. Competencies are identified for both prelicensure and graduate students, and numerous resources are available. In the prelicensure competencies, for example, one element relates directly to leading and managing: teamwork and collaboration. An example of what is expected in communication is shown in the box above.
Research focused on communication found that three subcategories related to communication were critical for
Analyze differences in communication style preferences among patients and families, nurses, and other members of the health team. Describe the impact of one’s own communication style on others. Discuss effective strategies for communicating and resolving conflict.
Communicate with team members, adapting one’s own style of communicating to needs of the team and situation. Demonstrate commitment to team goals. Solicit input from other team members to improve individual, as well as team, performance. Initiate actions to resolve conflict.
Value teamwork and the relationships upon which it is based. Value different styles of communication used by patients, families, and healthcare providers. Contribute to resolution of conflict and disagreement.
Source: QSEN Institute (n.d.). QSEN Competencies. http://qsen.org/competencies/prelicensure- ksas/#teamwork_collaboration.
safety: fluent information transfer, an open culture of communication, and being actively engaged in collecting information (Kanerva, Kivinen, & Lammintakanen, 2015). Each of these critical elements can be found in numerous exchanges we engage in throughout any work period.
Choosing Wisely is a multidisciplinary approach to helping patients make wise decisions related to various care conditions. Begun by the American Board of Internal Medicine, the Choosing Wisely lists of practices for clinicians and cautions for patients are created by numerous specialty organizations and professional societies. As an example, the American Academy of Nursing adopted this strategy as a major way to influence patients and their health.
E x e r c i s e 2 . 4 Review the Choosing Wisely website (www.choosingwisely.org) and review back pain tests and treatments. Consider whether the suggestions found at Choosing Wisely reflect your local practices. If not, what are the differences? What ideas do you have about the reason for these differences?
78
Meaning for leading and managing in nursing Many of the approaches to patient safety and, before that, aviation and nuclear energy safety consist of strategies to alert people to safety issues. For example, the use of SBAR (Situation, Background, Assessment, and Recommendation), handoffs, and checklists are designed to decrease omission of important information and practices. These practices aren’t designed to limit a professional’s distinctive contributions. Rather, they are designed to increase the likelihood of safe practice.
We rely on many sources to enhance safety as much as we can, and the combination of electronic risk assessment tools plus nurses’ perceptions would seem to have a good potential for being effective in determining which patients are at risk for harm (Stafos et al., 2017). Although the tools in this study were very useful, they did not assess behavioral or psychosocial issues that could predict whether a patient was at risk. Thus nurses’ substantial judgment continues to play a key role in patient safety.
Numerous issues also relate to clinical safety for nurses. Key issues are shift work, sleep disruptions, musculoskeletal injuries, needlesticks, and product allergies. The American Nurses Association has vast resources related to various safety issues for nurses, including fatigue and shift work, mental health, and bullying. These issues can be addressed through activities such as shared governance and clinical safety committees. Leaders throughout the organization have the obligation to proactively address these issues. Perhaps a place to begin to address safety issues is on a peer basis. Although these types of conversations often are not comfortable, if we have knowledge of someone experiencing a needlestick, appearing sleepy, or engaging in unsafe practices, we each have the opportunity to address, and thus perhaps prevent, a patient safety issue. Lockett et al. (2015) proposed a model, through a research design, that elicited several attributes of an appropriate peer-to-peer accountability approach. These included empowerment to speak up, truth and transparency, reciprocal exchange of information, and respectful communication.
Although the major focus of safety for the people who receive our services has been in hospitals, every other setting where we provide care also has specific concerns related to safety—for both the patient and the nurse. Perhaps the most challenging, however, is the home setting, because most of the issues related to a safe environment are not controlled in the same manner as they are in an institutional setting. As Marrelli (2017) points out, safety issues range from the community and the neighborhood to the individual home environment, and when vulnerable populations, such as children or older adults, are involved, additional precautions come into consideration. If the neighborhood, as an example, is unsafe for clients, it is also unsafe for nurses who enter that neighborhood to provide care.
To think that manager and leader decisions do not affect patient safety is erroneous. Creating a positive environment, ensuring appropriate staffing and equipment, intervening and supporting others in doing so in cases of incivility, and supporting the use of the best evidence in practice all create a safer patient environment. That is, accountability applies to all of us—calling attention to, intervening, or solving threats to clinical safety. Furthermore, with so many organizations focusing on safety (and from multiple perspectives), nurses are challenged to remain clear about what is current and relevant. Conducting a crosswalk, a process of comparison across competencies and standards, may lend clarity (Lyle-Edrosolo & Waxman, 2016). This process is likely too tedious for individuals to perform and is ideally geared for a team within an organization. Additional ideas about a focus on safety are evident in the chapters on change, quality, and translating research into practice.
One of the challenges for nurses in any position, and especially for leaders and managers, is the obligation to have the greatest influence for patient safety. As one cross-sectional study shows, nurse staffing and overtime, which are highly influenced by leaders and managers, are associated with patient safety, the quality of care, and omitted care (Cho et al., 2016) as the Research Perspective shows. The idea of omitted care is further supported as an issue in a study by Jones, Johnstone, and Duke (2016). Basically, the idea of “cutting corners” was studied and found to likely contribute to preventable patient safety issues.
Many frontline nurses are unaware of the work that happens at executive levels on behalf of patient safety. Yet it is equally critical to the organization’s overall success in addressing patient safety issues. Seeing the whole picture related to patient safety enhances our potential to solve
79
problems that can lead to harm for patients, nurses, or both. A study of nurse perceptions versus electronic assessment tool scores supports the expectation for nurses to engage actively in assessing for risks (see the second Research Perspective).
R e s e a r c h Pe r s p e c t i ve Resource: Cho, E., Lee, N.J., Kim, E.Y., Kim, S., Lee, K., Park, K.O., & Sung, Y.H. (2016). Nurse staffing level and overtime associated with patient safety, quality of care and care left undone in hospitals: A cross-sectional study. International Journal of Nursing Studies, 60, 263-271.
This self-report study from South Korea used a common protocol (International Hospital Outcomes Study) in 65 acute care hospitals of 100 beds or more. Fifty-one hospitals and 3037 direct care registered nurses (RNs) participated. Anonymity was maintained by having RNs place responses to questions in a sealed envelope and deposit them into locked boxes. One day was selected to conduct this study, and the response rate was 96.2%. When RNs had a higher number of patients to care for, the odds were higher for reporting poor/failing patient safety, poor/fair quality of care, and care left undone. When RNs worked overtime, the odds in each of those areas also were reported as higher.
Implications for Practice Although the percentages of RNs selecting poor or fail responses were higher in South Korea (16.4%) than in the United States (6%), the outcomes seem to reflect what is experienced in other countries, including the United States. Addressing the numbers of patients cared for and the amount of overtime a nurse is expected to provide are two key components a nurse leader must address.
R e s e a r c h Pe r s p e c t i ve Resource: Stafos, A., Stark, S., Barbay, K., & Schedler, S. (2017). Identifying hospitalized patients at risk for harm: A comparison of nurse perceptions vs. electronic risk assessment tool scores. American Journal of Nursing, 117(4), 26-31.
A nonexperimental correlation study was conducted on three clinical units to compare what nurses perceived of as patients at risk and what electronic tool scores showed. Significant differences were found in the 746 data pairs, which supported the importance of nurses completing risk assessments. The differences were most significant when behavioral or psychosocial factors were involved. These factors were not part of the electronic tools. The findings also involved situations where the tool indicated risk but nurses did not. This was found in cases where the risk had been identified and was already addressed in the plan for care.
Implications for Practice Nurses have a crucial role in keeping patients safe through their careful assessment of patients to determine who might be at risk. Until electronic tools assess with great accuracy the behavioral and psychosocial factors, nurses will be key determinants of keeping patients from harm.
80
Conclusion Creating a culture of safety (IHI, 2018) is everybody’s business, and nurses, who are so integral to care, are key players in this important work. Every nurse has the accountability to challenge any act that appears unsafe and to stop actions that do not concur with the patient’s best interest. Being proactive is insufficient in itself; examining practices and conditions that support errors is critical, as is sharing knowledge that can redirect care. In this challenging context, nurses continue to provide care and provide the organizational “glue” that supports patient care being accomplished in a safe, effective, and efficient manner. Nurses who serve as leaders and managers have additional opportunities to create conditions where ideas are heard, problems are solved, and the best evidence is used.
T h e S o l u t i o n Katheren Koehn
One of the guiding principles of the Nursing Practice Council was that it was a direct-care nurse council, with liaison members from the CNS group and nursing administration. It was led by direct-care nurses, and direct-care nurses made the decisions, with input from other stakeholders. The first problem with the Clinical Question Process was that it was being led by a liaison CNS member, violating the guiding principal. The solution was going to have to come from the nurses.
We decided to devote an entire meeting to solving the problem. We broke the 35-member Council into small groups to discuss the following questions:
• Which clinical questions had actually been resolved? • Which clinical questions could be combined into a single question? • Which questions were not actually clinical questions at all? • How would we create a system for the members of the Nursing Practice Council to
have more ownership and responsibility over the process and work with the CNSs?
• How would decisions about Clinical Questions be communicated to the Nursing Units and Nursing Policy?
By the end of the meeting, decisions were made that invigorated the Process, moving from unending discussion to decisions and outcomes. The several-page list of questions had been refined into a list that was manageable and trackable. The nurse on the Council from the unit where the question had been submitted would take the lead on the research and discussion in partnership with the CNS and others on the Council who were most interested in that question. Decisions at the time of the meeting would be clear, and methods of communication would be determined, both to nurses on the units and the Nursing Policy Committee.
Would this be a suitable approach for you? Why?
81
Reflections Think about clinical safety from what you have experienced and observed. What will be your biggest challenges in facing issues, and leading solutions, related to clinical safety, and how will you resolve them? What do you know about yourself that will provide you strength to take on issues of clinical safety? What do you need to develop to be more confident in what you can do?
82
The evidence Numerous studies support various practices to ensure that staffing is adequate, that the clinical environment is free from incivility, that systems are addressed to identify unsafe practices and promote best practices, that nurses have a voice in creating solutions to safe clinical environments, and that using evidence is a high priority.
83
Tips for clinical safety • Use the IOM competencies to frame your actions. • Keep current with the evidence and best practices. • Use only quality sources, especially for websites. • Read general nursing literature regarding other organizations’ work related to safety. • Practice hand hygiene. • Be prepared to intervene in unsafe situations. • Report faulty equipment (e.g., furniture, monitors, lifts) immediately (Rich & El-Shammaa,
2017).
84
References Agency for Healthcare Research and Quality (AHRQ). (2018). Making Health Care
Safer II: An updated critical analysis of the evidence for patient safety practices. http://www.ahrq.gov/research/findings/evidence-based- reports/ptsafetyuptp.html.
Cho E., Lee N.J., Kim E.Y., Kim S., Lee K., Park K.O., et al. Nurse staffing level and overtime associated with patient safety, quality of care and care left undone in hospitals: A cross-sectional study. International Journal of Nursing Studies. 2016;60:263–271. doi:10.1016/j.ijnurstu.2016.05.009.
Institute for Healthcare Improvement. Develop a culture of safety. www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx. 2018.
Institute of Medicine (IOM). To err is human: Building a safer health system. Washington, DC: National Academy Press; 2000.
Institute of Medicine (IOM). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001.
Institute of Medicine (IOM). Health professions education: A bridge to quality. Washington, DC: National Academy Press; 2003.
Institute of Medicine (IOM). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press; 2004.
Institute of Medicine (IOM). Improving the quality of health care for mental and substance-use conditions: Quality Chasm Series. Washington, DC: National Academy Press; 2005.
Institute of Medicine (IOM). Preventing medication errors: Quality Chasm Series. Washington, DC: National Academy Press; 2006.
Institute of Medicine (IOM). The future of nursing: Leading change, advancing health. Washington, DC: National Academy Press; 2010.
Jones A., Johnstone M.J., Duke M. Recognising and responding to ‘cutting corners’ when providing nursing care: a qualitative study. Journal of Clinical Nursing. 2016 August 2016, 25(15–16), 2126–2133.
Kanerva A., Kivinen T., Lammintakanen J. Communication elements supporting patient safety in psychiatric inpatient care. Journal of Psychiatric and Mental Health Nursing. 2015;22(5):298–305. doi:10.1111/jpm.12187.
Kowalski S.L., Anthony M. Nursing’s evolving role in patient safety. American Journal of Nursing. 2017;117(2):34–48.
Lockett J.J., Barkley L., Stichler J., Palomo J., Kik B., Walker C., et al. Defining peer- to-peer accountability from the nurse’s perspective. JONA. 2015;45:557–562. doi:10.1097/NNA.0000000000000263.
Lyle-Edrosolo G., Waxman K.T. Aligning healthcare safety and quality competencies: Quality and safety education for nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet ® standards crosswalk. Nurse Leader. February, 2016;70–75.
Marrelli T.M. Home care nursing: Surviving in an ever-changing care environment. Indianapolis, IN: Sigma Theta Tau International; 2017.
Rich S., El-Shammaa M. Medical device reporting: A model for patient safety. American Nurse Today. 2017;12(2):10–12.
Rogers E.M. Diffusion of innovations. 5th ed. New York: The Free Press; 2003. Stafos A., Stark S., Barbay K., Frost K., Jacket D., Peters L., et al. Identifying
hospitalized patients at risk for harm: A comparison of nurse perceptions vs. electronic risk assessment tool scores. American Journal of Nursing. 2017;117(4):26–31.
85
Van Gerven E., Vander Elst T., Vandenbroeck S., Dierickx S., Euwema M., Sermeus W., et al. Increased risk of burnout for physicians and nurses involved in a patient safety incident. Medical Care. 2016;54(10):937–943. doi:10.1097/MLR.0000000000000582.
Wolf L.A., Perhats C., Delao A.M., Clark P.R., Moon M.D. On the threshold of safety: A qualitative exploration of nurses’ perceptions of factors involved in safe staffing levels in emergency departments. Journal of Emergency Nursing. 2016;43(2):150–157.
86
Legal and Ethical Issues Myra A. Broadway
LEARNING OUTCOMES
• Examine nurse practice acts, including the legal difference between licensed registered nurses and licensed practical (vocational) nurses.
• Define unprofessional conduct according to the state nurse practice act. • Apply various legal principles, including negligence and malpractice, privacy,
confidentiality, reporting statutes, and doctrines that minimize one’s liability, when acting in leading and managing roles in nursing practice settings.
• Evaluate informed-consent issues, including patients’ rights in research and health literacy, from a nurse manager’s perspective.
• Analyze key aspects of employment law and give examples of how these laws benefit professional nursing practice.
• Analyze ethical principles, including autonomy, beneficence, nonmaleficence, veracity, justice, paternalism, fidelity, and respect for others.
• Apply the Code of Ethics for Nurses and the MORAL model from the nurse manager’s perspective.
• Discuss moral distress and its implications for nurse managers. • Analyze the role of institutional ethics committees. • Analyze decision making when legal and ethical situations overlap, using the Theresa M.
Schiavo case as the framework for this analysis.
87
KEY TERMS apparent agency autonomy beneficence collective bargaining confidentiality corporate liability emancipated minor ethics ethics committee failure to warn fidelity foreseeability health literacy indemnification independent contractor informed consent justice law liability liable licensure malpractice moral distress negligence nonmaleficence nurse practice act paternalism personal liability privacy respect for others respondeat superior standard of care statute unprofessional conduct veracity vicarious liability whistle-blowing
T h e C h a l l e n g e Acacia Syring, BSN, RN Staff Nurse Emergency Center, PeaceHealth Southwest Washington Medical Center, Vancouver, Washington
88
In my role as a staff nurse in a busy Level 1 trauma emergency center, staff members were often confronted with questions about family presence during lifesaving techniques. Should the family or other loved ones be allowed to be present during cardiopulmonary resuscitation? Did the presence of family members hinder the ability of staff members to provide appropriate and competent care? Did their presence in some way benefit the patient? Was there a legal right for family members to be present at this time?
Currently the issue of family presence is being addressed on a case-by-case basis. The primary healthcare professional has the final say in whether family (1) can be present, (2) are given the option of being present, or (3) are tactfully escorted to another area of the unit. I continued to be ambivalent, especially when an 18-month-old girl was transported to the emergency center after falling from the family boat into a lake. Cardiopulmonary resuscitation was being given as the child was admitted; her mother was with her and her father was coming with other family members. The mother was escorted to the waiting area, crying, “I want to be with my baby!”
What would you do if you were this nurse?
89
Introduction The role of professional nursing continues to expand and incorporate increasingly higher levels of expertise, specialization, autonomy, and accountability from both legal and ethical perspectives. This evolving role continually creates new concerns for nurses, nurse managers, and nurse leaders and a heightened awareness of the interaction of legal and ethical principles. Areas of concern include professional nursing practice, legal issues, ethical principles, labor-management interactions, and employment. Each of these areas is individually addressed in this chapter. Although this chapter emphasizes the perspective of the nurse manager, all nurses benefit from understanding the legal and ethical aspects of managing, if only to understand the guidelines their managers are, or should be, following. Furthermore, all nurses have accountability for their practice and compliance with laws, professional standards, and ethical principles.
90
Professional nursing practice: nurse practice acts The scope of nursing practice, those actions and duties that are allowable by the profession, is defined and guided by each state in the nurse practice act. The state nurse practice act is the most important piece of legislation for nursing because it affects all facets of nursing practice. Furthermore, the act is the law within a state or US territory, and state boards of nursing cannot grant exceptions, waive the act’s provisions, or expand practice outside the act’s specific provisions.
Nurse practice acts define three categories of nurses: licensed practical or vocational nurses (LPNs and LVNs, respectively), licensed registered nurses (RNs), and advanced practice registered nurses. The various state nurse practice acts set educational and examination requirements, provide for licensing of individuals who have met these requirements, and define the functions of each category of nurse, both in general and in more specific terminology. The nurse practice act must be read to ascertain what actions are allowable for the three categories of nurses. In the few states where separate acts for RNs and LPNs/LVNs exist, the acts must be reviewed at the same time to ensure that all allowable actions are included in one of the two acts and that no overlap exists between the acts. In addition, nurse managers should understand that individual state nurse practice acts may vary among states in defining or delineating nursing practice, especially for advanced nursing roles.
Each practice act also establishes a state board of nursing. The main purpose of state boards of nursing is to ensure enforcement of the act to protect the public. The board enforces the act by regulating those practitioners who come under its provisions and preventing individuals not addressed within the act from practicing nursing. To protect the public, all those who present themselves as nurses must be licensed to practice within the state. The National Council of State Boards of Nursing (NCSBN) is a membership organization consisting of all US state and territorial boards of nursing (except Puerto Rico). NCSBN maintains a database (NURSYS), which enables states to enter and to access current information regarding licensure and discipline of nurses throughout the country. The NCSBN’s website features a public portion that allows individuals access to certain nonconfidential information that is valuable to the nurse manager and employer.
The various boards of nursing develop and implement rules and regulations regarding the discipline of nursing and must be read in conjunction with the nurse practice act. Often any changes within the state’s definition of nursing practice occur through modifications in the rules and regulations rather than in the act itself. This mandates that nurses and their nurse managers periodically review both the state act and the board of nursing rules and regulations.
Because each state has its own nurse practice act and state courts have jurisdiction for the state, nurses are well advised to understand the provisions of the state’s nurse practice act. This is especially true in the areas of diagnosis and treatment; states vary on whether nurses can diagnose and treat or merely assess and evaluate. Thus an acceptable action in one state may be the practice of medicine in another state.
The nurse practice act may state that unprofessional conduct is a violation of the statute. Usually deliberate definition of what constitutes unprofessional conduct is found in rules and regulations. Typical examples of unprofessional conduct include boundary issues; practicing while impaired; violating patient confidentiality; failing to supervise persons to whom nursing functions have been delegated; inaccurate recording, falsifying, or altering a patient or healthcare provider record; and sexual misconduct.
With the advent of the Nurse Licensure Compact (NLC), commonly referred to as “the Compact,” the need to know and understand provisions of state nurse practice acts has become even more critical. Multistate licensure permits an RN or LPN/LVN to be licensed in one state and to practice legally in states belonging to the NLC without obtaining additional state licenses. For the purposes of the law, the state nurse practice act that regulates the practice of the RN is the state in which the patient or client resides, not the state in which the nurse holds his or her license. Nurses residing in Compact states who have a Privilege to Practice may care for a patient in another Compact state. For example, a nurse in Compact state A may provide nursing care to a patient in Compact state B via a telephonic nursing advice or triage service program. Many of the nurses practicing under provisions of the Compact work with patients in a variety of states through such electronic capabilities as telenursing, Internet applications, and telecommunications technology such as telephone triage and advice. Others work for agencies or clinics that serve patients across state
91
borders. Many healthcare systems include facilities and practices in more than one jurisdiction. The enhanced Nurse Licensure Compact (eNLC) became effective in most US jurisdictions in 2018 as requirements for a multistate practice privilege changed from the previous NLC in a concerted effort to enable all states to join.
All nurses must know applicable state law and use the nurse practice act for guidance and appropriate action. Nurse managers have this same basic responsibility to apply legal principles in their practice. However, they are also responsible for monitoring the practice of employees under their supervision and for ensuring that personnel maintain current and valid licensure. NCSBN provides the employer the ability to subscribe to its E-Notify program to make nurse managers aware of nurses whose licenses are due for renewal. Subscription to E-Notify also alerts the nurse manager to any discipline the state board may have imposed on the nurse. Unless nurses and nurse managers remain current with the nurse practice act in their state or with nurse practice acts in all states in which nurse managers supervise employees, a potential for liability exists.
E x e r c i s e 3 . 1 Review your state’s nurse practice act, including rules and regulations that the state board of nursing has promulgated for the profession. You may need to read two acts if RNs and LPNs/LVNs come under different licensing boards. How does your state address advanced practice? How do the definitions of nursing vary for RNs, LPNs/LVNs, and advanced practice registered nurses? Describe why it is vital that the nurse manager understands these distinctions.
92
Negligence and malpractice Nurse managers frequently serve as mentors and consultants for the nurses whom they supervise. Nurse managers must have a full appreciation for this area of the law, because negligence and malpractice continue to be the major causes of action brought against nursing staff members. Managers cannot guide and counsel their employees unless the managers are fully knowledgeable about this area of the law.
Negligence as defined by Black’s Law Dictionary (2014) is the “failure to use such care as a reasonably prudent and careful person would use under similar circumstances.” Negligence applies to both the manager and the direct care nurse. Many experts equate negligence with carelessness, a deviation from the care that a reasonable person would deliver. If managers are careless in their responsibilities, they could be found negligent. The same applies to the direct care nurse. Malpractice, as defined by Black’s Law Dictionary (2014), is “professional misconduct or unreasonable lack of skill.” Malpractice concerns professional actions and is the failure of a person with professional education and skills to act in a reasonable and prudent manner. Issues of malpractice have become increasingly important to the nurse as the authority, accountability, and autonomy of nurses have increased. The same types of actions may be the basis for either negligence or malpractice, though some actions almost always are seen as malpractice because only the professional person would be performing the action. Specific examples include drawing blood for arterial blood gas analysis via a direct arterial puncture or initiating blood transfusions. Common allegations and/or causes of malpractice or negligence among nurses include the failure to follow standards of care, to use equipment responsibly, to document, to communicate, and to access and monitor patients (Reising, 2012).
Negligence and malpractice have two commonalities. Negligence and malpractice both concern actions that are a result of omission (the failure to do something that the reasonable, prudent person or nurse would have done) or commission (acting in a way that causes injury to the patient). They also concern nonintentional actions; though there is some injury to a patient, the individual who caused the harm never intended to hurt the patient.
Six elements must be presented in a successful malpractice suit. All of these factors must be shown before the court will find liability against the nurse and/or institution. These six elements are described in Table 3.1.
Table 3.1
Elements of Malpractice
Elements Examples Duty owed the patient Failure to monitor a patient’s response to treatment Breach of the duty owed Failure to communicate change in patient status to the primary healthcare provider Foreseeability Failure to ensure minimum standards are met Causation Failure to provide adequate patient education Injury Fractured hip and head concussion after a patient fall Damages Additional hospitalization time; future medical and nursing care needs and costs
Elements of Malpractice Duty Owed the Patient The first element is duty owed the patient, which involves both the existence of the duty and the nature of the duty. Existence of the duty of care is generally established by showing the valid employment of the nurse within the institution. As the Literature Perspective shows, the concept of duty of care is complex, with many implications. The more difficult part is the nature of the duty, which involves the standard of care that represents the minimum requirements for acceptable practice or the minimum requirements for how one conducts oneself. Standards of care are established by reviewing the institution’s policy and procedure manual, the individual’s job description, and the practitioner’s education and skills, as well as pertinent standards established by professional organizations, journal articles, and standing orders and protocols.
93
L i t e r a t u r e Pe r s p e c t i ve Resource: Dowie, I. (2017). Legal, ethical and professional aspects of duty of care for nurses. Nursing Standard, 32(16-19), 47-52.
The author first points out that duty of care is not unique to professionals, because we all have societal duties of care such as ensuring safety when we drive or walk. Of course, because nurses, among other professionals, have specialized knowledge, they have a higher duty of care in terms of issues related to health. The author reminds us that our duty extends to the control of the environment, such as a spillage on the floor posing a hazard. When nurses leave a unit for a break, and they have sought coverage for their patients by someone who was equally well qualified to provide care, they would not likely be found to have violated the principle of being fair, just, or reasonable. The author cites how in England even not attending to such aspects as personal hygiene can be seen as a neglect of duty of care.
The distinction is made between the legal duty of care, which typically does not apply outside of the employment situation, and the ethical duty of care, which suggests we would respond in emergencies even if we were outside of our workplace and functioning primarily as a citizen. The key to liability is the foreseeability of harm, and in emergency situations that foreseeability is compromised.
Implications for Practice Two key points can be derived from this article. The first is that the idea of duty of care is not a distinct consideration in the United States. The second, and perhaps more important in today’s world, is that we are not legally bound to respond in emergency situations such as disasters; we are ethically expected to respond to the best of our ability.
Several sources may be used to determine the applicable standard of care. The American Nurses Association (ANA), as well as a cadre of specialty nursing organizations, publishes standards for nursing practice. Accreditation standards, such as those published yearly by The Joint Commission (TJC), also assist in establishing the acceptable standard of care for healthcare facilities. In addition, many states have healthcare standards that affect individual institutions and their employees.
Nurse managers are directly responsible for ensuring that standards of care, as written in the hospital policy and procedure manuals, are current and that all nursing staff follow these standards of care. Should a standard of care be revised or changed, nurse managers must ensure that all staff members who are expected to implement this altered standard are apprised of the revised standard. If the new standard entails new skills, staff members must be educated about this revision and acquire the necessary skills before they implement the new standard. For example, if the institution alters a policy regarding a specific skill to be implemented, the nurse manager must first ensure that all nurses who will be performing this skill understand how to perform the skill safely, know possible complications that could occur, and know the most appropriate interventions to take should those complications occur. The nurse manager may work with others, such as clinical nurse educators, in attaining the desired outcomes.
Breach of the Duty of Care Owed the Patient The second element required in a malpractice case is breach of the duty of care owed the patient. Once the standard of care is established, the breach or falling below the standard of care is relatively easy to show. To determine the appropriate standard of care, expert witnesses give testimony in court on a case-by-case basis, assisting the judge and jury in understanding nursing standards of care. In nursing malpractice suits, nurses serve as expert witnesses. Their testimony helps the judge and jury understand the applicable standards of nursing care (Fig. 3.1).
94
FIG. 3.1 Nurse serving as an expert witness.
Opinions of experts attesting to the standard of care may differ depending on whether the injured party is trying to establish the standard of care or whether the defendant nurse’s attorney is establishing an acceptable standard of care for the given circumstances. The injured party will attempt to show that the acceptable standard of care is at a much higher level than that shown by the defendant, hospital, and staff. An example appears in Case Example Box 3.1.
Case Example Box 3.1 An older case example, Sabol v. Richmond Heights General Hospital (1996), shows the importance of duty to the patient. A patient was admitted to a general acute care hospital for treatment after attempting to commit suicide by drug overdose. While in the acute care facility, the patient became increasingly paranoid and delusional. A nurse sat with the patient and tried to calm him. Restraints were not applied, because the staff feared this would compound the situation by raising the patient’s level of paranoia and agitation. The patient jumped out of bed, knocked down the nurse who was in his room, fought his way past two nurses in the hallway, ran off the unit, and jumped from a third-story window, fracturing his arm and sustaining other relatively minor injuries.
Expert witnesses for the patient introduced standards of care pertinent to psychiatric patients, specifically those hospitalized in psychiatric facilities or in acute care hospitals with separate psychiatric units. The court ruled that the nurses in this general acute care situation were not professionally negligent in this patient’s care. The court stated that the nurses’ actions were consistent with basic professional standards of practice for medical-surgical nurses in an acute care hospital. They did not have, nor were they expected to have, specialized psychiatric nursing training and would not be judged as though they did.
Foreseeability The third element needed for a successful malpractice case, foreseeability, involves the concept that certain events may reasonably be expected to cause specific results. The nurse must have prior knowledge or information that failure to meet a standard of care may result in harm. The challenge
95
is to show what was foreseeable given the facts of the case at the time of the occurrence, not when the case finally comes to court. Some of the more common areas concerning foreseeability are medication errors, patient falls, and failure to enact physician orders. For example, in an older case, Massey v. Mercy Medical Center (2009), a resident known to be at high risk for falls was left unattended standing next to his walker. When he attempted to move forward, he lost his balance and sustained a compression fracture at the level of the twelfth thoracic vertebra. Without difficulty the court could find this was foreseeable.
Causation The fourth element of a malpractice suit is causation: the nurse’s actions or lack of actions directly caused the patient’s harm. A direct relationship must exist between the failure to meet the standard of care and the patient’s injury. Merely breaching this standard of care is insufficient to show malpractice; a direct cause-effect factor must be present. For example, O’Shea v. State of New York (2007) concerned a patient who sustained an accident in which two fingers were severed while using a power saw. The patient permanently lost the two fingers when the nursing staff failed to follow the order for an immediate orthopedist consultation.
Injury The resultant injury, the fifth malpractice element, must be physical, not merely psychological or transient. In other words, the patient must incur some physical harm before malpractice will be found against the healthcare provider. Although some specific exceptions exist to the requirement that a physical injury must result, they are extremely limited and usually involve specific relationships, such as the parent–child relationship. Pain and suffering are allowed when they accompany actual physical injuries.
Damages The injured party must be able to prove damages, the sixth element of malpractice. Damages are vital, because malpractice is nonintentional. Thus the patient must show financial harm before the courts will allow a finding of liability against the defendant nurse and/or hospital. Acceptable damages may be for immediate as well as future medical costs.
A nurse manager must know the applicable standards of care and ensure that all employees of the institution meet or exceed them. The standards must be reviewed periodically to ensure that the staff members remain current and attuned to advances in technology and newer ways of performing skills. If standards of care appear outdated or absent, the appropriate committee within the institution should be notified so that timely revisions can be made. Finally, the nurse manager must ensure that all nursing employees meet the standards of care. This may be done by (1) performing or reviewing all performance evaluations for evidence that standards of care are met, (2) reviewing randomly selected patient charts for standards of care documentation, and (3) inquiring of employees what constitutes standards of care and appropriate references for standards of care within the institution.
E x e r c i s e 3 . 2 You are the nurse manager for a skilled nursing facility that will now accept patients requiring long-term ventilator support. How should you begin to ensure that all the staff in the facility are educated in the care of ventilator-dependent patients, know what complications to anticipate, and know how to respond should these complications arise? Should all staff members be educated in this skill?
Liability: Personal, Vicarious, and Corporate Personal liability defines each person’s responsibility and accountability for individual actions or omissions. Even if others can be shown to be liable for a patient injury, each individual retains personal accountability for his or her actions. The law, though, sometimes allows other parties to be liable for certain causes of negligence. Known as vicarious liability, or substituted liability, the doctrine of respondeat superior (let the master answer) makes employers accountable for the
96
negligence of their employees. The rationale underlying the doctrine is that the employee would not have been in a position to cause the wrongdoing unless hired by the employer, and the injured party would be allowed to suffer a double wrong if the employee was unable to pay damages for the wrongdoings. Nurse managers can best prevent these issues by ensuring that the staff they supervise know and follow hospital policies and procedures and continually deliver safe, competent nursing care or raise issues about policies and procedures through formal channels.
Nurses often believe that the doctrine of vicarious liability shields them from personal liability; the institution may be sued but not the individual nurse or nurses. However, patients injured because of substandard care have the right to sue both the institution and the nurse. This includes potentially suing the direct care nurse’s manager if he or she knowingly allowed substandard and unsafe care to be given to a patient. In addition, the institution has the right under indemnification to countersue the nurse for damages paid to an injured patient. The principle of indemnification is applicable when the employer is held liable based solely on the actions of the staff member’s negligence and the employer pays monetary damages because of the employee’s negligent actions.
Corporate liability holds that the institution has the responsibility and accountability for maintaining an environment that ensures quality healthcare delivery for consumers. Corporate liability issues include negligent hiring and firing issues; failure to maintain safety in the physical environment; and lack of a qualified, competent, and adequate staff. In Wellstar Health System, Inc., v. Green (2002), a hospital was held liable to an injured patient for the negligent credentialing of a nurse practitioner. Nurse managers must be aware of trends in court cases and implications for persons in leadership positions, because court outcomes follow precedents. In September 2015 the owner of a peanut butter manufacturing facility in Georgia was sentenced by a federal judge to 28 years in prison for the Salmonella-related deaths of nine persons (U.S. vs Parnell, Parnell, Lightest & Wilkerson, 2015.) The essence of the case was the knowledge of the person in a leadership position of the presence of Salmonella and his failure to take remedial action. Although this case didn’t relate to a healthcare facility, it validated the idea that leaders have accountability for actions within organizations. The literature argues that hospital administration (which may include nurses in leadership positions) are not immune from criminal and civil liability, particularly in situations where hospital-acquired infections (HAIs) cause harm. If defendants have knowledge of the danger and risk posed by HAIs in the facility but take no action to correct the situation, hospital administration may not be immune from civil and criminal prosecution for serious injury and death resulting from HAIs and the failure to take remedial action in light of knowledge of the condition (Ricciardi, 2017).
Nurse managers play a key role in assisting the institution to avoid corporate liability. For example, nurse managers ensure that staff members remain competent and qualified; that personnel within their supervision have current licensure; and that incompetent, illegal, or unethical practices are reported to the proper persons or agencies. Nurse managers also play a pivotal role in whether a nurse remains employed on the unit or is discharged or reassigned.
Perhaps the key to avoiding corporate liability is ensuring that all members of the healthcare team fully collaborate and work with other disciplines to ensure quality, competent health care, regardless of the care setting. Such collaboration is a competency that must be mastered across disciplines.
Causes of Malpractice for Nurse Managers Nurse managers are charged with maintaining a standard of safe and competent nursing care within the institution. Several potential sources of liability for malpractice among nurse managers may be identified; thus guidelines to prevent or avoid these pitfalls should be developed.
Assignment, Delegation, and Supervision The field of nursing management involves supervision of various personnel who directly provide nursing care to patients. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual’s performance of an activity. The nurse manager retains personal liability for the reasonable exercise of assignment, delegation, and supervision activities. The failure to assign, delegate, and supervise within acceptable standards of professional nursing practice may constitute malpractice. In addition, failure to delegate and supervise within acceptable standards may extend to direct corporate liability for the institution.
97
Delegation, used in nursing practice throughout history, has evolved into a complex, work- enhancing strategy that has the potential for varying levels of legal liability. Before the early 1970s, nurses used delegation to direct the multiple tasks performed by the various levels of staff members in a team-nursing model. Subsequently, the concept of primary nursing and assignment became the desirable nursing model in acute care settings, with the focus on an all-professional staff, requiring little delegation but considerable assignment of duties. By the mid-1990s, a nursing shortage had again shifted the nursing model to a multilevel staff, with the return of the need for delegation. Regardless of the nursing model used, nurse managers must fully understand and implement delegation principles effectively and properly.
Nurse managers need to know certain definitions regarding this area of the law. Delegation involves at least two people, a delegator and a delegatee, with the transfer of authority to perform some type of task or work. A working definition could be that delegation is the transfer of responsibility for the performance of an activity from one individual to another, with the delegator retaining accountability for the outcome. In other words, delegation involves the transfer of responsibility for the performance of tasks and skills without the transfer of accountability for the ultimate outcome. Examples include an RN who delegates patients’ personal care tasks to certified nursing assistants who work in a long-term care setting. In delegating these tasks, the RN retains the ultimate accountability and responsibility for ensuring that the delegated tasks are completed in a safe and competent manner.
Typically, delegation involves the tasks and procedures that are given to unlicensed nursing personnel, such as certified nursing aides, orderlies, assistants, attendants, and technicians. However, delegation can also occur with licensed staff members. For example, if one RN has the accountability for an outcome and asks another RN to perform a specific component of the overall function, that is delegation. This is typically the type of delegation that occurs between professional staff members when one member leaves the unit or work area for a meal break.
Delegation is complex because it involves the delegation relationship and communication. It also involves trusting others, because both the delegator and the delegatee have shared accountability for certain tasks and duties. Interventions are needed to improve this relationship and communication effectiveness, which directly affects the quality of competent care delivery. Multiple players, usually with varying degrees of education and experience and different scopes of practice, are involved in the process. Understanding these variances and communicating effectively to the delegatee involve an understanding of competencies and the ability to communicate with all levels of staff personnel.
Assignment is the transfer of both the accountability and the responsibility from one person to another. This is typically what happens between professional staff members. The nurse manager assigns patient care responsibilities to other professional nurses working in the same unit of the institution or community healthcare setting. The level of accountability for the nurse manager who assigns as opposed to delegates is fairly obvious, although some accountability can occur in both instances. The degree of knowledge concerning the skills and competencies of those one supervises is of paramount importance. The doctrine of respondent superior has been extended to include “knew or should have known” as a legal standard in both assigning and delegating tasks to individuals whom one supervises. If it can be shown that the nurse manager assigned or delegated tasks appropriately and had no reason to believe that the nurse to whom tasks were assigned or delegated was not competent to perform the task, the nurse manager potentially has no or minimal personal liability. The converse is also true: if it can be shown that the nurse manager was aware of incompetence in a given employee or that the assigned or delegated task was outside the employee’s capabilities, the nurse manager becomes substantially liable for the subsequent injury to a patient.
E x e r c i s e 3 . 3 You are the nurse manager on a busy 38-bed surgical postoperative unit. A newly postoperative patient, Mrs. R., requires assistance with feeding, and you note that an unlicensed nursing personnel has been delegated to feed her. Reading Mrs. R.’s care plan, you also note that she is an older adult, has had periods of confusion, and has had difficulty swallowing since her surgery. Determine whether this is the right circumstance for such delegation. What are your next actions
98
and why?
Nurse managers have a duty to ensure that the staff members under their supervision are practicing in a safe and competent manner. The nurse manager must be aware of the staff members’ knowledge, skills, and competencies and should know whether they are maintaining their competencies. Knowingly allowing a staff member to function below the acceptable standard of care subjects both the nurse manager and the institution to potential liability. This point is illustrated in Case Example Box 3.2.
Case Example Box 3.2 In Estate of Travaglini v. Ingalls Health (2009), an 84-year-old patient was admitted to the hospital with general complaints of “not feeling well.” At the time of his admission, the physician told the admitting nurse that the patient had dysphagia and must be observed whenever he was eating or trying to swallow liquids. At 10:00 that evening, an aide came to the patient’s room and left a sandwich for him to eat. Shortly afterward, the patient’s roommate heard the patient choking and summoned help. At autopsy, it was confirmed that he had aspirated the turkey sandwich, and that this was the cause of the cardiopulmonary arrest that killed the patient. Though liability was found against the aide and her supervisor, the court also upheld a verdict of $500,000 against the hospital.
As this case illustrates, delegation is both a process and a condition (Potter, Deshields, & Kuhrik, 2010). It is a process of delegating appropriate tasks and activities to others, and it is a condition because a mutual understanding must be held by both the delegator and the delegatee of the specific results expected and the means of attaining those results.
Duty to Orient, Educate, and Evaluate Most healthcare institutions have continuing education departments to orient nurses who are new to the institution and to supply in-service education addressing new equipment, procedures, and interventions to existing employees. Nurse managers also have a duty to orient, educate, and evaluate. Nurse managers and their representatives are responsible for the daily evaluation of whether nurses are performing safe and competent care. The key to meeting this requirement is reasonableness and is determined by courts on a case-by-case basis. Nurse managers should ensure that they promptly respond to all allegations, whether by patients or staff, of incompetent or questionable nursing care. Nurse managers should thoroughly investigate such allegations, recommend options for correcting the situation, and follow up on recommended options and suggestions.
For example, in Marinock v. Manor at St Luke’s (2010), the nursing facility had experienced multiple problems with patients falling or being dropped during Hoyer lift transfers because some staff members were unaware of how to properly secure patients in the sling before beginning the transfer. These incidents apparently did not lead to additional training, and subsequently an 82- year-old patient was dropped during a transfer from one bed to another bed, resulting in a femur fracture. The patient’s lawsuit resulted in a $310,000 judgment against the facility for failure to properly orient and train its personnel.
E x e r c i s e 3 . 4 In a landmark study, the National Academy of Medicine (formerly the Institute of Medicine) (1999) outlined six characteristics for a safe healthcare system, noting that incorporating these six characteristics created a culture of safety. For example, culture focuses on effective systems and teamwork to accomplish the goal of safe, high-quality patient care. Review the National Academy of Medicine report and consider how nurse managers might begin to apply the characteristics of a culture of safety to the facts in the Marinock v. Manor at St. Luke’s (2010) lawsuit.
Failure to Warn
99
Another area of potential liability for nurse managers is failure to warn potential employers of staff incompetence or impairment. Information about suspected addictions, violent behavior, and incompetency is of vital importance to subsequent employers. If the institution has sufficient information and suspicion to warrant the discharge of an employee or force a resignation, subsequent employers should be advised of those issues. In addition, the state board of nursing or agency that oversees disciplinary actions of professional and nonprofessional nursing staff should also be notified whenever a cause to dismiss an employee for incompetency or impairment exists unless the employee voluntarily enters a peer assistance program.
One means of supplying this information is through the use of qualified privilege to certain communications. In general, qualified privilege concerns communications made in good faith between persons or entities with a need to know. Most states recognize this privilege and allow previous employers to give factual, objective information to subsequent employers. Note, however, that the previous employee must have listed the nurse manager or institution as a reference before this privilege arises.
Staffing Issues Three issues arise under the general term staffing. These include (1) maintaining adequate numbers of staff members in a time of advancing patient acuity and limited resources; (2) floating staff from one unit to another; and (3) using temporary or “agency” staff to augment the healthcare facility’s current staffing. Though each area is addressed separately, common to all three of these staffing issues is the requisite of collaboration among nurse managers in addressing the needs for the entire institution or healthcare agency.
Accreditation standards, such as those of TJC and the Community Health Accreditation Program (CHAP), as well as other state and federal standards, mandate that healthcare institutions provide adequate staffing with qualified personnel. This applies not only to the number of staff but also to the legal status of the staff. For instance, some areas of an institution, such as critical care areas, postanesthesia care areas, and emergency care centers, must have greater percentages of RNs than LPNs/LVNs. Other areas, such as the general nursing areas and some long-term care areas, may have equal or lower percentages of RNs to LPNs/LVNs or nursing assistants. Whether understaffing exists in a given situation depends on the number of patients, care acuity scores, and number and classification of staff. Courts determine whether understaffing existed on an individual case basis.
California was the first state to adopt legislation that mandated fixed nurse-to-patient ratios, passing this historic legislation in 1999. These types of ratios require set nurse-to-patient ratios based solely on numbers of patients within given nursing care areas and do not consider issues such as patient acuity, level of staff preparation, or environmental factors. Though a first step toward beginning to ensure adequate numbers of nurses, many states favor the concept of safe staffing rather than specific nurse-to-patient ratios. Generally, these safe staffing measures call for a committee to develop, oversee, and evaluate a plan for each specific nursing unit and shift based on patient care needs, appropriate skill mix of RNs and other nursing personnel, the physical layout of the unit, and national standards or recommendations regarding nursing staffing. Nurse managers must also know whether their states require public posting of the staffing plan (Safe Nurse Staffing Legislation, March 2008).
As early as 2015 federal legislation was introduced as the Registered Nurse Safe Staffing Act and included such provisions as a required public reporting of staffing information, a procedure for receiving and investigating complaints, and allowing the imposition of civil monetary penalties for each known violation. The proposed legislation also included provision for nurse managers to work with direct care nurses to establish safe staffing based on variable factors. Because staffing has major implications for quality, legislation likely will be introduced and refined over several sessions.
Although the institution is ultimately responsible for staffing issues, nurse managers may also incur liability because they directly oversee numbers of personnel assigned to a given unit. Courts have looked to the constant exercise of professional judgment, rather than reliance on concrete nurse-to-patient ratios, in cases involving staffing issues. Thus nurse managers should exercise sound judgment to ensure patient safety and quality care rather than rely on exact nurse-to-patient ratios. For liability to incur against the nurse manager, it must be shown that a resultant patient injury was directly caused by staffing issues and not by the incompetent or inappropriate actions of
100
an individual staff member. To prevent nurse managers’ liability, they must show that sufficient numbers of competent staff were available to meet nursing needs.
Guidelines for nurse managers in inadequate staffing issues include alerting hospital administrators and upper-level managers of concerns. First, however, the nurse manager must do whatever is under his or her control to alleviate the circumstances, such as approving overtime for adequate coverage, reassigning personnel among those areas he or she supervises, and restricting new admissions to the area. Second, nurse managers have a legal duty to notify the chief operating officer, either directly or indirectly, when understaffing endangers patient welfare. One way of notifying the chief operating officer is through formal nursing channels, for example, by notifying the nurse manager’s direct supervisor. Upper management must then decide how to alleviate the staffing issue, either on a short-term or a long-term basis. Appropriate measures could be closing a unit or units, restricting elective surgeries, hiring new staff members, or temporarily reassigning personnel from other departments. Once the nurse manager can show that he or she acted appropriately, used sound judgment given the circumstances, and alerted his or her supervisors of the serious nature of the situation, the institution and not the nurse manager becomes potentially liable for staffing issues.
Several states prohibit the use of mandatory overtime by nurses. Generally these laws state that the healthcare facility may not require an employee to work in excess of agreed to, predetermined, and regularly scheduled daily work shifts unless an unforeseeable declared national, state, or municipal emergency or catastrophic event occurs that is unpredicted or unavoidable and that substantially affects or increases the need for healthcare services. In addition, many of these laws define “normal work schedule” as 12 or fewer hours; protect employees from disciplinary action or retribution for refusing to work overtime; and establish monetary penalties for the employer’s failure to adhere to the law. Some states also mandate that healthcare facilities are required to have a process for complaints related to patient safety. Note that nothing in these laws negates voluntary overtime.
Floating staff from unit to unit is the second issue that concerns overall staffing. Institutions have a duty to ensure that all areas of the institution are staffed adequately. Units temporarily overstaffed because of low patient census or a lower patient acuity ratio usually float staff to units that are understaffed. Although floating nurses to areas with which they have less familiarity and expertise can increase potential liability for the nurse manager, leaving another area dangerously understaffed can also increase potential liability.
Before floating staff from one area to another, the nurse manager should consider staff expertise, patient-care delivery systems, and patient-care requirements. Nurses should be floated to units as comparable to their own unit as possible. This requires the nurse manager to match the nurse’s home unit and float unit as much as possible or to consider negotiating with another nurse manager to cross-float a nurse. For example, a manager might float a critical care nurse to an intermediate care unit and float an intermediate care unit nurse to a general medical-surgical unit. Or the nurse manager might consider floating the general unit nurse to the postpartum unit and floating a postpartum nurse to labor and delivery. Open communications regarding staff limitations and concerns, as well as creative solutions for staffing, can alleviate some of the potential liability involved and create better morale among the floating nurses. A positive option is to cross-train nurses within the institution so that nurses are familiar with two or three areas and can competently float to areas in which they have been cross-trained.
The use of temporary or “agency” personnel has increased liability concerns among nurses and nurse managers. Previously most jurisdictions held that such personnel were considered independent contractors and thus the institution was not liable for their actions, although their primary employment agency did retain potential liability. However, courts have begun to hold the institution liable under the principle of apparent agency. Apparent authority or apparent agency refers to the doctrine whereby a principal becomes accountable for the actions of his or her agent. Apparent agency is created when a person (agent) holds himself or herself as acting on behalf of the principal; in the instance of the agency nurse, the patient cannot ascertain whether the nurse works directly for the hospital (has a valid employment contract) or is working for a different employer. At law, lack of actual authority is no defense. This principle applies when it can be shown that a reasonable patient believed that the healthcare worker was an employee of the institution. If it appears to the reasonable patient that this worker is an employee of the institution, the law will consider the worker an employee for the purposes of corporate and vicarious liability.
These trends in the law mean that nurse managers must consider the temporary worker’s skills,
101
competencies, and knowledge when delegating tasks and supervising the worker’s actions. If a manager suspects that the temporary worker is incompetent, he or she must convey this fact to the agency. The nurse manager must also either send the temporary worker home or reassign the worker to other duties and areas. The same screening procedures should be performed with temporary workers as are used with new institutional employees.
Additional areas that nurse managers should stress when using agency or temporary personnel include ensuring that the temporary staff member is given a brief but thorough orientation to institution policies and procedures, is made aware of resource materials within the institution, and is made aware of documentation procedures. Also, nurse managers should assign a resource person to the temporary staff member. This resource person serves in the role of mentor for the agency nurse and serves to prevent potential problems that could arise merely because the agency staff member does not know the institution routine or is unaware of where to turn for assistance. The resource person also serves as a mentor with critical decision making for the agency nurse.
Protective and Reporting Laws Protective and reporting laws ensure the safety or rights of specific classes of individuals. Most states have reporting laws for suspected child and elder abuse and laws for reporting certain categories of diseases and injuries. Examples of reporting laws include reporting cases of sexually transmitted diseases, abuse of residents in nursing and convalescent homes, and suspected child abuse. Nurse managers are often the individuals who are responsible for ensuring that the correct information is reported to the correct agencies, thus avoiding potential liability against the institution.
Many states now also have mandatory reporting of incompetent practice, especially through nurse practice acts, medical practice acts, and the National Practitioner Data Bank. In addition, the NCSBN maintains an electronic license verification system called NURSYS that monitors nurses’ licensure status in all states and US territories for discipline issues and licensure renewals. State boards submit data to NURSYS regarding disciplinary actions taken by the respective boards. Alerts are then sent to other US jurisdictions in which the nurse is licensed. Special provisions may apply if nurses who struggle with substance abuse or misuse are enrolled in peer assistance programs.
Mandatory reporting of incompetent practitioners is a complex process, involving both legal and ethical concerns. Nurse managers must know what the law requires, when reporting is mandated, to whom the report must be sent, and what the individual institution expects of its nurse managers. When in doubt, seek clarification from the state board of nursing, hospital administration, or state professional nursing association.
102
Informed consent Informed consent becomes an important concept for nurse managers in three different instances. First, direct care nurses may approach the nurse manager with questions about informed consent; thus the nurse manager becomes a consultant for the direct care nurse. Second, and more often, the nurse manager is queried about patients’ rights in research studies that are being conducted in the institution. Third, the issue of medical literacy has implications for the provision of valid informed consent by an ever-growing number of patients.
Remember: informed consent is the authorization by the patient or the patient’s legal representative to do something to the patient; it is based on legal capacity, voluntary action, and comprehension. Legal capacity is usually the first requirement and is determined by age and competency. All states have a legal age for adult status defined by statute; generally, this age is 18 years. Competency involves the ability to understand the consequences of actions or the ability to handle personal affairs. State statutes mandate who can serve as the representative for a minor or incompetent adult. The following types of minors may be able to give valid informed consent: emancipated minors, minors seeking treatment for substance abuse or communicable diseases, and pregnant minors.
Voluntary action, the second requirement, means that the patient was not coerced by fraud, duress, or deceit into allowing the procedure or treatment. Comprehension is the third requirement and the most difficult to ascertain. The law states that the patient must be given sufficient information, in terms he or she can reasonably be expected to comprehend, to make an informed choice. Inherent in the doctrine of informed consent is the right of the patient to informed refusal. Patients must clearly understand the possible consequences of their refusal. In recent years, most states have enacted statutes to ensure that a competent adult has the right to refuse care and that the healthcare provider is protected should the adult validly refuse care. This refusal of care is most frequently seen in end-of-life decisions. Box 3.1 lists the information needed for obtaining informed consent.
Box 3.1
I n f o r m a t i o n R e q u i r e d f o r I n f o r m e d C o n s e n t
• An explanation of the treatment or procedure to be performed and the expected results of the treatment or procedure
• Description of the risks involved • Benefits that are likely to result because of the treatment or procedure • Options to this course of action, including absence of treatment • Name of the person(s) performing the treatment/procedure • Statement that the patient may withdraw his or her consent at any time
Nurses often ask about issues concerning informed consent that concern the actual signing of the informed consent document, not the teaching and information that make up informed consent. Many nurses serve as witnesses to the signing of the informed consent document; in this capacity they are attesting only to the voluntary nature of the patient’s signature. No duty on the part of the nurse to insist that the patient repeat what has been said or what he or she remembers is present. If the patient asks questions that alert the nurse to the inadequacy of true comprehension on the patient’s part or expresses uncertainty while signing the document, the nurse has an obligation to inform the primary healthcare provider and appropriate persons that informed consent has not been obtained.
A separate issue with informed consent concerns a patient who is part of a research study. Federal laws regulate this area, because patients are generally considered to come under the heading of vulnerable populations. Whenever research is involved, such as a drug study or a new procedure, the investigators must disclose the research to the subject or the subject’s representative
103
and obtain informed consent. Federal guidelines have been developed that specify the procedures used to review research and the disclosures that must be made to ensure that valid informed consent is obtained.
The federal government mandates the basic elements of information that must be included to meet the standards of informed consent. Elements of informed consent are enumerated in Box 3.2.
Box 3.2
E l e m e n t s o f I n f o r m e d C o n s e n t i n R e s e a r c h S t u d i e s
• A statement that the study involves research, an explanation of the purposes of the research and the expected duration of the subject’s participation, a description of the procedures to be followed, and identification of any procedures that are experimental
• A description of any reasonably foreseeable risks or discomforts to the subject • A description of any benefits to the subjects or others that may reasonably be expected from
the research • A disclosure of appropriate alternative procedures or courses of treatment, if any, that may be
advantageous to the subject • A statement describing the extent, if any, to which confidentiality of records identifying the
subject will be maintained • For research involving more than minimal research, an explanation as to any compensation
and an explanation as to whether any medical treatments are available if injury occurs and, if so, what they consist of or where further information may be obtained
• An explanation of whom to contact for answers to pertinent questions about the research and research subjects’ rights and whom to contact in the event of a research-related injury to the subject
• A statement that participation is voluntary, refusal to participate will involve no benefits to which the subject is otherwise entitled, and the subject may discontinue participation at any time without penalty or loss of benefits to which the subject is otherwise entitled
Source: 45 Code of Federal Regulations (CFR), Sec. 46.116 (1991).
The information given must be in a language that is understandable by the subject or the subject’s legal representative. No exculpatory wording may be included, such as a statement that the researcher incurs no liability for the outcomes of the study or any injury to an individual subject. Subjects should be advised of the elements listed in Box 3.3.
Box 3.3
E l e m e n t s o f C o n c e r n i n R e s e a r c h S t u d i e s
• Any additional costs that they might incur because of the research • Potential for any foreseeable risks • Rights to withdraw at will, with no questions asked or additional incentives given • Consequences, if any, of withdrawal before the study is completed • A statement that any significant new findings will be disclosed • The number of proposed subjects for the study
Source: 45 Code of Federal Regulations (CFR), Sec. 46.101(b) (1991).
Excluded from these strict requirements are studies that use existing data, documents, records, or
104
pathologic and diagnostic specimens, if these sources are publicly available or the information is recorded so that the subjects cannot be identified. Other studies that involve only minimal risks to subjects, such as moderate exercise by healthy adults, may be expedited through the review process (Protection of Human Subjects, 1991, Section 46.110). Nurse managers must verify that staff members understand any research protocol with which their patients are involved.
The advent of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law [P.L.] 104-191) affected how health record information can be used in research studies. No separate permission need be secured from the patient to use medical record information if deidentified information is used. Deidentified information is health information that cannot be linked to an individual. Most of the 18 demographic items constituting the protected health information (PHI) must be removed before researchers are permitted to use patient records without obtaining the individual patient’s permission to use/disclose PHI. The deidentified data set that is permissible for usage may contain the following demographic factors: gender and age of individuals and a three-digit ZIP code. Note that all individuals 90 years of age or older are listed as 90 years of age.
To prevent the onerous task of requiring patients who have been discharged from healthcare settings to sign such permission forms, researchers are allowed to submit a request for a waiver. The waiver is a request to forego the authorization requirements based on two conditions: (1) the use and/or disclosure of PHI involves minimal risk to the subject’s privacy, and (2) the research cannot be done practically without this waiver. Additional information about HIPAA and confidentiality are covered later in this chapter.
Concerns over the past abuses that have occurred in the area of research with children have led to the adoption of federal guidelines specifically designed to protect children when they are enrolled as research subjects. Before proceeding under these specific guidelines, state and local laws must be reviewed for laws regulating research on human subjects. In 1998 Subpart D: Additional Protections for Children Involved as Subjects in Research was added to the code (Protection of Human Subjects, 1998, 46.401 et seq.). These sections were added to give further protection to children when they are subjects of research studies and to encourage researchers to involve children, where appropriate, in research.
A final issue with informed consent about which nurses and nurse managers should be cognizant concerns health literacy, or the degree to which individuals have the capacity to obtain, process, and understand basic health information, including services needed to make appropriate health decisions. Functional health literacy relates to the person’s ability to act on the basic health information received. Comprehending medical jargon is difficult for well-educated Americans; about 12% of American adults are considered proficient in health literacy (Department of Health and Human Services, 2012). Comprehending medical instructions and terms may be impossible for individuals whose first language is not English, who cannot read at greater than a second-grade level, or who have vision or cognitive problems caused by aging or disabilities. These individuals have difficulty following instructions printed on medication labels (both prescription and over-the- counter), interpreting hospital consent forms, and even understanding diagnoses, treatment options, and discharge instructions.
Nurses play a significant role in addressing this growing problem. The first issue to address is awareness of the problem, because many patients and their family members hide the fact that they cannot read or do not understand what healthcare providers are attempting to convey. A second issue involves ensuring that the information and words nurses use to communicate with patients are at a level that the person can comprehend. One means to ensure that patients do understand patient discharge information and medication instructions is to give a patient a bottle of prescription medication and ask him or her to tell you how he or she would take the medication at home.
105
Privacy and confidentiality Privacy is the patient’s right to protection against unreasonable and unwarranted interference with his or her solitude. This right extends to protection of the person’s reputation as well as protection of one’s right to be left alone. Within a medical context, the law recognizes the patient’s right to protection against (1) appropriation of the patient’s name or picture for the institution’s sole advantage, (2) intrusion by the institution on the patient’s seclusion or affairs, (3) publication of facts that place the patient in a false light, and (4) public disclosure of private facts about the patient by the hospital or staff. Confidentiality is the right to privacy of the health record. Institutions can reduce potential liability in this area by allowing access to patient data, either written or oral, only to those with a “need to know.” Persons with a need to know include physicians and nurses caring for the patient, technicians, unit clerks, therapists, social service workers, and patient advocates. Usually this need to know extends to the house staff and consultants. Others wishing to access patient data must first ask the patient for permission to review a record. Administrative staff of the institution can access the patient record for statistical analysis, staffing, and quality-of-care review.
The nurse manager is cautioned to ensure that staff members both understand and abide by rules regarding patient privacy and confidentiality. “Interesting” patients should not be discussed with others, and all information concerning patients should be given only in private and secluded areas. All nurses may need to review the current means of giving reports to oncoming shifts and policies about telephone information. Many institutions have now added to the nursing care plan a place to list persons to whom the patient has allowed information to be given. If the caller identifies himself or herself as one of those listed persons, the nurse can give patient information without violating the patient’s privacy rights. Patients are becoming more knowledgeable about their rights in these areas, and some have been willing to take offending staff members to court over such issues. With the advent of social media, nurses must be cautious that their personal posts on Facebook, Twitter, or other platforms do not include pictures and/or information about their patients. This would constitute a violation of the patient’s right to privacy and confidentiality. This would also be considered professional misconduct according to the nurse practice act.
The patient’s right of access to his or her health record is another confidentiality issue. Although the patient has a right of access, individual states mandate when this right applies. Most states give the right of access only after the health record is completed; thus the patient has the right to review the record after discharge. Some states give the right of access while the patient is hospitalized, and therefore individual state law governs individual nurses’ actions. When supervising a patient’s review of his or her record, the nurse manager or representative should explain only the entries that the patient questions or about which the patient requests further clarification. The nurse makes a note in the record after the session, indicating that the patient viewed the record and what questions were answered.
Patients also have a right to copies of the record, at their expense. The health record belongs to the institution as a business record, and patients never have the right to retain the original record. This is also true in instances in which a subpoena is obtained to secure an individual’s health record for court purposes. A hospital representative will verify that the copy is a “true and valid” copy of the original record.
An issue that is closely related to the health record is that of incident reports or unusual occurrence reports. These reports are mandated by TJC and serve to alert the institution to risk management and quality assurance issues within the setting. As such, incident reports are considered internal documents and thus not discoverable (open for review) by the injured party or attorneys representing the injured party. In most jurisdictions where this question has arisen, however, the courts have held that the incident report was discoverable and thus open to review by both sides of the suit.
Therefore prudent nurse managers complete and have staff members complete incident reports as though they will be open records, omitting any language of liability, such as, “The patient would not have fallen if Jane Jones, RN, had ensured the side rails were in their up and locked position.” This document should contain only pertinent observations and care given the patient, such as x- rays that were obtained for a potential broken bone, medication that was given, and consultants who were called to examine the patient. Making any notation of the incident report in the official patient record is inadvisable, because such a notation incorporates the incident report “by
106
reference,” and thus can be seen by the injured party or attorneys for the injured party. PHI is at the crux of the confidentiality aspect of the law. The privacy standards limit how PHI
may be used or shared, mandate safeguards for protecting the health information, and shift the control of health information from providers to the patient by giving patients significant rights. Healthcare facilities must provide patients with a documented Notice of Privacy Rights, explaining how PHI will be used or shared with other entities. This document also alerts patients to the process for complaints if they later determine that their information rights have been violated. Nurse managers have the responsibility to ensure that those they supervise uphold these patient rights as dictated by HIPAA and to take corrective actions should these rights not be upheld.
107
Policies and procedures Risk management is a process that identifies, analyzes, and treats potential hazards within a given setting. The object of risk management is to identify potential hazards and eliminate them before anyone is harmed or disabled. Risk management activities include writing policies and procedures, which is a requirement of TJC. These documents set standards of care for the institution and direct practice. They must be clearly stated, well delineated, and based on current practice. Nurse managers should review the policies and procedures frequently for compliance and timeliness. If policies are absent or outdated, the nurse manager must request the appropriate person or committee to either initiate or update the policy.
E x e r c i s e 3 . 5 You are assigned some risk management activities in the nursing facility where you work. In investigating incident reports filed by staff, you discover that this is the third incident this week in which a patient has fallen while attempting to get out of bed and sit in a chair. How would you begin to address this issue? Decide how you would start a more complete investigation of this issue. For example, is it a facility-wide issue or one that is confined to one unit? Does it affect all shifts or only one? What safety issues are you going to discuss with your staff, and how are you going to discuss these issues? Do these falls involve the same staff member?
108
Employment laws The federal and individual state governments have enacted laws regulating employment. To be effective and legally correct, nurse managers must be familiar with these laws and how the individual laws affect the institution and labor relations. Many nurse managers have come to fear the legal system because of personal experience or the experiences of colleagues, but much of this concern may be directly attributable to uncertainty with the law or partial knowledge of the law. By understanding and correctly following federal employment laws, nurse managers may actually decrease their potential liability by complying with both federal and state laws. Table 3.2 gives an overview of key federal employment laws.
Table 3.2
Selected Federal Labor Legislation
Year Legislation Primary Purpose of the Legislation 1935 Wagner Act; National Labor Act Unions, National Labor Relations Board established; unionization rights established 1947 Taft-Hartley Act Established a more equal balance of power between unions and management 1962 Executive Order 10988 Allowed public employees to join labor unions 1963 Equal Pay Act Became illegal to pay lower wages based solely on gender 1964 Civil Rights Act Protected against discrimination based on race, color, creed, national origin, etc. 1967 Age Discrimination in Employment Act Protected against discrimination based on age 1970 Occupational Safety and Health Act Established the development and enforcement of standards for occupational health and
safety 1974 Wagner Amendments Allowed nonprofit organizations to unionize and allowed collective bargaining in
nursing 1990 Americans With Disabilities Act Barred discrimination against workers with disabilities in the workplace 1991 Civil Rights Act Addressed sexual harassment in the workplace 1993 Family and Medical Leave Act Allowed work leaves based on family and medical needs 1996 Health Insurance Portability and
Accountability Act Provided for the phased introduction of a comprehensive system of mandated health insurance reforms
2010 Patient Protection and Accountability Act Provided for the phased introduction of a comprehensive system of mandated health insurance reforms
2010 Health Care and Education Reconciliation Act
Amended the Patient Protection and Affordable Care Act to clarify budget resolutions
Equal Employment Opportunity Laws Several federal laws have been enacted to expand equal employment opportunities by prohibiting discrimination based on gender, age, race, religion, handicap, pregnancy, and national origin. The Equal Employment Opportunity Commission (EEOC) enforces these laws. All states have also enacted statutes that address employment opportunities, and the nurse manager should consider both when hiring and assigning nursing employees.
The most significant legislation affecting equal employment opportunities today is the amended Civil Rights Act of 1964. Section 703(a) of Title VII makes it illegal for an employer “to refuse to hire, discharge an individual, or otherwise to discriminate against an individual, with respect to his compensation, terms, conditions, or privileges of employment because of the individual’s race, color, religion, sex, or national origin.” The Equal Employment Opportunity Act of 1972 also amended Title VII so that it applies to private institutions with 15 or more employees, state and local governments, labor unions, and employment agencies.
The amended Civil Rights Act of 1991 further broadened the issue of sexual harassment in the workplace and supersedes many of the sections of Title VII. Sections of the new legislation define sexual harassment, its elements, and the employer’s responsibilities regarding harassment in the workplace, especially prevention and corrective action. The Civil Rights Act of 1991 is enforced by the EEOC. The primary activity of the EEOC is processing complaints of employment discrimination. Three phases comprise processing complaints: investigation, conciliation, and litigation. Investigation focuses on determining whether the employer has violated provisions of Title VII. If the EEOC finds “probable cause,” an attempt is made to reach an agreement or conciliation between the EEOC, the complainant, and the employer. If conciliation fails, the EEOC may file suit against the employer in federal court or issue to the complainant the right to sue for discrimination under its auspices, including those relating to staffing practices and sexual
109
harassment in the workplace. The EEOC defines sexual harassment broadly, and this has generally been upheld in the courts.
Nurse managers must realize that it is the duty of employers (management) to prevent employees from sexually harassing other employees. The EEOC issues policies and practices for employers to implement, both to sensitize employees to this problem and to prevent its occurrence. Nurse managers should be aware of these policies and practices and seek guidance in implementing them if sexual harassment occurs in their units.
Employers may seek exceptions to Title VII on a number of premises. For example, employment decisions made on the basis of national origin, religion, and gender (never race or color) are lawful if such decisions are necessary for the normal operation of the business, although the courts have viewed this exception very narrowly. Promotions and layoffs based on bona fide seniority or merit systems are permissible, as are exceptions based on business necessity.
Age Discrimination in Employment Act of 1967 The Age Discrimination in Employment Act of 1967 made discrimination against older men and women by employers, unions, and employment agencies illegal. A 1986 amendment to the law prohibits discrimination against persons older than 40 years. The practical outcome of this act has been that mandatory retirement is no longer allowed in the American workplace.
As with Title VII, some exceptions to this act exist. Reasonable factors other than age may be used when terminations become necessary. Reasonable factors may include a performance evaluation system or certain limited occupational qualifications, such as the tedious physical demands of a specific job.
Americans With Disabilities Act of 1990 The Americans with Disabilities Act (ADA) of 1990 provides protection to persons with disabilities and is the most significant civil rights legislation since the Civil Rights Act of 1964. The purpose of the ADA is to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities and to provide clear, strong, consistent, enforceable standards addressing discrimination in the workplace. The ADA is closely related to the Civil Rights Act of 1991 and incorporates the antidiscrimination principles established in Section 504 of the Rehabilitation Act of 1973.
The act has five titles; Table 3.3 depicts the pertinent issues of each title. The ADA has jurisdiction over employers, private and public; employment agencies; labor organizations; and joint labor- management committees. Disability is defined broadly. With respect to an individual, a disability is (1) a physical or mental impairment that substantially limits one or more of the major life activities of such individual, (2) a record of such impairment, or (3) an individual being regarded as having such impairment (ADA Amended Act, 2008). The effects of this amended act were to allow the definition of disability to be as broad as possible, and also to disallow impairments that are transitory (6-month duration or less) and minor. It also allows the definition to include an impairment that is episodic or in remission if the disability substantially limits a major life event when not in remission.
Table 3.3
Americans With Disabilities Act of 1990
Title Provisions I Employment: defines the purpose of the act and who is qualified under the act as having a disability II Public services: concerns services, programs, and activities of public entities as well as public transportation III Public accommodations and services operated by private entities: prohibits discrimination against persons with disabilities in areas of
public accommodations, commercial facilities, and public transportation services IV Telecommunications: intended to make telephone services accessible to individuals with hearing or speech impairments V Miscellaneous provisions: certain insurance matters; incorporation of this act with other federal and state laws
Source: Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 et seq. (1990).
The overall effect of the legislation is that persons with disabilities will not be excluded from job opportunities or adversely affected in any aspect of employment unless they are not qualified or are otherwise unable to perform the job. The ADA thus protects qualified individuals with disabilities
110
in regard to job application procedures, hiring, compensation, advancement, and all other employment matters.
The number of lawsuits filed under the ADA since its enactment is extensive. This is due in part to the fact that to prevent the act from being overly narrow, the determination of qualified individuals is done case by case, and the individual must show (1) that he or she has a physical or mental impairment, (2) that the impairment substantially limits one or more major life activities, and (3) that he or she is still able to perform the essential function of the employment position sought or in which the individual is currently employed.
The ADA requires an employer or potential employer to make reasonable accommodations to employ persons with a disability. The law does not mandate that individuals with a disability be hired before fully qualified persons who do not have a disability; it does mandate that those with disabilities not be disqualified merely because of an easily accommodated disability. An example appears in the Case Example Box 3.3.
Case Example Box 3.3 The issue of reasonable accommodations was well illustrated by the court in Zamudio v. Patia (1997). The court stated that the employer would be required to inform Ms. Zamudio when a position became available for which the reasonable accommodation she required could be met. She would be allowed to apply, but “as a disabled employee seeking reasonable accommodation she did not have to be given preference over other employees without disabilities who might have better qualifications or more seniority” (Zamudio v. Patia, 1997, at 808).
Moreover, the court will not impose job restructuring on an employer if the person needing accommodation qualifies for other jobs not requiring such accommodation. In Mauro v. Borgess Medical Center (1995), the court refused to impose accommodation on the employer hospital merely because the affected employee desired to stay within a certain unit of the institution. In this case an operating surgical technician who tested positive for HIV was offered an equivalent position by the hospital in an area where there would be no patient contact. He refused the transfer, desiring accommodation within the operating arena, and was denied such accommodation by the Michigan court.
The act also provides for essential job functions. These are defined by the ADA as those functions that the person must be able to perform to be qualified for employment positions. Courts have assisted in determining these essential job functions. For example, in Moschke v. Memorial Medical Center of West Michigan (2003), the court determined that the ability to take “on-call” work is an essential function of a surgical nurse’s job. Such on-call work involves the ability of the surgical nurse to be available when emergency cases or scheduling problems require the staff to work beyond their assigned shifts. In Laurin v. Providence Hospital and Massachusetts Nurses Association (1998), the ability to work rotating shifts was held to be an essential job function.
The act specifically excludes the following from the definition of disability: homosexuality and bisexuality, sexual behavioral disorders, gambling addiction, kleptomania, pyromania, and current use of illegal drugs (ADA, 1990). Employers may hold persons with alcohol issues to the same job qualifications and job performance standards as other employees, even if the unsatisfactory behavior or performance is related to alcoholism (ADA, 1990). As with other federal employment laws, the nurse manager should have a thorough understanding of the law as it applies to the institution and his or her specific job description and should know whom to contact within the institution structure for clarification as needed.
Affirmative Action The policy of affirmative action (AA) differs from the policy of equal employment opportunity (EEO). AA policy enhances employment opportunities of protected groups of people; EEO policy is concerned with implementing employment practices that do not discriminate against or impair the employment opportunities of protected groups. Thus AA can be seen in conjunction with several federal employment laws. For example, in conjunction with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, AA requires that employers with government contracts take steps to enhance the employment opportunities of veterans with disabilities who served during the
111
Vietnam Era.
Equal Pay Act of 1963 The Equal Pay Act of 1963 makes it illegal to pay lower wages to employees of one gender when the jobs (1) require equal skill in experience, training, education, and ability; (2) require equal effort in mental or physical exertion; (3) are of equal responsibility and accountability; and (4) are performed under similar working conditions. Courts have held that unequal pay may be legal if it is based on seniority, merit, incentive systems, or a factor other than gender. The main cases filed under this law in the area of nursing have been by nonprofessionals.
Occupational Safety and Health Act The Occupational Safety and Health Administration (OSHA) Act of 1970 was enacted to ensure that healthful and safe working conditions would exist in the workplace. Among other provisions, the law requires isolation procedures, placarding areas containing ionizing radiation, proper grounding of electrical equipment, protective storage of flammable and combustible liquids, and the gloving of all personnel when handling bodily fluids. The statute provides that if no federal standard has been established, state statutes prevail. Nurse managers should know the relevant OSHA laws for the institution and their specific area. Frequent review of new additions to the law also must be undertaken, especially in this era of acquired immunodeficiency syndrome (AIDS) and other infectious diseases.
Violence in the workplace is an issue that OSHA continues to address in its rules. Violence is perhaps the greatest hidden health and safety threat in the workplace today, and nurses, as the largest group of healthcare professionals, are most at risk of assault at work. In 1996 OSHA developed voluntary guidelines to protect healthcare workers and consumers. Relatively few states have laws that mandate employers to report incidents of workplace violence, although more states have enacted laws that strengthen or increase penalties for acts of workplace violence. Additionally, TJC created standards that address the incidence and prevention of workplace violence, and the American Nurses Association (ANA) generated a model state bill entitled The Violence Prevention in Health Care Facilities Act (ANA, 2012a).
Another important workplace concern is the issue of safe patient handling, preventing injury to healthcare workers while ensuring that patients are protected as they are transferred or moved in healthcare settings. The ANA (2012b) reported that more than one-third of back injuries in nurses are associated with the handling of patients. Given these data and recognizing that manual patient lifting simply is not safe, the ANA promotes legislation that would require hospitals and other healthcare institutions to develop programs to prevent work-related musculoskeletal disorders and eliminate manual patient lifting. Toward this end, a few states have passed safe patient handling legislation.
In 2012, OSHA initiated its National Emphasis Program (NEP) for nursing and residential care facilities to focus on the workplace hazards that are the most common in the healthcare industry, including ergonomic stressors related to patient lifting. The desire is that this momentum will lead to federal laws that would require mechanical lifting equipment and friction-reducing devices for all healthcare workers, patients, and residents across all healthcare settings. Published in 2015, the “Inspection Guidance for Inpatient Healthcare Settings” memorandum further directs OSHA Regional Administrators and State Plans to focus inspections at these facilities to reduce five primary hazards: musculoskeletal disorders related to patient or resident handling; blood-borne pathogens; workplace violence; tuberculosis; and, slips, trips, and falls.
Family and Medical Leave Act of 1993 The Family and Medical Leave Act of 1993 was passed because of the large numbers of single- parent and two-parent households in which the single parent or both parents are employed full time, placing job security and parenting at odds. The law also supports the growing demands that aging parents are placing on their working children. The act was written in an attempt to balance the demands of the workplace with the demands of the family, allowing employed individuals to take leaves for medical reasons, including the birth or adoption of children and the care of a spouse, child, or parent who has serious health problems. Essentially, the act provides job security for
112
unpaid leave while the employee is caring for a new infant or other family healthcare needs. The act is gender-neutral and allows both men and women the same leave provisions. Medical leave may be taken to care for a spouse, son, daughter, or parent of the employee when that person has a serious medical condition. Employees are also permitted to use medical leave for their own serious health condition.
To be eligible under the act, the employee must have worked for at least 12 months and worked at least 1250 hours during the preceding 12-month period. The employee may take up to 12 weeks of unpaid leave. The act allows the employer to require the employee to use all or part of any paid vacation, personal leave, or sick leave as part of the 12-week family leave. Employees must give the employer 30 days advance notice, or such notice as is practical in emergency cases, before using the medical leave.
On January 28, 2008, President George W. Bush signed the Family and Medical Leave Amended Act of 2008, which became effective January 16, 2009. The amendments permit a spouse, son, daughter, parent, or next of kin to take up to 26 work weeks of leave to care for a member of the U.S. Armed Forces, including a member of the National Guard or Reserves, who is undergoing medical treatment, recuperation, or therapy; is otherwise in outpatient status; or is otherwise on the temporary disability retired list, for a serious injury or illness. In addition, the act permits an employee to take leave for any qualifying exigency arising out of the fact that the spouse or a son, daughter, or parent of the employee is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation. In 2013 the FMLA was amended to address changes concerning calculating employee eligibility for FMLA leave, military caregiver leave for veterans, qualifying exigency leave for parental care, tracking intermittent or reduced-schedule FMLA leave, and special leave provisions for flight crew employees.
Employment-at-Will and Wrongful Discharge Historically, the employment relationship has been considered a “free will” relationship. Employees were free to take or not take a job at will, and employers were free to hire, retain, or discharge employees for any reason. Many laws, some federal but predominantly state, have been slowly eroding this at-will employment relationship. Evolving case law provides at least three exceptions to the broad doctrine of employment-at-will.
The first exception is a public policy exception. This exception involves cases in which an employee is discharged in direct conflict with established public policy. Under this exception, an employer may not discharge an employee if it would violate the state’s public policy doctrine or a state or federal statute. Some examples include discharging an employee for serving on a jury, reporting employers’ illegal actions (better known as whistle-blowing, or the disclosure of information regarding misconduct within a workplace that either is illegal or endangers the welfare of others), and filing a workers’ compensation claim. Most states and the District of Columbia recognize public policy as an exception to the at-will rule.
Several recent court cases attest to the number of terminations in healthcare settings that serve as retaliation for the employer. More commonly known as whistle-blowing cases, the healthcare provider in these cases is terminated for one of three distinct reasons: (1) speaking out against unsafe practices, (2) reporting violations of federal laws, or (3) filing lawsuits against employers. Essentially, whistleblower laws state that no employer can discharge, threaten, or discriminate against an employee regarding compensation, terms, conditions, location, or privileges of employment because the employee in good faith reported or caused to be reported, verbally or in writing, what the employee had a reasonable cause to believe was a violation of a state or federal law, rule, or regulation. Most whistleblowers are internal; that is, they report misconduct to a fellow employee or supervisor within the agency. External whistleblowers are those who report misconduct to outside persons or entities. Examples appear in the Case Example Boxes 3.4 and 3.5.
Case Example Box 3.4 Martell v. Tarpon Springs Hospital (2010) concerned a hospital surgical nursing supervisor with a spotless 14-year record who was fired 10 days after she voiced a complaint that the hospital administrator had falsified records. In these falsified records, the administrator had personally
113
certified a number of hospital nurses’ annual cardiopulmonary resuscitation retraining, which neither he nor anyone else had actually done. During the trial, it was further disclosed that this same administrator had been fired from his previous employments for falsifying time records and for poor performance.
The jury in the case awarded the former nursing supervisor $425,000 as damages for compensation for emotional distress and the fact that her new employment paid less, had fewer benefits, and was less personally satisfying than her former position. The jury also noted that complaining about an illegal action by a superior was expressly protected by the state’s whistleblower-protection law and that the hospital had no grounds on which to dismiss her.
Case Example Box 3.5 Perhaps one of the best-known whistleblower cases involving nurses is what has become known as the Winkler County Nurses Lawsuit (Yoder-Wise, 2010). The case became nationally known after two registered nurses, Anne Mitchell and Vicki Galle, were terminated by the Winkler County Hospital in Kermit, Texas. The nurses first attempted to report a physician’s behavior and negligent healthcare practices through designated hospital channels. When the hospital took no action, they reported the physician to the Texas Medical Board for serious misconduct, substandard care, and an inappropriate business partnership with the sheriff of Winkler County.
Although the usual procedure was for the medical board to investigate and keep the complainants’ names confidential, the sheriff used the power of his position to learn that the reporting nurses had worked at the hospital for about 20 years and that each nurse was about 50 years old. That information allowed the sheriff to identify the two nurses; he then used his office to confiscate the nurses’ computers, where he found the letter to the Texas Medical Board. The nurses were subsequently terminated and indicted on felony charges of misuse of official information, which could have resulted in their imprisonment for 10 years.
The criminal charges against Vicki Galle were dismissed the day before the trial was to occur, though the trial proceeded against Anne Mitchell. The trial lasted less than 4 days, with the jury returning a not guilty verdict. The nurses later filed successful civil lawsuits against the physician, Winkler County, the hospital and its administrator, the sheriff, and the district and county attorneys of Winkler County (Mitchell & Galle v. Winkler County et al., 2010). Their cause of action included violations of their rights of free speech and due process, whistleblower retaliation, and interference with their business relationship, specifically their employment status.
The second exception to wrongful discharge involves situations in which an implied contract exists. The courts have generally treated employee handbooks, company policies, and oral statements made at the time of employment as “framing the employment relationship” (Watkins v. Unemployment Compensation Board of Review, 1997). For example, in Trombley v. Southwestern Vermont Medical Center (1999), the court found that the employee handbook outlined the procedure for progressive discipline, mandating that such procedure be followed before a nurse could be terminated for incompetent nursing care.
The third exception to wrongful discharge is a “good faith and fair dealing” exception. The purpose of this exception is to prevent unfair or malicious terminations, and the courts use the exception sparingly. States also do not favor this exception, and today less than a quarter of the states recognize breach of such implied contracts. Although this exception is rarely seen in nursing, it remains a valid exception to wrongful discharge of an employee.
Nurse managers are urged to know their respective state laws concerning this growing area of the law, particularly in conjunction with whistleblower laws. Managers should review institution documents, especially employee handbooks and recruiting brochures, for unwanted statements implying job security or other unintentional promises. Managers are also cautioned not to say anything during the preemployment negotiations and interviews that might be construed as implying job security or other unintentional promises to the potential employee. To prevent successful suits for retaliation by whistleblowers, nurse managers should carefully monitor the treatment of an employee after a complaint is filed and ensure that performance evaluations are conducted and placed in the appropriate files. The nurse manager should also take steps to correct the whistleblower’s complaint or refer the complaint to upper management so that it can effectively
114
be addressed.
Collective Bargaining Collective bargaining, also called labor relations, is the joining together of employees for the purpose of increasing their ability to influence the employer and improve working conditions. Collective bargaining is defined and protected by the National Labor Relations Act of 1935 and its amendments; the National Labor Relations Board (NLRB) oversees the act and those who come under its auspices. The NLRB ensures that employees can choose freely whether they want to be represented by a particular bargaining unit, and it serves to prevent or remedy any violation of the labor laws. Chapter 14 provides further detail regarding collective bargaining and collective action.
115
Professional nursing practice: ethics Ethics is the study of standards of conduct and moral judgment and is an area of professional practice in which nurse managers should have a solid foundation because it is increasingly an issue in clinical practice settings. However, it remains an area in which many nurses feel the most inadequate. This is partially because ethics is much more nebulous than are laws and regulations. In ethics, right and wrong answers are usually not possible, just better or worse answers, and nurses seek mentorship and counseling from nurse managers when they encounter difficult situations. Thus nurse managers must have a deep understanding of ethical principles and their application.
Ethics may be distinguished from the law because ethics is internal to an individual, looks to the ultimate “good” of an individual rather than society as a whole, and concerns the “why” of one’s actions. The law, comprising rules and regulations pertinent to society as a whole, is external to oneself and concerns one’s actions and conduct. Ethics concerns the individual within society, whereas law concerns society as a whole. Law can be enforced through the courts, statutes, and boards of nursing, whereas ethics is enforced via ethics committees and professional codes.
Today, ethics and legal issues often become entwined, and it may be difficult to separate ethics from legal concerns. Legal principles and doctrines assist the nurse manager in decision making; ethical theories and principles are often involved in those decisions. Thus the nurse manager must be cognizant of both laws and ethics in everyday management concerns, remembering that ethical principles form the essential base of knowledge from which to proceed, rather than giving easy, straightforward answers.
Ethical Principles Ethical principles, used daily in patient care situations, are equally paramount to the nurse manager. Ethical principles that nurse managers should consider when making decisions include the eight items listed in Box 3.4. Each of the principles is applied daily in clinical practice, though some principles are used a greater degree than others.
Box 3.4
E t h i c a l P r i n c i p l e s
The principle of autonomy addresses personal freedom and self-determination, the right to choose what will happen to oneself as well as the accountability for making individual choices. The legal doctrine of informed consent is a direct reflection of this principle. Autonomy involves respect for others’ decisions, even if the nurse manager does not agree with the decision chosen. An example could be in the instance of progressive discipline. The employee has the option to meet delineated expectations or accept the consequences of not complying with these delineated expectations.
The principle of beneficence states that the actions one takes should promote good; beneficence is the basic obligation to assist others. Nurse managers use this principle when encouraging employees to seek more challenging clinical experiences or to take on additional responsibilities, such as the position of assistant manager of a specific unit. Progressive discipline incorporates this principle when the employee’s positive attributes and qualities are included when developing goals and expected outcomes.
The corollary of beneficence, the principle of nonmaleficence, states that one should do no harm. For a nurse manager following this principle, performance evaluation should emphasize an employee’s good qualities and give positive direction for growth. Destroying the employee’s self- esteem and self-worth would be considered doing harm under this principle.
116
Veracity concerns telling the truth and demands that the truth be told completely. Nurse managers employ this principle when they give all the facts of a situation truthfully and then assist employees to make appropriate decisions. For example, when encouraging a staff member to accept a promotion to a position of greater responsibility, both the challenges and the benefits of the position must be discussed.
Justice is the principle of treating all persons equally and fairly. This principle most often arises in times of short supplies or when competition for resources or benefits is occurring. Nurse managers use justice when they decide which staff members to promote or to recommend for professional development opportunities. The staff member’s overall performance and skills should be considered rather than who may have seniority or the popular vote of his or her peer group. Justice is also encountered when deciding who should be floated to another unit or service within the institution or which staff member should be moved to a straight day position rather than remaining on a rotating schedule.
The principle of paternalism allows one person to make partial decisions for another and is most frequently deemed to be a negative or undesirable principle. Paternalism, however, may be used to assist persons to make decisions when they do not have sufficient data or expertise. Paternalism becomes undesirable when the entire decision is taken from the employee. Nurse managers use this principle in a positive manner by assisting employees in deciding major career moves and plans, helping the staff member more
L i t e r a t u r e Pe r s p e c t i ve Resource: Hyatt, J. (2017). Recognizing moral disengagement and its impact on patient safety. Journal of Nursing Regulation, 7(4), 15-19.
This article focuses on moral disengagement, the process of changing one’s moral perceptions to justify actions that are unethical. One of the most common examples of this is when nurses say they were simply following policy; in other words, it is the organization’s fault. The author points out that one of the major precursors is dysfunctional or culture issues related to power issues and disruptive actions. In essence, moral disengagement is cognitive dissonance. “Moral disengagement reduces cognitive dissonance by reframing the situation so the person performing the unethical act no longer perceives it as unethical” (p.16). Several clinical, organizational, and interpersonal examples are provided to illustrate the potential complexity and severity of this problem. Hyatt identifies the process of moving from moral distress, to cognitive dissonance, to moral numbness, to moral disengagement. Three primary mechanisms are at play: shifting blame, reevaluating the gravity of the act, and minimizing the consequences.
Implications for Practice The complexity of care in many settings contributes to the potential to become disengaged. Knowing how moral distress moves to disengagement allows us to intervene early in our feelings of angst so that we don’t threaten patient safety.
fully understand all aspects of a possible career change, or, conversely, assisting staff members to comprehend why such a potential change could affect their future growth opportunities within the organization.
Fidelity means keeping one’s promises or commitments. Nurse managers abide by this principle when they follow through on any promises they have previously made to employees, such as a promised leave, a certain shift to be worked, or a promotion to a preceptor position within the unit.
Many consider the principle of respect for others as the highest principle. Respect for others acknowledges the right of individuals to make decisions and to live by these decisions. Respect for others also transcends cultural differences, gender issues, and racial concerns and is the first principle enumerated in the American Nurses Association’s Code of Ethics for Nurses (2015). Nurse managers positively reinforce this principle daily in their actions with employees, patients, and peers because they serve as leaders and models for staff members and others in the institution.
When nurses disengage from the ethics of the profession and their moral perceptions, patient safety is at risk, as the Literature Perspective shows.
117
Codes of Ethics Professional codes of ethics are formal statements that articulate values and beliefs of a given professional, serving as a standard of professional actions and reflecting the ethical principles shared by its members. Professional codes of ethics generally serve the following purposes:
• Inform the public of the minimum standards acceptable for conduct by members of the discipline and assist the public in understanding a discipline’s professional responsibilities
• Outline the major ethical considerations of the profession • Provide to its members guidelines for professional practice • Serve as a guide for the discipline’s self-regulation
The Code of Ethics for Nurses (ANA, 2015) should be the starting point for any nurse faced with an ethical issue. The first American nursing code was adopted in 1950, and it focused on the character of the nurse and the virtues that were essential to the profession. In 1968 the focus shifted to a duty-based ethical focus, and in 2001 the ANA Code of Ethics for Nurses blended these duty- based ethics with a historical focus on character and virtue. In 2015 the revised provisions and interpretive statements were developed with an eye toward the future based on knowledge gained from the past. The Code of Ethics for Nurses (ANA, 2015) has nine points that guide nurses in understanding the extent of their commitment to the patient, themselves, other nurses, and the nursing profession. Further provisions in the code assist nurses in understanding that patients, whether as individuals or as members of families, groups, or communities, are their first obligation and that nurses must not only ensure quality care but also protect the safety of these patients. Nurses and their nurse managers should ensure that the provisions of the code are incorporated into nursing care delivery in all clinical settings. Along with establishing the ethical standard for the disciplines, the nursing code of ethics provides a basis for ethical analysis and decision making in clinical situations.
Ethical Decision-Making Framework Ethical decision making involves reflection on many factors such as intended outcomes, resources available, professional organizational directives, and likely and unintended consequences.
When making decisions, nurses need to combine all of these elements using an orderly, systematic, and objective method; ethical decision-making models assist in accomplishing this goal.
For most nurses, ethical decision-making models are considered only when complex ethical dilemmas present in clinical settings. In truth, however, nurses use ethical decision-making models each time an ethical situation arises, although the decision-making model may not be acknowledged or fully appreciated. Ethical dilemmas involve situations in which a choice must be made between equally unacceptable options that an individual perceives he or she can accept and reasonably justify on a moral plane or in which there is not a more favorable or appropriate choice that dominates the situation.
Ethical decision making is always a process. To facilitate this process, the nurse manager must use all available resources, including the institutional ethics committee, and communicate with and support all those involved in the process. Some decisions are easier to reach and support than others. Allowing sufficient time for the process contributes to a supportable option being reached.
Moral Distress Nurses experience stress in clinical practice settings as they are confronted with situations involving ethical dilemmas. Moral distress most often occurs when one is faced with situations in which two ethical principles compete, such as when the nurse is balancing the patient’s autonomy issues with attempting to do what the nurse knows is in the patient’s best interest. Moral distress may occur also when the nurse manager is balancing a direct care nurse’s autonomy with what the nurse manager perceives to be a better solution to an ethical dilemma. Though the dilemmas are stressful, nurses must make decisions and implement those decisions.
Seen as a major issue in nursing today, moral distress is experienced when nurses cannot provide what they perceive to be best for a given patient. Examples of moral distress include constraints caused by financial pressures, limited patient care resources, disagreements among family members
118
regarding patient interventions, and/or limitations imposed by primary healthcare providers. Moral distress may also be experienced when actions nurses perform violate their personal beliefs.
The impact of moral distress can be quite serious. McAndrew, Leske, and Garcia (2011) reported that moral distress compromises patient care and that moral distress may be manifested in such behaviors as avoiding or withdrawing from patient care situations. Additional behaviors include failure to act as a patient advocate, which often further contributes to patient discomfort and suffering.
Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions. A bibliometric analysis revealed that since 1984, 239 articles were published, with an increase after 2011. Most of them (71%) focused on nursing. Of the 239 articles, 17 empirical studies were systematically analyzed. Moral distress correlated with organizational environment (poor ethical climate and collaboration), professional attitudes (low work satisfaction and engagement), and psychological characteristics (low psychological empowerment and autonomy) (Lamiari, Borghi, & Argentero, 2015).
Nurse managers can best assist nurses experiencing moral distress by remembering that such distress may be lessened through adequate levels of knowledge regarding nursing ethics and its application, acknowledging that such distress does occur, and serving as an advocate for nurses. In this latter role, the nurse manager advocates for improvement in conditions that may directly influence moral distress, such as additional staff during periods of high patient acuity, additional counselors to work with patients’ family issues and disputes, and the implementation of in-service education and/or education concerning better communication among all levels of healthcare practitioners. These positive aspects of leadership may significantly reduce the level of moral distress encountered by direct care nurses and greatly increase their job satisfaction. Furthermore, nurses in leadership positions experience moral distress that direct care nurses do not. However, those sources of distress are the same types that direct care nurses experience—those issues simply are seen from a different perspective.
Ethics Committees With the increasing numbers of ethical dilemmas in patient situations and administrative decisions, healthcare providers are increasingly turning to hospital ethics committees for guidance. Such committees can provide both long-term and short-term assistance. Ethics committees provide structure and guidelines for potential problems, serve as open forums for discussion, and function as true patient advocates by placing the patient at the core of the committee discussions.
To form such a committee, the involved individuals should begin as a bioethical study group so that all potential members can explore ethical principles and theories. The composition of the committee should include nurses, physicians, clergy, clinical social workers, nutritional experts, pharmacists, administrative personnel, and legal experts. Once the committee has become active, individual patients or patients’ families and additional representatives of members of the healthcare delivery team may be invited to committee deliberations.
Ethics committees traditionally follow one of three distinct structures, although some institutional committees blend the three structures. The autonomy model facilitates decision making for competent patients. The patient-benefit model uses substituted judgment (what the patient would want for himself or herself if capable of making these issues known) and facilitates decision making for the incompetent patient. The social justice model considers broad social issues and is accountable to the overall institution.
In most settings, the ethics committee already exists, because complex issues divide healthcare workers. In many centers, ethical rounds, conducted weekly or monthly, allow staff members, who may later become involved in ethical decision making, to begin reviewing all the issues and to become more comfortable with ethical issues and their resolution.
Blending Ethical and Legal Issues Blending legal demands with ethics is a challenge for nursing, and no case better portrays this type of difficult decision making than does the case of Theresa (Terri) M. Schiavo. The Case Example Box 3.6 describes this situation.
119
Case Example Box 3.6 Ms. Schiavo suffered a cardiac arrest in February 1990, sustaining a period of approximately 11 minutes when she was anoxic. She was resuscitated and, at the insistence of her husband, was intubated, placed on a ventilator, and eventually received a tracheotomy. The cause of her cardiac arrest was determined to be a severe electrolyte imbalance that was directly caused by an eating disorder. In the 6 years preceding the cardiac event, Ms. Schiavo had lost approximately 140 pounds, going from 250 to 110 pounds.
During the first 2 months after her cardiac arrest, Ms. Schiavo was in a coma. She then regained some wakefulness and was eventually diagnosed as being in persistent vegetative state (PVS). She was successfully weaned from the ventilator and was able to swallow her saliva, both reflexive behaviors. However, she was not able to eat food or drink liquids, which is characteristic of PVS. A permanent feeding tube was placed so that she could receive nutrition and hydration.
Throughout the early years of her PVS, there was no challenge to the diagnosis or to the appointment of her husband as her legal guardian. Four years after her cardiac arrest, a successful lawsuit was filed against a fertility physician who failed to detect her electrolyte imbalance. A judgment of $300,000 went to her husband for loss of companionship and $700,000 was placed in a court-managed trust fund to maintain and provide care for Ms. Schiavo.
Sometime after this successful lawsuit, the close family relationship that Ms. Schiavo’s husband and her parents had began to erode and the public first became aware of Ms. Schiavo’s plight. As her court-appointed guardian noted (Wolfson, 2005): “Thereafter, what is for millions of Americans a profoundly private matter catapulted a close, loving family into an internationally watched blood feud. The end product was a most public death for a very private individual. Theresa was by all accounts a very shy, fun loving, and sweet woman who loved her husband and her parents very much. The family breach and public circus would have been anathema to her” (p. 17).
The court battles regarding the removal or retention of her feeding tube were numerous. There was adequate medical and legal evidence to show that Ms. Schiavo had been correctly diagnosed and that she would not have wanted to be kept alive by artificial means. Laws in the state of Florida, where Ms. Schiavo was a patient, allowed the removal of tubal nutrition and hydration in patients with PVS. The feeding tube was removed and later reinstated after a court order.
In October 2003, there was a second removal of the feeding tube after a higher court overturned the lower court decision that had caused the feeding tube to be reinserted. With this second removal, the Florida legislature passed what has come to be known as Terri’s Law. This law gave the Florida governor the right to demand the feeding tube be reinserted and also appoint a special guardian to review the entire case. The special guardian ad litem was appointed in October 2003. Terri’s Law was later declared unconstitutional by the Florida Supreme Court, and the US Supreme Court refused to overrule that decision.
In early 2005, during the last weeks of Ms. Schiavo’s life, the US Congress attempted to move the issue to the federal rather than Florida state court system. Finally, the Federal District Court in Florida and the 11th Circuit Court of Appeals ruled that there was insufficient evidence to create a new trial, and the US Supreme Court refused to review the findings of these two lower courts (Wolfson, 2005). Ms. Schiavo died on March 31, 2005; she was 41 years old.
Whichever side of the case one supported, the plight of Terri Schiavo created numerous ethical concerns for the nurses caring for her, as well as for the nurse managers in the clinical setting. Issues that created these conflicts ranged from working with feuding family members, to multiple media personnel attempting to cover the story, to constant editorial and news stories invading the privacy of this individual, to masses of people lined at the borders of the hospice center insisting that she be fed, to individual emotions about the correctness of either keeping or removing the feeding tube. One issue remains clear: the nurse managers and nurses caring for this particular patient had a legal obligation to either remove or reinsert the feeding tube based on the prevailing court decision or legislative act. Their individual reflections about the correctness or justice of such court decrees were secondary to the prevailing court orders.
Nurse managers should ensure that nurses whose ethical values differ from court orders are given opportunities to voice their concerns and feelings, mechanisms for requesting reassignment, and time for quiet reflection. Although no deviance can occur from one’s legal obligation, the nurse
120
manager must ensure that the emotional and psychological well-being of those he or she supervises are also recognized. Merely acknowledging that such discord can occur and allowing positive means to express this concern may be the best solution in handling these difficult legal and ethical patient situations.
Other Ethical Concerns for Nurses Other issues of concern involve autonomy and independent practice among nurses, quality of care in home and community settings, and development of nurses as leaders in the healthcare delivery field. Issues that continue to permeate ethical concerns for nurses include the patient’s right to refuse health care; issues surrounding death and dying, including the issues of hydration and nutrition for patients in persistent vegetative states; nurses’ ability to be patient advocates in today’s healthcare structure; and the ability to perform competent, quality nursing care in health care delivery systems that often reward cost-saving measures rather than quality healthcare delivery. As with ethical dilemmas in patient care, the more expertise and time one has to resolve issues, usually, the better the outcome.
121
Conclusion In addition to knowing and understanding legal terms and issues related to clinical concerns, formal leaders and managers need to know employment law, union laws, the nursing practice act, and numerous other legal findings. Though each state may have distinctive laws governing being a manager and working in a healthcare organization, the key decisions tested in court or laws that govern all healthcare operations within the United States are ones with which we must all be familiar. Legal and ethical aspects present additional opportunities for nurses to exhibit leadership capabilities.
T h e S o l u t i o n Acacia Syring
Staff members and nursing leadership began by working together to understand the varied viewpoints of the healthcare team. We attempted to understand why some of the primary healthcare providers allowed family members to be present and other primary healthcare providers insisted that family members not be present during resuscitation efforts. When asked, primary healthcare providers often noted that the behaviors and attitudes of the family members were a factor in their decision, and that one could not know in advance whether the family members might be hostile or belligerent and thus distract or prevent the healthcare team from being able to provide necessary care. Additionally, no clear hospital policy existed, many of these primary healthcare providers were more comfortable in not having the family members present, and the current practice was to assign a chaplain and social worker to provide supportive services as well as comfort and information to family members when such situations arose. Thus the family members, though not present within the patient’s room, were also not alone during this time and had the opportunity to ask questions.
We then looked at the issue from an ethical perspective. For many patients and family members, being present during this crucial time could have many positive effects, thus beneficence and respect for others were the two ethical principles that most clearly seemed to support family presence. Seeing for themselves and understanding that everything possible was being done to save their loved one’s life were the most positive outcomes to support family presence. Family members could later have an opportunity to more fully question why certain aspects were performed, and the nursing staff as well as the primary care provider could then explain in more detail answers to the family members’ questions.
Viewing the literature about this topic was enlightening. We discovered that this topic has continually been studied, dating back to the early 1980s. These studies almost uniformly noted that family presence did not alter the effectiveness of the healthcare team’s interventions, nor did family presence interfere with the duration of resuscitative efforts or selection of medications. Some of the more recent studies addressed the issue of interference by family members and noted that very few family members were aggressive or in conflict with the team’s performance and that family members excluded from being present expressed regret at not having been present during resuscitation. Interestingly, some of the reviewed studies continued to question how to best determine which family members should be given the option of viewing resuscitation measures or whether all families should be given this option. At present, we continue to explore possible guidelines concerning family presence during resuscitation, recognizing that such a complex issue cannot be rapidly resolved.
Would this be a suitable approach for you? Why?
122
Reflections Consider a situation you may have observed in the clinical area that made you wonder if the action taken was legal or ethical. What triggered that thought for you? What did you think you would have done differently?
123
The evidence State boards of nursing have worked diligently to uphold high standards of accountability to the public. One example is the enhanced nurse licensure compact agreement. When nurses face ethical or legal concerns, they have resources available through their employment setting, the state board of nursing, and the state professional nursing association.
124
Tips for incorporating legal and ethical issues in practice settings
• Read the state nurse practice act, ensuring compliance with the allowable scope of practice. • Apply legal principles in all healthcare settings. • Understand and follow state and federal employment laws. • Follow the Code of Ethics for Nurses (ANA, 2015) in all aspects of healthcare delivery. • Remember that no right and wrong answers exist in ethical situations, merely better or
worse solutions. Consider all aspects and consult with others before proceeding if there are unanswered questions.
• If legal and ethical issues are contradictory, legal aspects are enacted first.
125
References Age Discrimination in Employment Act of 1967, P.L. 90-202, 29 United States Code
621 (December 15, 1967). American Nurses Association. Workplace violence. Available at
http://nursingworld.org/workplaceviolence. 2012a. American Nurses Association. Safe patient handling. Available at
http://www.anasafepatienthandling.org. 2012b. American Nurses Association (ANA). Code of ethics for nurses with interpretive
statements. Washington, DC: Author; 2015. Americans with Disabilities Act of 1990, Public Law 101-336, 104 Statutes 327 (July
26, 1990). Americans with Disabilities Amended Act of 2008, Public Law 110-325 (September
25, 2008). Black's Law Dictionary. (1979). (5th ed.). St. Paul, MN: West Publishing Company. Civil Rights Act of 1964, P. L. 88-352, 78 Statutes 241, § 703 et seq. (July 2, 1964). Civil Rights Act of 1991, P. L. 102-166 (November 21, 1991). Department of Health and Human Services. Quick guide to health literacy: Fact
sheet. U.S. Department of Printing and Engraving Washington, DC: Author; 2012.
Equal Employment Opportunity Act of 1972, 78 Statutes 253; 42 U.S.C. 2000e (March 24, 1972).
Equal Pay Act of 1963, P. L. 88-38, 77 Statutes 56 (June 10, 1963). Family and Medical Leave Act of 1993, P. L. 103-3, 107 Statutes 6 (February 5, 1993). Family and Medical Leave Amended Act of 2008, P. L. 110-181, 122 Statutes 128
(January 28, 2008). Health Insurance Portability and Accountability Act of 1996, Public Law 104-191,
100 Statutes 2548, (August 21, 1996). Lamiari, G., Borghi, L., & Argentero, P. (2015). When healthcare professionals
cannot do the right thing: A systematic review of moral distress and its correlates. Journal of Health Psychology, July 27, 2015.
Laurin v. Providence Hospital and Massachusetts Nurses Association, 150 F.3d 52 (1st Cir., 1998).
Marinock v. Manor at St. Luke’s, 2010 WL 3233125 (Ct. Com. Pl. Luzerne Co., Pennsylvania, January 29, 2010).
Mitchell & Galle v. Winkler County et al., CV 00037-RAJ, Document 42, Winkler County Trail Court, filed April 18, 2010.
Martell v. Tarpon Springs Hospital, 2010 WL 5485106 (Cir. Ct. Pinellas Co., Florida, September 29, 2010).
Massey v. Mercy Medical Center, 180 Cal. App. 4th 690, 103 Cal. Rept. 3d 209 (Cal. App., December 22, 2009).
Mauro v. Borgess Medical Center, 4:94 CV 05 (Mich., 1995). McAndrew N.S., Leske J.S., Garcia A. Influence of moral distress on the
professional practice environment during prognostic conflict in critical care. Journal of Trauma Nursing. 2011;18(4):221–230.
Moschke v. Memorial Medical Center of West Michigan, 2003 WL 462374 (Mich. App., February 21, 2003).
National Academy of Medicine (formerly Institute of Medicine). To err is human: Building a safer health care system. Washington, DC: The National Academies Press, Institute of Medicine; 1999.
National Labor Relations Act, P. L. 74-198, 49 Statutes 449 (July 5, 1935).
126
National Safety Council Safety and Health, Understanding OSHA’s Special Emphasis Programs, February 4, 2015.
Occupational Safety and Health Administration Act of 1970, P. L. 91-595, 84 Statutes 1590 (December 29, 1970).
O’Shea v. State of New York, WL 1516492 (N.Y. Ct. Cl., January 22, 2007). Potter P., Deshields T., Kuhrik M. Delegation practices between registered nurses
and nursing assistive personnel. Journal of Nursing Management. 2010;18:157– 165.
Protection of Human Subjects, 45 Code of Federal Regulations, Sec. 46.111, 46.101(b), 46.110, 46.116 (1991).
Protection of Human Subjects, 45 Code of Federal Regulations, Sec. 46.401 et seq. (1998).
Registered Nurse Safe Staffing Act of 2011. United States House Bill 876/United States Senate Bill 58. http://legiscan.com/US/comments/HB876/2011; http://legiscan.com/US/bill/SB58/2011.
Reising, D. L. (2012). Make your nursing care malpractice proof. American Nurse Today, 7(1). probability.com
Ricciardi, C. L. (2015). Hospital administration not immune–criminal and civil liability: A risk for health care administrators. Becker’s Hospital Review 2015, ASC Communications.
Sabol v. Richmond Heights General Hospital, 676 N. E.2d 958 (Ohio App. 1996). Safe Nurse Staffing Legislation, Washington State HB 3123 (March, 2008). Trombley v. Southwestern Vermont Medical Center, 738 A.2d 103 (Vt., 1999). U.S. vs Parnell, Parnell, Lightsey & Wilkerson, U.S. District Court for Middle District
of GA, 2015. Vietnam Era Veterans’ Readjustment Assistance Act of 1974, 38 United States Code
§ 4212 (1974). Watkins v. Unemployment Compensation Board of Review, 689 A.2d 1019 (Pa.
Commonwealth, 1997). Wellstar Health System, Inc. v. Green, WL 31324127 (Ga. App., October 18, 2002). Wolfson J. Erring on the side of Theresa Schiavo: Reflections of the special guardian
ad litem. The Hastings Center Report. 2005;35(3):16–19. Yoder-Wise P. More serendipity: The Winkler County trial. The Journal of
Continuing Education in Nursing. 2010;41(4):147–148. Zamudio v. Patia, 956 F. Supp. 803 (N.D. Ill., 1997).
127
Cultural Diversity and Inclusion in Health Care Karen A. Quintana
LEARNING OUTCOMES
• Describe common characteristics of any culture. • Evaluate the use of concepts and principles of acculturation, culture, cultural diversity, and
cultural sensitivity in leading and managing situations. • Analyze differences between cross-cultural, transcultural, multicultural, and intracultural
concepts; cultural humility; and cultural marginality. • Evaluate individual and societal factors involved with cultural diversity. • Value the contributions a diverse workforce can make to the care of people.
KEY TERMS acculturation cross-culturalism cultural competence cultural diversity
128
cultural humility cultural imposition cultural marginality cultural sensitivity culture ethnicity ethnocentrism global inclusion multiculturalism transculturalism
T h e C h a l l e n g e Sally C. Fernandez, RN, MSN, ANP Nurse Manager, Emergency Center, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
I work with a large staff of men and women from several cultures, and they have different perspectives about their assignments. Hispanics, Asians, Asian Indians, and Nigerians provide a challenge for me. If I try to address a work issue, such as assignments, some become defensive. Some men feel that they are superior to me. It might be because I am a woman. In contrast, I have noticed that some Asians are more submissive and do better with female-to-female interactions. We frequently have a high patient census in the emergency department. There are times when either the charge nurse or I tell staff members to complete a task more quickly within their assignment because of the number of patients waiting to be seen in the emergency department. This does not sit well with some staff, who tend to become defensive. For example, a male staff member of one culture felt he was being “overpowered” by the charge nurse from another culture.
What would you do if you were this nurse?
129
Introduction As our nation grows and evolves within various cultures, the United States of America is swiftly becoming one of the most diverse nations in the world. As a result, leaders and managers need to consider culture as a factor in working with others just as they would consider education, experience, and competence.
Culture influences leadership from two perspectives. One is the way in which we meet patient needs; the other is the way in which we work together in a diverse workforce. Effective leaders can shape the culture of their organization to be accepting of persons from all races, ethnicities, religions, ages, lifestyles, and genders. These interactions of acceptance should involve a minimum of misunderstandings. Multicultural phenomena are cogent for each person, place, and time. Therefore culture-centered leadership provides organizational leaders, such as nurse managers and effective team members, the opportunity to influence cultural differences and similarities among their unit staff and to provide care to a culturally diverse patient population.
130
Concepts and principles What is culture? Does it exhibit certain characteristics? What is cultural diversity, and what do we think of when we refer to cultural sensitivity? Are culture and ethnicity the same? Various authors have different views.
Cultural background stems from one’s ethnic background, socioeconomic status, and family rituals, to name three key factors. Ethnicity, according to The Merriam-Webster Dictionary (Merriam- Webster, Inc., 2016), is defined as related to groups of people who are “classified” according to common racial, tribal, national, religious, linguistic, or cultural backgrounds. This description differs from what is commonly used to identify racial groups. This broader definition encourages people to think about how diverse the populations in the United States are.
Inherent characteristics of culture are often identified with the following four factors:
1. Culture develops over time and is responsive to its members and their familial and social environments.
2. A culture’s members learn it and share it. 3. Culture is essential for survival and acceptance. 4. Culture changes with difficulty.
For the nurse leader or manager, the characteristics of ethnicity and culture are important to keep in mind, because the underlying thread in all of them is that culture and ethnicity of staff and patients have been with them their entire lives. All people view their cultural background as normal; the diversity challenge is for others to also view it as normal and to assimilate it into the existing workforce. Cultural diversity is the term currently used to describe a vast range of cultural differences among individuals or groups, whereas cultural sensitivity describes the affective behaviors in individuals—the capacity to feel, convey, or react to ideas, habits, customs, or traditions unique to a group of people.
Spector (2017) addressed three themes involved with acculturation. (1) Socialization refers to growing up or being raised within a culture and taking on the characteristics of that group. All of us are socialized to some culture, and sometimes this change in our identity can be painful. (2) Acculturation refers to adapting to the dominant culture. An example of this might be what a particular society calls a particular food or how healthcare organizations are changing to blame-free environments to encourage safety disclosures. The overall process of acculturation into a new society is extremely difficult and involuntary. “America” has a core culture and numerous subcultures. For example, think how differently people in rural American regions dress from those in urban centers, or how a city looks on a Saturday night versus a Sunday morning. In other words, subcultures expand on how the core culture might be described. “Acculturation also refers to cultural or behavioral assimilation and may be defined as the changes of one’s cultural pattern to those of the host society” (Spector, 2017, p. 25). (3) Assimilation refers to the change that occurs when nurses move from another country to the United States, or from one part of the country to another. The person becomes similar to the members of a dominant culture. They face different social and nursing practices, and individuals now define themselves as members of the dominant culture. An example of this might be when nurses no longer say they are from their country of origin. They say they are from where they live and practice.
Providing care for a person or people from a culture other than one’s own is a dynamic and complex experience. The experience, according to the classic work of Spence (2001, 2004), might involve “prejudice, paradox and possibility” (p. 140). Spence used prejudice as conditions that enabled or constrained interpretation based on one’s values, attitudes, and actions. By talking with people outside their “circle of familiarity,” nurses can enhance their understanding of personally held prejudices.
Prejudices “enable us to make sense of the situations in which we find ourselves, yet they also constrain understanding and limit the capacity to come to new or different ways of understanding. It is this contradiction that makes prejudice paradoxical” (Spence, 2004, p. 163). Paradox, although it may seem incongruent with prejudice, describes the dynamic interplay of tensions between individuals or groups. We have the responsibility to acknowledge the “possibility of tension” as a potential for new and different understandings derived from our communication and
131
interpretation. Possibility therefore presumes a condition for openness with a person from another culture (Spence, 2004).
E x e r c i s e 4 . 1 In a group, discuss the values and beliefs of justice and equality. As a nurse, you may have strong values and beliefs, but you may never have observed their application in health care. Consider language, skin color, dress, and gestures of patients and staff from other cultures. How will you learn and value what differences exist?
Cultural humility helps us explore cultural competency as a process rather than an outcome. Hook, Davis, Owen, Worthington, and Utsey (2013) visualized cultural humility as the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person]” (p. 2). When exploring cultural humility, we find three factors, first described by Tervalon and Murray-Garcia (1998), that help shape the process:
1. A lifelong commitment to self-evaluation and self-critique. 2. Desire to fix power imbalances. 3. Aspiration to develop partnerships with people and groups who advocate for others.
The first factor, a lifelong commitment to self-evaluation and self-critique, looks at our lives as never being finished with learning. The idea of life-long learning is a hallmark of being a professional and, as with clinically based learning, we need to incorporate our newly acquired knowledge into our approach to others. We must remain humble to a point of being able to look at ourselves critically. We need to maintain the desire to learn more.
The second factor holds a desire to fix imbalances where none should exist. The work related to the social determinants of health relates to this factor. This factor acknowledges that everyone brings value to our lives. Everyone holds important information in the big picture. Waters and Asbill (2013) presented the example of the practitioner interviewing a client, and the client’s role as the expert of his or her own life, symptoms, and strengths. “The practitioner holds the body of knowledge that the client does not; however, the client also has understanding outside the scope of the practitioner” (p. 2). The practitioner, who is the expert in the scientific knowledge, and the client, the expert in the personal history, must collaborate with each other for successful outcomes. Similarly, the members of a team are each experts in their own lives. The leader’s task is to facilitate the sharing of the “how I see it” perspective so that broad considerations are made rather than quick, and often stereotyped, decisions.
The final factor in cultural humility is aspiring to develop partnerships with people and groups who advocate for others. Individuals can create positive change, but groups can have a more profound impact, and a more inclusive perspective, on communities and systems. Change cannot occur on an individual level without the correction of power imbalances within a larger system. “Cultural humility, by definition, is larger than our individual selves—we must advocate for it systemically” (Waters & Asbill, 2013, p. 2).
Cultural marginality is defined as “the resulting sense of being between two cultures or more, living at the edges of each, but rarely at the center” (Bennett, 2014, p. 269). This “betweenness” is a time when managers might perceive disinterest in cultural considerations. This situation might actually reflect cognitive processing of information that is not yet reflected in effective behaviors.
Ethnocentrism classically is defined as “the belief that one’s own ways are the best, most superior, or preferred ways to act, believe, or behave” (Leininger, 2002b, p. 50), whereas cultural imposition is defined as “the tendency of an individual or group to impose their values, beliefs, and practices on another culture for varied reasons” (Leininger, 2002b, p. 51). Such practices constitute a major concern in nursing and “a largely unrecognized problem as a result of cultural ignorance, blindness, ethnocentric tendencies, biases, racism or other factors” (Leininger, 2002b, p. 51).
Providing quality of life and human care is difficult to accomplish if the nurse does not have knowledge of the recipient’s culture as it relates to care. Leininger believed that “culture reflects
132
shared values, beliefs, ideas, and meanings that are learned and that guide human thoughts, decisions, and actions. Cultures have manifest (readily recognized) and implicit (covert and ideal) rules of behavior and expectations. Human cultures have material items or symbols such as artifacts, objects, dress, and actions that have special meaning in a culture” (Leininger, 2002b, p. 48). Leininger (2002b) stated that her views of cultural care are “a synthesized construct that is the foundational basis to understanding and helping people of different cultures in transcultural nursing practices” (p. 48). (See the Theory Box on p. 66). Accordingly, “quality of life” must be addressed from an emic (insider) cultural viewpoint and compared with an etic (outsider) professional’s perspective. By comparing these two viewpoints, more meaningful nursing practice interventions will evolve. The same is true for collegial relationships. This comparative analysis will require nurses to include global views in their cultural studies that consider the social and environmental context of different cultures.
E x e r c i s e 4 . 2 As a small group activity, assess several clinical settings. Do these settings have programs related to cultural diversity? Why? What are the programs like? If there are no programs, why do you think they have not been implemented?
133
Theory How do leaders, managers, or followers take all of the expanding information on the diversity of healthcare beliefs and practices and give it some organizing structure to provide culturally competent and culturally sensitive care to patients or clients? Historically, Purnell and Paulanka (2008), Campinha-Bacote (1999, 2002), Giger and Davidhizar (2002), and Leininger (2002a) provided an overview of each of their theoretical models to guide healthcare providers for delivering culturally competent and culturally sensitive care in the workplace.
Purnell and Paulanka’s (2008) Model for Cultural Competence provides an organizing framework. The model uses a circle with the outer zone representing global society, the second zone representing community, the third zone representing family, and the inner zone representing the person. The interior of the circle is divided into 12 pie-shaped wedges delineating cultural domains and their concepts (e.g., workplace issues, family roles and organization, spirituality, and healthcare practices). The innermost center circle is black, representing unknown phenomena. Cultural consciousness is expressed in behaviors from “unconsciously incompetent—consciously incompetent—consciously competent to unconsciously competent” (p. 10). The usefulness of this model is derived from its concise structure, applicability to any setting, and wide range of experiences that can foster inductive and deductive thinking when assessing cultural domains. Purnell (2009) described the dominant cultural characteristics of selected ethnocultural groups and a guide for assessing their beliefs and practices. The Purnell Model for Cultural Competence serves as an organizing framework for providing cultural care, which is based on 20 major assumptions. Much of this model can also help us consider how we enact a culturally appropriate workplace.
Campinha-Bacote’s (1999, 2002) classic culturally competent model of care identifies five constructs: (1) awareness, (2) knowledge, (3) skill, (4) encounters, and (5) desire. She defined cultural competence as “the process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of a client (individual, family, or community)” (Campinha-Bacote, 1999, p. 203). Cultural awareness is the self-examination and in- depth exploration of one’s own cultural and professional background. It involves the recognition of one’s bias, prejudices, and assumptions about the individuals who are different (Campinha-Bacote, 2002). “One’s world view can be considered a paradigm or way of viewing the world and phenomena in it” (Campinha-Bacote, 1999, p. 204). Cultural knowledge is the process of seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups. Obtaining cultural information about the patient’s health-related beliefs and values will help explain how he or she interprets his or her illness and how it guides his or her thinking, doing, and being (Campinha-Bacote, 2002). The skill of conducting a cultural assessment is learned while assessing one’s values, beliefs, and practices to provide culturally competent services. The process of cultural encounters encourages direct engagement in cross-cultural interactions with individuals from other cultures. This process allows the person to validate, negate, or modify his or her existing cultural knowledge. It provides culturally specific knowledge bases from which the individual can develop culturally relevant interventions. Cultural desire requires the intrinsic qualities of motivation and genuine caring of the healthcare provider to “want to” engage in becoming culturally competent. Again, these five constructs can help us in our work as professionals interacting to provide quality care.
The Giger and Davidhizar Transcultural Assessment Model identified phenomena to assess provision of care for patients who are of different cultures (2002). Their model includes six cultural phenomena: communication, time, space, social organization, environmental control, and biological variations. Each one is described based on several premises (e.g., culture is a patterned behavioral response that develops over time; is shaped by values, beliefs, norms, and practices; guides our thinking, doing, and being; and implies a dynamic, ever-changing, active or passive process). These phenomena are also appropriate considerations in the workplace.
Leininger’s (2002a) central purpose in her theory of transcultural nursing care is “to discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups” (p. 190). She uses her classic “Sunrise Model” to identify the multifaceted theory and provides five enablers beneficial to “teasing out vague ideas,” two of which are the Observation, Participation, and Reflection Enabler and the Researcher’s Domain of Inquiry. Nurses can use Leininger’s model to provide culturally congruent, safe, and meaningful
134
care to patients or clients of diverse or similar cultures. See the Theory Box for an example of Leininger’s work.
135
National and global directives The American Nurses Association (ANA) has a long and vital history related to ethics, human rights, and numerous efforts to eliminate discriminatory practices against nurses as well as patients. The ANA Code of Ethics for Nurses with Interpretive Statements, Provision 8, states, “The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs” (ANA, 2015, p. 47). This provision helps the nurse recognize that health care must be provided to culturally diverse populations in the United States and on all continents of the world. Although a nurse may be inclined to impose his or her own cultural values on others, whether patients or staff, avoiding this imposition affirms the respect and sensitivity for the values and healthcare practices associated with different cultures. This provision is reinforced by the ANA revised position statement (2016), The Nurse’s Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity, and Human Rights in Practice Settings. The value of human rights is placed at the forefront for nurses whose specific actions are to promote and protect the human rights of every individual in all practice care environments.
Similar statements are made with an international emphasis and a specialty emphasis. For example, the International Council of Nurses (ICN)’s ICN Code of Ethics for Nurses (2012) states:
The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent to care and related treatment. The ICN Code of Ethics for Nurses is a guide for action based on social values and needs and was first adopted in 1953. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity. (p. 3)
Throughout history, the emphasis and support has been on recipients of care such as patients, but the same attentiveness is needed in the workforce. Patients are aware of how they are treated, and they also see how staff interact with each other.
T h e o r y B o x Cultural Care Theory
Theory/Contributor Key Ideas Application to Practice Leininger (2002a) is credited with developing and advancing a theory of transcultural nursing care since the mid-1950s.
The theory is explicitly focused on the close relationships of culture and care on well-being, health, illness, and death; it is holistic and multidimensional, generic (emic, folk) and professional (etic) care and has a specifically designed research method (ethnonursing).
Care is the essence of nursing, and culturally based care is essential for well-being, health, growth, and survival and for facing handicaps or death.
136
Special issues Health disparities between majority and ethnic minority populations are not new issues and continue to be problematic because they exist for multiple and complex reasons. Causes of disparities in health care include poor education, health behaviors of the minority group, inadequate financial resources, and environmental factors. Disparities in health care that relate to quality of care include provider–patient relationships, actual access to care, treatment regimens that necessarily reflect current evidence, provider bias and discrimination, mistrust of the healthcare system, and refusal of treatment (Baldwin, 2003). Health disparities in ethnic and racial groups are observed in cardiovascular disease, which has a 40% higher incidence in US blacks than in US whites; cancer, which has a 30% higher death rate for all cancers in US blacks than in US whites; and diabetes in Hispanics, who are twice as likely to die of this disease than non-Hispanic whites. Native Americans have a life expectancy that is less than the national average, whereas Asians and Pacific Islanders are considered among the healthiest population groups. However, within the Asian and Pacific Islander population, health outcomes are more diverse. Solutions to health and healthcare disparities among ethnic and racial populations must be accomplished through research to improve care. Consider how these disparities in disease and in healthcare services might affect the healthcare providers in the workplace in relationship to their ethnic or racial group. Increasing healthcare providers’ knowledge of such disparities is necessary to more effectively manage and treat diseases related to ethnic and racial minorities, which increasingly might include themselves. Consider also what disparities exist in the workplace. Are all employees treated fairly? Do we value the views of various groups or those of only some groups?
The healthcare system in the United States has consistently focused on individuals and their health problems, but it has failed to recognize the cultural differences, beliefs, symbolisms, and interpretations of illness of some people as a group. As health care moves toward provision of care for populations, culture can have an even greater influence on approaches to care. Often, patients for whom healthcare practitioners provide care are newcomers to health care in the United States. Similarly, new staff are commonly neither acculturated nor assimilated into the cultural values of the dominant culture.
Currently, accessibility to health care in the United States is linked to specific social strata. This challenges nurse leaders, managers, and followers who strive for worth, recognition, and individuality for patients and staff regardless of their ascribed economic and social standing. Beginning nurse leaders, managers, and followers may sense that the knowledge they bring to their job lacks “real-life” experiences that provide the springboard to address staff and patient needs. In reality, although lack of experience may be slightly hampering, it is by no means an obstacle to addressing individualized attention to staff and patients. The key is that if the nurse manager and staff respect people and their needs, economic and social standings become moot points. This challenge will intensify as the implications of the Patient Protection and Affordable Care Act of 2010 and subsequent changes unfold. If nothing else happens, the diversity of insured patients will increase. Even in the culture of the military, where rank carries numerous privileges, respecting people and their needs is a driving force in providing care.
137
Language Translating a message in one language to another language to ensure equivalence includes maintaining the same meaning of the word or concept. Equivalency is accomplished through interpretation, which extends beyond “word-for-word” translation to explain the meaning of concepts. When providing care to a language-diverse patient, the nurse must realize that the process of translation of illness and disease conditions and treatment is complex and requires certain tasks. Two important tasks are “(a) transferring data from the source language to the target language and (b) maintaining or establishing cross-cultural semantic equivalence” (International Council of Nurses, 2008, p. 5).
The current practice seems to be one of using interpreters rather than translators when speaking with non–English-speaking patients and clients. Why? Purnell and Paulanka (2008) advocate that trained healthcare providers as interpreters can decode words and provide the right meaning of the message. However, the authors also suggest being aware that interpreters might affect the reporting of symptoms, using their own ideas or omitting information. Therefore nurses must allow time for translation and interpretation and clarification of information as needed.
Promotion of culturally competent care with a translator has legal implications in the United States. The legal
L i t e r a t u r e Pe r s p e c t i ve Resource: Gregory, C. (2017). Effective communication for a global workforce. Nurse Leader, 15(6), 392-395.
Because of the increasing numbers of foreign-born healthcare workers, how to create clear communication becomes even more critical than it has been. This article addresses accented speech, meaning the sound of English words spoken by someone who speaks English but has a different tonality to speech than found in the United States. A hospital system committed to helping international nurses be better understood in the culture in which they now worked. To achieve this, the system created an educational program ACCENT: A, accentuate your unique background; C, communicate slowly, clearly, and confidently; C, communicate reflectively (repeat back); E, empathize; N, narrate your care; and T, therapeutic touch, smile, and other nonverbal cues (p. 394). This approach was integrated into the Studer Group’s approach known as AIDET (acknowledge, introduce, duration, explanation, and thank you). A key outcome associated with this program is an 8% less turnover rate for nurses who participate in this program.
Implications for Practice Because the numbers of workers from other parts of the world are likely to increase over the next decades, being proactive about helping with numerous aspects of acculturation is important. Communication clearly is one of those important aspects.
foundation for language access lies in Title VI of the 1964 Civil Rights Act, which states: “No person in the United States, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefit of, or be subjected to discrimination under any program or activity receiving federal financial assistance” (Chen, Youdelman, & Brooks, 2007). The federal government has interpreted and treated language as a proxy for national origin, and language assistance should be pursued. These activities supported by the Civil Rights Act include access to health care. Additionally, once a healthcare provider accepts any federal funds (e.g., Medicaid payments), the provider is responsible for providing language access to all the provider’s patients.
One often overlooked need for language competency relates to generational and regional differences. Word choices of millennials, as an example, often differ from those of Gen X or Baby Boomers. In addition, what someone living in Louisiana may call something may differ dramatically from someone from Vermont. Formal translations services for such differences do not exist, so seeking clarity from the person becomes critical.
In many organizations, several nurses typically come from other cultures and languages. As the Literature Perspective shows, deliberate strategies can promote self-esteem with the end goals of
138
cross-cultural understanding and effective patient care.
139
Meaning of diversity in the organization Leading and managing cultural diversity in an organization means managing personal thinking and helping others think in new ways. Nursing leaders need a workforce that can provide culturally competent care; in essence, not having this can lead to unsafe care. In addition, nursing’s goal is to create a workforce that reflects the population it serves. This diversity can occur across roles, including advanced practice registered nurses, managers, and chief nurse executives.
Managing issues that involve culture—whether institutional, ethnic, gender, religious, or any other kind—requires patience, persistence, and much understanding. One way to promote this understanding is through shared stories that have symbolic power.
E x e r c i s e 4 . 3 Think of a recent event in a clinical area, such as a project, task force, celebration, or something similar. What meaning did people give the event? Was it viewed as being a symbol of some quality of the workplace, such as its effectiveness, its values and beliefs, or its innovations? Or was it seen as a meaningless gesture? What makes an event relevant and value-centric?
Staff who know what is valuable to patients and to themselves can act accordingly and derive satisfaction from work. Having a clear mission, goals, rewards, and acknowledgment of efforts leads to greater productivity from a culturally diverse staff who aspire to unity and uniqueness. As the Literature Perspective illustrates, leaders have an obligation to create an inclusive culture.
L i t e r a t u r e Pe r s p e c t i ve Resource: Aurilio, L.A. (2017). Creating an inclusive culture for the next generation of nurses. Nurse Leader, 15(5), 315-318.
By 2060, over half of the US population will derive from a minority race or ethnic group, and they often have experienced (or are experiencing) health disparities. Nurses who have these diverse backgrounds not only understand the statistics and reports but also, in some cases, the lived experiences. This distinct combination of knowledge and experience creates the opportunity to address health inequities from a different perspective.
An inclusive culture where differences are embraced allows teams to leverage their distinctiveness, which in turn can support creativity and innovation. To create such teams, leaders must identify their personal biases and create respectful environments, to name two key commitments. Box 4.1 identifies 8 key commitments leaders can make to create an inclusive environment.
Box 4.1
K e y C o m m i t m e n t s t o C r e a t i n g I n c l u s i o n
• Identify unconscious biases. • Understand team differences. • Create a respectful social environment. • Provide flexible scheduling. • Support ongoing professional development. • Create social support systems. • Create effective communication systems. • Empower staff through shared governance.
140
Implications for Practice Most of the 8 commitments can be adopted—or adapted—by individuals or teams, even in an environment where leaders have not committed to inclusion. Without these commitments being ingrained in the workplace, nurses (and others) will be ill-prepared to address the needs of patients in the future.
When assessing staff diversity, the nurse leader or manager can ask these two questions:
• What is the cultural representation of the workforce? • What type of team-building activities are needed to create a cohesive workforce for
effective healthcare delivery?
141
Cultural relevance in the workplace Although the literature has addressed multicultural needs of patients, it is sparse in identifying effective methods for nurse managers to use when working with multicultural staff. Differences in education and culture can impede patient care, and uncomfortable situations may emerge from such differences. For example, staff members may be reluctant to admit language problems that hamper their written communication. They may also be reluctant to admit their lack of understanding when interpreting directions. Psychosocial skills may be problematic as well, because non-Westernized countries encourage emotional restraint. Staff may have difficulty addressing issues that relate to private family matters. Non-Asian nurses may have difficulty accepting the intensified family involvement of Asian cultures. The lack of assertiveness and the subservient physician–nurse relationships of some cultures are other issues that provide challenges for nurse managers. Unit-oriented workshops arranged by the nurse manager to address effective assertive techniques and family involvement as it relates to cultural differences are two ways of assisting staff with cultural work situations. Respecting cultural diversity in the team fosters cooperation and supports sound decision making.
Nurse leaders and managers who ascribe to a positive view of culture and its characteristics effectively acknowledge cultural diversity among patients and staff. This includes providing culturally sensitive care to patients while simultaneously balancing a culturally diverse staff. For example, cultural diversity might mean being sensitive to or being able to embrace the emotions of a large multicultural group comprising staff and patients. Unless we understand the differences, we cannot come together and make decisions that are in the best interest of the patient.
Transculturalism sometimes has been considered in a narrow sense as a comparison of health beliefs and practices of people from different countries or geographic regions. However, culture can be construed more broadly to include differences in health beliefs and practices by gender, race, ethnicity, economic status, sexual preference, age, and disability or physical challenge. Thus when concepts of transcultural care are discussed, we should consider differences in health beliefs and practices not only between and among countries but also between and among, for example, races, ethnic groups, genders, and different economic strata. This requires us to consider multiple factors about all individuals. One strategy to initiate discussion about differences is to ask what everyone does on New Year’s Day. Every culture marks a new year, even though the date may not be January 1. Asking about family traditions regarding food and activity allows us to gain a perspective that we all may differ, even within a defined culture, yet we all acknowledge starting a new year may have special meaning.
The range of attitudes toward culturally diverse groups can be viewed along a continuum of intensity (Lenburg et al., 1995, p. 4) from hate to contempt to tolerance to respect and ending with celebration/affirmation. Managers need to be aware of this continuum so that they can apply strategies appropriately to the workforce—for example, contempt versus affirmation. Both responses are reflected in employee groups. The goal is to move from acknowledging differences to inclusion.
Variables that may influence the nurse’s response may include how the illness is perceived by the culture and the cultural competency of the healthcare provider. If the nurse’s culture is different from the patient’s, whose cultural perspective dominates? It might not be possible to adapt care totally to the patient’s perspective. However, knowing that a difference exists allows for a mutual conversation related to the rationale for care. Similarly, if a workplace dispute occurs, trying to see “the other view” can create new insights into a situation.
To make cultural competence relevant to clinical practice, Engebretson, Mahoney, and Carlson (2008) linked a cultural competency continuum, in which they identified the levels of competence, to values in health care. They cited the levels as cultural destructiveness, cultural incapacity, cultural blindness, cultural precompetence, and proficiency that would be complementary to patient care. The “clinically relevant continuum” included behaviors of maleficence, incompetence, standardization, and outcomes focused (positive health outcomes). A model was developed that integrated the cultural competence continuum with the clinically relevant continuum and the components of evidence-based care; namely, best research practice, clinical expertise, and patients’ values and circumstances. The goal was to suggest how to make cultural concerns relevant to clinical practitioners at the level of the patient–provider encounter.
142
To understand, value, and use diversity, nurse managers need to approach every staff person as an individual. This same strategy works for all of us. Although staff of different cultural groups may be diverse in appearance, values, beliefs, communication patterns, and mannerisms, they have many things in common. Staff members want to be accepted by others and to succeed in their jobs. With fairness and respect, nurse managers should openly support the competencies and contributions of staff members from all cultural groups with a goal of achieving quality patient care. Nurse managers hold the key to allowing the full potential of each person on the staff.
Body movements, eye contact, gestures, verbal tone, and physical closeness when communicating are all part of a person’s culture. For the nurse manager, understanding these cultural behaviors is critical in accomplishing effective communication within a diverse workforce population. As if language differences are not challenging enough, add on the slang, idioms, and fads inherent to US culture. It is no surprise that culturally sensitive communication is difficult to achieve. Nurses need to ensure that ineffective communication among staff, with patients, and with others does not lead to misunderstandings and eventual alienation.
Failure to address cultural diversity leads to negative effects on performance and staff interactions. Nurse managers can find many ways to address this issue. For example, in relation to performance, a nurse manager can make sure messages about patient care are received. This might be accomplished by sitting down with a nurse and analyzing a situation to ensure that understanding has occurred. In addition, the nurse manager might use a communication notebook that allows the nurse to slowly “digest” information by writing down communication areas that may be unclear. For effective staff interaction, the nurse manager also can make a special effort to pair mentors and mentees who have different ethnic backgrounds and encourage staff to learn another language, one prominent among the population served. Even a “word a day” approach could alter a team’s ability to interact with patients.
E x e r c i s e 4 . 4 During one of your group meetings, have everyone share one or two slang words that may have a different meaning for different groups of people. After this meeting, have one in your group post a list of the words and meanings discussed in the meeting. Allow everyone to continue to add slang words that staff members use that may create confusion or misunderstanding. Reviewing the list regularly allows staff to understand phrases and, in some instances, to gain a cultural perspective connected to the phrase.
143
Individual and societal factors Nurse managers must work with staff to foster respect of different lifestyles. To do this, nurse managers need to accept three key principles: multiculturalism, which refers to maintaining several different cultures; cross-culturalism, which means mediating between/among cultures; and transculturalism, which denotes bridging significant differences in cultural practices. Each of those principles operates in the workplace. Sometimes we want to keep distinct cultures. For instance, we may advocate for equality unless a particular unit has excellent safety scores. Anyone who wanted to make all cultures alike, and thus increase safety incidents, would be seen as foolish. Healthcare organizations have, as an example, provided various ways to celebrate holy days based on the cultural mix of staff and patients. These practices are designed to acknowledge the individuals who comprise the organization.
When promoting cultural competency within different lifestyles, nurses must also explore the nursing care of the LGBT (or the subsequent group recognitions) patients and staff. LGBT has been an acronym that is typically tied together to suggest homogeneity (Ard & Makadon, 2012). The acronym represents lesbian, gay, bisexual, and transgendered (and subsequent others) and has referred to the behavior, identity, and desire of each group. This broader group has long been addressed as a minority within a wide range of races, ethnicities, ages, and socioeconomic statuses. Often this group has been discriminated against, with healthcare needs not being addressed because of this discrimination. People who define themselves in this gender-identification diverse manner find challenges in accessing culturally competent health services. The T, transgendered, has long held additional subcategories under its name. This adds an additional layer of cultural understanding. For example, in healthcare settings, the term Male to Female (or MTF) transgendered is used to describe a person born with male genitalia but who identifies as a female. Female to Male, or FTM, is the reverse. Some people reject the nature of gender and see themselves as neither and commonly are referred to as androgynous.
More nurses and nurse managers must embrace the increasing demographics within this diverse community. This increasing population has seen a history of bias, which has continued to challenge access to care despite the increasing social acceptance. This bias was defined in health care, and until 1973 homosexuality was listed as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (National LGBT Health Education Center, 2016). This stigma and discrimination, combined with a lack of access to culturally competent and individualized health care, result in health disparities for the gender-diverse community. Some of these health disparities include higher rates of smoking, depression, anxiety, substance abuse, and violence victimization. The Department of Health and Human Services Healthy People 2020 and the National Academy of Medicine Report both acknowledge these disparities and have asked for steps to address them.
One of the steps in addressing these disparities starts with creating an inclusive environment. Something as simple as changing intake forms can provide a sense of belonging. “As of 2016, HRSA (Health Resources & Services Administration) requires health centers to report sexual orientation and gender identity data in the uniform data system” (The National LGBT Health Education Center, 2016). These forms of data, whether during the history-taking assessment, on paper forms, or electronically, should all pay attention to the sexual orientation and gender identity of the patient.
Providing such culturally competent care and understanding is not limited to patients in the healthcare setting, but also includes the staff within this community. The correct terminology and nonjudgmental support needs to be provided to the nursing staff and healthcare team members. Doing so will facilitate a positive and inclusive work setting. Taking steps to understand the varied cultures will also help clinicians ensure their gender-diverse patients, as well as all of their patients, receive the most positive level of health.
E x e r c i s e 4 . 5 Create a group of 4 to 6 people. Ask each group member to write down four to six cultural beliefs that he or she values. When everyone has finished writing, have the group members exchange their lists and discuss why these beliefs are valued. When everyone has had a chance to share lists, have
144
a volunteer compile an all-encompassing list that reflects the values of your workforce. (The key to this exercise is that many of the values are similar or perhaps even identical.)
Cultural differences among groups should not be taken in the context that all members of a certain group or subgroup are indistinguishable. For example, regarding gender differences, women are perceived to have a more participative management style; however, this does not mean that all male managers use an authoritative management model. Likewise, female managers may use multiple sources of information to make decisions, and this does not mean that all male managers make decisions on limited data. Thus the norm for gender recognition should be that women and men be hired, promoted, rewarded, and respected for how successfully they do the job, not for who they are, where they come from, whom they know, or the gender they represent.
In today’s workplace, female-male collaboration should provide efficacious models for the future. Gender does not determine response in any given situation. However, men reportedly seem to be better at deciphering what needs to be done, whereas women are better at collaborating and getting others to collaborate in accomplishing a task. Men tend to take neutral, logical, and objective stands on problems, whereas women become involved in how the problems affect people. Women and men bring separate perspectives to resolving problems, which can help them function more effectively as a team on the nursing unit. Men and women must learn to work together and value the contributions of the other and the differences they bring to any situation. Similar kinds of comparisons can be made related to other elements of diversity. Nurses have embraced information related to generational differences and have used religious and ethnic contexts as ways to begin dialogs about values and beliefs (Fig. 4.1).
FIG. 4.1 A diverse workforce brings a richness of perspectives to care.
145
146
Dealing effectively with cultural diversity The first individuals in most organizational structures who have to address cultural diversity are the leaders and managers. They have to give unwavering support to embracing diversity in the workplace rather than using a standard cookie-cutter approach. Creating a culturally sensitive work environment involves a long-term vision and financial and healthcare provider commitment. Leaders and managers need to make the strategic decision to design services and programs especially to meet the needs of diverse cultural, ethnic, and racial differences of staff and patients. Policies in healthcare organizations prohibit discrimination based on several aspects. Such policies, however, do not necessarily succeed at promoting a culturally aware environment.
Nurse managers hold the key to making the best use of cultural diversity. Managers have positions of power to begin programs that enrich the diversity among staff. For example, capitalizing on the knowledge that all staff bring to the patient is possible for better quality care outcomes. One method that can be used is to allow staff to verbalize their feelings about particular cultures in relationship to personal beliefs. Another is to have two or three staff members of different ethnic origins present a patient-care conference, giving their views on how they would care for a specific patient’s needs based on their own ethnic values.
Mentorship programs should be established so that all staff can expand their knowledge about cultural diversity. Mentors have specific relationships with their mentees. The more closely aligned a mentor is with the mentee (e.g., same gender, age group, ethnicity, and primary language), the more effective the relationship. Programs that address the staff’s cultural diversity should not try to make people of different cultures pattern their behavior after the prevailing culture. Nurse managers must carefully select mentors who ascribe to transcultural, rather than ethnocentric, values and beliefs. A much richer staff exists when nurse managers build on the valuable culture of all staff members and when diversity is rewarded. The pacesetter for the cultural norm of the unit is the nurse manager. For example, to demonstrate commitment to cultural diversity, a nurse manager might make a special effort to ensure that US black, Asian American, and Hispanic holidays or other cultural representations on the unit are recognized by the staff. Staff members who are active participants in these programs can then be given positive reinforcement by the nurse manager. These activities promote a better understanding and appreciation of individuals’ cultural heritage.
Nurse managers are aware of the increasing shortage of nurses, demanding work environment with its surrounding influences, and statistics indicating that many leave their first professional nursing position by the first year because of job dissatisfaction and level of stress. Nursing workforce projections indicate the registered nurse (RN) shortage will continue at dramatic rates.
This period may be even more challenging for individuals whose culture differs from the predominant unit culture.
Continuing-education programs should help nurses learn about the care of different ethnic groups. Professional organizations related to cultural groups have an opportunity for education within the larger community. Examples of these groups include the National Black Nurses Association, National Hispanic Nurses Association, Philippine Nurses Association of America, Nurse Christian Fellowship, and Association of Jewish Registered Nurses. Some groups may want to develop or sponsor a workshop or conference on cross-cultural nursing for nursing service staff and faculty in schools of nursing who have had limited preparation in cultural care or cultural beliefs in healing.
E x e r c i s e 4 . 6 Identify a situation in which working with culturally diverse staff had positive or negative outcomes. If a negative outcome resulted, what could you have done to make it a positive one? If a positive outcome resulted, what strategies could you use in another situation?
Muslims are one of the fastest growing populations in the United States and worldwide. For example, Muslim nurses may feel uncomfortable without long sleeves because of their Islamic dress code. Jewish nurses likely would find a pulled pork barbeque an inappropriate celebration. Males may feel awkward participating in a unit baby shower. The point of all of these examples is to think
147
proactively, ask for input, and consider how best to exhibit cultural sensitivity. Choices, decisions, and behaviors reflect learned beliefs, values, ideals, and preferences. The goal
of communication is maintenance or restoration of personal integrity and recognition of worth and respect of individuals or groups.
The two scenarios described in Box 4.2 on p. 74 illustrate how problem-solving communication can promote mutual understanding and respect. The first scenario involves a compromise between staff members and a patient’s family, and the second involves a nurse manager and a staff member from a different culture.
Box 4.2
P r o b l e m - S o l v i n g C o m m u n i c a t i o n : H o n o r i n g C u l t u r a l At t i t u d e s T o wa r d D e a t h a n d D y i n g Scenario 1: Staff and a Patient’s Family What nurses often call interference with the care of a patient commonly reflects family attitudes toward death and dying. Often, Hispanic families rush to the hospital as soon as they hear of a relative’s illness. Because most Hispanics believe that death is the passing of an individual to a life that offers tranquility and everlasting happiness, being at the bedside offering prayers and encouragement is the norm rather than the unusual exception. The nurse manager in this situation, herself a non–American-educated nurse manager, had worked extensively at helping her staff understand different cultures. A consensus compromise was worked out between the staff and one such Hispanic family. The family, consisting of three generations, was given the authority to decide what family members could stay at the loved one’s side and for how long. By doing this, the family felt they had control of the environment and quickly developed a priority list of family members who could stay no more than 5 minutes at the patient’s side. As the family member left the bedside, his or her task was to report the condition of the patient to other family members “camping” in the visitors’ lounge. Although their loved one did not survive a massive intracranial hemorrhage, all of the family felt that they were a part of their loved one’s “passage of life.”
Scenario 2: A Nurse Manager and Another Staff Member Eastern World cultures that profess Catholicism as their faith celebrate the death of a loved one 40 days after the death. The nurse manager needs to recognize that time off for the nurse involved in this celebration is imperative. Such an occurrence had to be addressed by a nurse manager of Asian descent. The nurse manager quickly realized that the nurse, whose mother died in India, did not ask for any time off to make the necessary burial arrangements but, rather, waited 40 days to celebrate his mother’s death. The celebration included formal invitations to a church service, as well as a dinner after the service. One day during early morning rounds, the nurse explained how death is celebrated by Eastern World Catholics. The Bible’s description of the Ascension of the Lord into heaven 40 days after his death served as the conceptual framework for the loved one’s death. The grieving family believed their loved one’s spirit would stay on earth for 40 days. During these 40 days, the family held prayer sessions meant to assist the “spirit” to prepare for its ascension into heaven. When the 40 days have passed, the celebration previously described marks the ascension of the loved one’s spirit into heaven.
Because this particular unit truly espoused a multicultural concept, the nurses had no difficulty in allowing the Indian nurse 2 weeks of unplanned vacation so that his mother’s “passage of life” celebration could be accomplished in a respectful, dignified manner.
E x e r c i s e 4 . 7 Identify a situation involving a staff member requesting additional days of leave that required a culturally sensitive decision. What religious or ethnic practices did you learn about in regard to this request and decision?
Passages of life that culminate in happy events also can challenge the nurse manager—for
148
example, the quinceañera observed by Hispanic families. This event is the celebration for 15-year- old girls to be introduced into society. A nurse whose daughter is celebrating this event must have time to make plans for this festive celebration. Because of the significance of the celebration and the pride that the parents take in their daughter, inviting “key” staff to the quinceañera is common. Nurse managers who understand and value cultural rituals can help individuals meet their needs and help staff, in general, learn and accept various cultural practices and perspectives.
E x e r c i s e 4 . 8 Holiday celebrations have cultural significance. Select a specific holiday such as Chinese Lunar New Year (China and Chinatowns) or Araw ng mga Patay (Philippines) or Diwali (India). What is the cultural meaning of the specific holiday? How do staff members of the respective culture celebrate the festive day? Does the nursing unit engage in recognition of special holidays?
149
Implications in the workplace Considering culture from a healthcare staff perspective and the nursing workforce perspective is a daunting task, one that can lead to a more solidly aligned service–community relationship. Even if the workforce is not as diverse as one might desire, learning about the cultures of the groups within the workforce is important. Making clear that diversity is valued, in fact celebrated, attracts others to engage in the complexity of care. One way is to make clear how staff are valued as people, not as representatives of some group. Showing respect to all patients irrespective of their cultural differences tells the staff that their differences also can be valued. The key is for managers and leaders to attend to the workforce issues with the same zest as they do the patient issues. Cultural differences enrich all of us when we make deliberate efforts to include them in our daily values.
Embracing these differences will also enhance the Quality and Safety Education for Nurses (QSEN) Initiative. The overall goal of the QSEN Initiative is to prepare nurses with the knowledge, skills, and attitudes (KSAs) needed to continuously deliver quality and safe patient care. With this initiative we see the need to respect all patients and staff irrespective of their cultural differences to empower patient- and family-centered care, which is one of the QSEN initiative competencies. This component recognizes the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for a patient’s preferences, values, and needs (American Association of Colleges of Nursing, 2013).
150
Conclusion Understanding and valuing cultural differences benefits both patients and colleagues. Culture is a broad term encompassing many diversities. This broadness both enriches our perspective of diversity and provides a complex challenge. All nurses, regardless of their titles or positions, have a role in improving the workplace and patient care by attending to the implications of culture in health care.
T h e S o l u t i o n Sally C. Fernandez
As a nurse manager, I prefer to talk on a one-to-one basis. I had a meeting with the male staff member to learn from him. “What made you upset with the charge nurse when she made your assignment?” In our discussion, he told me, “The charge nurse used words [slang] for which I did not know the meaning … I did not understand why she said it … she was trying to overpower me … I didn’t like it … so I was defensive about it.” We talked about being sensitive to cultural communication and the need to understand meanings of words and to ask for immediate clarification when such situations arise with members of two different cultures.
Would this be a suitable approach for you? Why?
151
Reflections Consider how many people you know who are different from you in terms of race, ethnicity, gender, age, education, political beliefs, and socioeconomic backgrounds. What knowledge can you transfer to the workplace? What is one goal you could set for achieving a greater understanding of differences and commonalities?
152
The evidence Numerous studies have demonstrated the importance of understanding and valuing differences in patients’ backgrounds to provide high-quality care. Although fewer studies have related to workers in health care, more examples have appeared in recent years that support the value of having an inclusive approach to the workplace culture. Because the culture of the workplace has been shown to be highly influential in people’s perception of their work and their intent to stay, being sensitive to what else could be done to enhance the workplace, including inclusion, has potential for positive outcomes.
153
Tips for incorporating cultural diversity in health care • Listen for differences and seek clarity. • Value that people follow their perspective of how to act. • Seek opportunities to experience others’ cultures, even from a global perspective.
154
References American Association of Colleges of Nursing (AACN). Quality and Safety
Education for Nurses (QSEN) initiative. Robert Wood Johnson Foundation; 2013. American Nurses Association (ANA). Code of ethics for nurses with interpretative
statements. Washington, DC: American Nurses Publishing; 2015. American Nurses Association (ANA). Revised Position statement: The nurse’s role in
ethics and human rights: Protecting and promoting individual worth, dignity, and human rights in practice settings. American Nurses Association, Inc; 2016.
Ard K.L., Makadon H.G. Improving the health care of lesbian, gay, bisexual and transgender (LGBT) people: Understanding and eliminating health disparities. Boston: The National LGBT Health Education Center, The Fenway Institute, Brigham and Women's Hospital, and Harvard Medical School. 2012.
Baldwin D. Disparities in health and health care: Focusing efforts to eliminate unequal burdens. Online Journal of Issues in Nursing. 2003;8(1):2.
Bennett J.M. Cultural marginality: Identity issues in global leadership training. In Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education. 2014;38(5):203–207.
Campinha-Bacote J. A model and instrument for addressing cultural competence in health care. Journal of Nursing Education. 1999;38(5):203–207.
Campinha-Bacote J. The process of cultural competence in a delivery of healthcare services: A model of care. Journal of Transcultural Nursing. 2002;13(3):181–184.
Chen A.H., Youdelman M.K., Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. Journal of General Internal Medicine. 2007;22(Suppl. 2):362–367.
Engebretson J., Mahoney J., Carlson E.D. Cultural competence in the era of evidence-based practice. Journal of Professional Nursing. 2008;24(3):172–178.
Giger J.N., Davidhizar R. The Giger and Davidhizar transcultural assessment model. Journal of Transcultural Nursing. 2002;13(3):185–188.
Hook, J. N., Davis, D. E., Owen, J., Worthington Jr., E. L., & Utsey, S. O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology. https://doi.org/10.1037/a0032595.
International Council of Nurses. (2008). Translation guidelines for International Classification for Nursing Practice (ICNP). Geneva, Switzerland. www.icn.ch.
International Council of Nurses. The ICN code of ethics for nurses. Geneva, Switzerland: ICN-International Council of Nurses; 2012.1–11.
Leininger M. Cultural care theory: A major contribution to advance transcultural nursing knowledge and practice. Journal of Transcultural Nursing. 2002a;13(3):189–192.
Leininger, M. (2002b). Essential transcultural nursing care concepts, principles, examples, and policy statements. In M. Leininger & M. R. McFarland (Eds.), Transcultural nursing: Concepts, theories, research & practice (3rd ed). New York: McGraw-Hill Medical Publishing Division.
Lenburg C.B., Lipson J.G., Demi A.S., Blaney D.R., Stern P.N., Schultz P.R., et al. Promoting cultural competence in and through nursing education: A critical review and comprehensive plan for action. Washington, DC: American Academy of Nursing; 1995.
Merriam-Webster Inc. (2016). The Merriam-Webster dictionary. Springfield, MA: Merriam-Webster.
National LGBT Health Education Center. Understanding the health needs of LGBT People. A project supported by the Health Resources and Services
155
Administration (HRSA) agreement number U30CS22742. 2016. Purnell L.D. In: Guide to culturally competent health care. 2nd ed. Philadelphia: FA
Davis; 2009. Purnell L.D., Paulanka B.J. Transcultural health care: A culturally competent
approach. 3rd ed. Philadelphia: FA Davis; 2008. Spector R.E. Cultural diversity in health and illness. 9th ed. Upper Saddle River, NJ:
Pearson Prentice Hall; 2017. Spence D. Prejudice, paradox, and possibility: Nursing people from cultures other
than one’s own. Journal of Transcultural Nursing. 2001;12(2):100–106. Spence, D. (2004). Prejudice, paradox and possibility: The experience of nursing
people from cultures other than one’s own. In K. H. Kavanaugh & V. Knowlden (Eds.), Many voices: Toward caring culture in healthcare and healing. Madison, WI: The University of Wisconsin Press.
Tervalon M., Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved. 1998;9:117–125.
Waters, A., & Asbill, L. (2013). Reflections on cultural humility. American Psychological Association, CYF News.
156
PA R T 2 Know Yourself
157
Gaining Personal Insight: The Beginning of Being a Leader Jeffery Watson; Patricia S. Yoder-Wise
LEARNING OUTCOMES
• Value the need to gain insight into one’s self to develop leadership skills. • Determine how insight into personal talents and abilities can help nurses be effective in
their role of nurse and leader.
KEY TERMS emotional intelligence formal leadership informal leader journaling personal leadership reflection
158
value
T h e C h a l l e n g e Ellen Martin, PhD, RN, CPHQ Director of Practice, Texas Nurses Association, Austin, Texas
Transitioning to a new nursing specialty involves integrating one’s prior knowledge and experience with the essential skills and competencies of the new role. After 9 years of working with critically ill patients in a neurosurgical intensive care unit (ICU), I took a job as a home visiting nurse. I considered myself a very strong nurse with excellent technical skills but quickly realized that home health nursing required a completely different skill set. In the hospital, if I needed supplies, I could easily get them. If I needed to update a physician or clarify orders, they generally responded quickly. Time management was not a problem because most everything we did was on a strict time schedule. I was ready to learn something new and wanted to help people recover from hospitalization in the comfort of their own home.
My first independent visit was to a gentleman with advanced chronic obstructive pulmonary disease (COPD) who was so severely short of breath I was concerned he had been discharged from the hospital too soon. He patted my hand and reassured me that he was having a good day and he only went to the hospital when his breathing “got really bad.” Another challenging visit was a person with heart failure who had orders for self-management instruction. His scale was broken and his pantry was mostly bare except for prepackaged ramen noodles, his preferred meal because they were easy to prepare and stored well between infrequent grocery store visits. Another patient who lived in a high-crime public housing project insisted that he meet me in the parking lot when I arrived and walked me back to my car after I changed his wound dressing. My last scheduled visit of that first week was a routine catheter change. It was only after the patient’s cat jumped on the bed and contaminated the sterile field that I realized that was my last Foley insertion kit.
After the first week of home care my confidence was at low ebb. I was aware of social determinants of health but did not realize how people make choices when they can only afford to fill two of their five hospital discharge prescriptions. I was overwhelmed by the intensity of the patients’ needs, the disruption when patients were not home at the time we scheduled, the volume of paperwork, and the chaotic nature of the home environment. I recognized I was a novice again and I was on a learning curve and questioned whether I could succeed as a home care nurse.
What would you do if you were this nurse?
159
Introduction Approximately 4 million people in the United States are registered nurses. That number seems enormous when we think of the numbers in other healthcare disciplines. In part because we are so large in numbers, we also have additional obligations in health care. One of those obligations is to capitalize on the role of leading and following in any position to the end that quality care is rendered.
Leadership is a journey. It is an iterative process, one that may take twists and turns and always contributes to our learning if we exhibit intentionality in our approach to learning. It begins with being an effective follower, and it never ends. Our task is to continue to develop personally and professionally so that our talents match the tasks we need to address and those evolve over our careers.
Being proactive about learning is a key strategy to developing effective followership and evolving that into effective leadership. That means we have to be mindful of our actions and the motivations behind those actions. As an example, some people think about leadership in terms of power, “being in charge,” and fame and glory. When someone exerts leadership from that perspective, he or she may have followers, but they commonly are not really engaged with the mission of the work they are doing. They may even behave very differently depending on the physical presence of the leader. An opposite example can be found when leadership derives from the desire to help others be their best. When leadership is exerted from that perspective, followers are engaged in the mission of their work and they behave consistently—with or without the formal leader being present.
Our task in leadership is to promote a focus on person- (or population-) centered care with the goal of providing the most accessible, least costly, and highest quality outcomes. To achieve that, we need the vision of each of us contributing something critical to the work at hand. This view of leadership is shared, meaning that one person may hold a title that conveys a position of ultimate authority and yet each person has the potential to step forward and lead the work when that person is the one most capable of a particular element of work.
We can learn leadership through multiple avenues. For example, attending professional association meetings, reading, and connecting with others at a local, state, or national level allow us to learn from others about their development as a leader. This chapter looks at some established tools and strategies that will help us individually even if we are not ready to discuss our leadership journey with someone else.
160
Informal and formal leadership When people think of leadership, they typically think of position. Those types of positions have official-sounding titles: president, chief executive, director, etc. That leadership is positional and therefore formal. The assumption is that people in formal leadership roles exert influence over others and that they are “in charge.” The other type of leadership is informal. Organizations do not typically have a titled position of Informal Leader, but if we are a member of a team, we know who these people are.
By its very nature, the term informal leaders means that they do not hold formal positions and they do not have official authority for a group (Ross, 2014). Rather, informal leaders are those individuals who influence others because they are engaged with those who listen to and follow the informal leaders. These individuals are often the “behind the scenes” people who motivate others to act. Wise formal leaders acknowledge that they do not have all the answers and thus look to their informal leaders whose talents may differ from their own.
Informal leaders are either the formal leaders’ closest allies or their worst fears. When the formal leader and the informal leader(s) are in concordance, great outcomes can be produced. When such does not exist, a lot of energy is expended on working around the other person(s) and creating an appearance of productivity rather than actually being productive.
Although only a small percentage of registered nurses will hold formal leadership positions, all of us are expected to accept the obligation to lead when we are the ones best suited to the work. As a result, all of us have a need to know about how we learn to be better at leading.
E x e r c i s e 5 . 1 Consider your recent clinical work. Someone was “in charge.” What did you or someone else do to illustrate informal leadership?
E x e r c i s e 5 . 2 Review your state’s nurse practice act to identify the legal definition of nurse and nursing. What key words suggest leadership expectations?
161
The core of learning to be a leader Personal leadership is an integration of you, your ideas, and your personhood, into the path you set for your life. It is the ability to lead from your core values and beliefs. Leadership is not a part that you play to fulfill a role responsibility; rather, it is a role responsibility that comes to life because of who you are. Incorporating your unique qualities into to the role of leader is a function of both living and learning. Fig. 5.1 suggests that being a nurse is integral to who we are as individuals and that being a leader overlaps both nurse and person, because we can exert leadership in our personal and professional lives. We are the sum of our life experiences, bringing the fullness of our personhood to the other roles we fulfill. In this case we are referring to the role of nurse and leader. Sometimes all three elements intersect, indicating that all the roles we assume in life are influenced by all others.
FIG. 5.1 Leadership integration.
Kouzes and Posner (2012) developed one of the most widely used models for considering leadership (see the Theory Box). Although this model is used widely in other fields, the key for us is that it is used widely in nursing and health care. The five elements of their model begin with modeling the way. Basically, that means if we want others to be civil, we must be that way too. Inspire a shared vision is an expectation of a formal leader, yet informal leaders contribute to this by
162
T h e o r y B o x Theory/Contributor Key Ideas Application to Practice Kouzes & Posner: The Leadership Challenge (2012)
Model the way Inspire a shared vision Challenge the process Enable others to act Encourage the heart
This approach to leadership provides a view of how to lead and develop others and how to remain personally relevant in leadership
taking such actions as translating a big picture vision to the practicalities faced in the roles of the members of the team. Members of the team, any of whom may exhibit leadership, have the obligation to challenge the process. We can all do this by asking questions or posing scenarios to help clarify how something is possible across a wide range of situations. Enable others to act refers to how we help others find the conditions that allow them to do their best. Finally, encourage the heart is about creating a positive work environment and self-renewal. Think for a moment about the feedback you receive. We expect feedback from those “above” us such as team leader, manager, or clinical director. The question is: Do you provide that same type of feedback to your leader? People in leadership positions are in “the middle” between those they are accountable for and those they are accountable to. They receive feedback from those to whom they report. An opportunity to exert leadership is to provide feedback to those individuals who seldom receive input from those they are accountable for. How powerful you can be if you take this model to heart! And, how do we enhance our current leadership skills? The answer begins with understanding one’s self.
At the core of leadership is awareness. Don Miguel Ruiz, in his classic text, The Four Agreements (1997), presents a set of agreements we can make with ourselves to enhance personal growth and awareness. These agreements focus on how we present ourselves to self and others and how we act in and interact with the world around us. These four agreements also can serve as core of who we are as leaders (Box 5.1).
Box 5.1
T h e F o u r A g r e e m e n t s
• Be impeccable with your word. • Don’t take anything personally. • Don’t make assumptions. • Always do your best.
From the book The Four Agreements. Copyright © 1997, Miguel Angel Ruiz, M.D. Reprinted by permission of Amber-Allen Publishing, Inc. San Rafael, CA. http://www.amberallen.com. All rights reserved.
The First Agreement: Be Impeccable With Your Word To be impeccable with your word means to maintain principled use of the words we speak about others and ourselves. It means to speak in truth. As leaders, we must use language that reinforces integrity of practice and honors humanity. In other words, leadership is demonstrated when we speak with integrity and when we follow through on our words. Being impeccable with your word is foundational to developing trust and reliability as a leader. Because trust is so critical to the functioning of any group, being true and truthful is highly critical.
E x e r c i s e 5 . 3 Think of a situation where someone promised to do something and then did not follow through. Recall how you felt and how your view of that person might have changed. If you pursued a discussion about the lack of follow through, do you recall what the response was and how that
163
affected your thinking about the person?
The Second Agreement: Don’t Take Anything Personally Personalizing every comment or action others make moves you away from the core of who you are. Listening and engaging in discussion are vital leadership skills. However, what others say is reflective of their reality, not yours. You will encounter numerous opinions about you, your work, your ideas, your philosophies, and so forth. Realizing those opinions are not about you but are rather a reflection of the person voicing those views frees you from self-imposed judgment. That said, we also need to acknowledge that some communication may be directed personally. A readily available example can be found in almost any political race. Deliberately destructive communication can also be found in toxic workplaces where incivility is tolerated. Although both examples are personally based, they actually say more about the originator than the target.
E x e r c i s e 5 . 4 Recall a situation when you believed your ideas or you yourself were being attacked by someone’s statements. What was your reaction? What would your reaction be if you said to yourself: “That statement is that person’s response. I wonder what made him feel that way.”
The Third Agreement: Don’t Make Assumptions In conversations, having the willingness to ask clarifying questions provides you the opportunity to avoid making assumptions. Assumptions are created by the imagination when clear communication fails. Personal courage is required to ask deeper questions so you get the information you want and need. Leaders in health care must avoid misunderstandings because of the potential risk to human life. As nurses, we would not assume that a medication authorization was what was intended if it fell outside what we know to be established standards. Why then, as leaders, would we attribute a motivation to someone’s behavior without testing our assumption?
E x e r c i s e 5 . 5 Consider again a time when you were interacting with someone and something they said made you feel uncomfortable, distressed, or angry. Did you seek clarification? If so, what did you say or ask? If not, what could you ask that would facilitate an honest rather than defensive response?
The Fourth Agreement: Always Do Your Best Numerous factors influence how you feel from day to day and even hour to hour. Yet you can commit to doing your best in each circumstance. In making the commitment to always do your best you acknowledge your humanness. You are able to release any looming self-judgment, because you have put forth your best effort. In other words, you have good days, bad days, and in-between days. On each of those days, and indeed, in varying moments throughout the day, your best will vary. And yet, at the end of the day, you want to be able to say “I did my best.” Does that mean we would tolerate “I’m doing my best” (and having a bad day) as rationale for subpar performance? Of course not! And we can use this agreement to enhance a group’s performance by acknowledging where we are in our performance. The intent of this agreement is to strive to do our best every day.
E x e r c i s e 5 . 6 Think of a situation in which everything did not go just as planned. Could you say that despite the situation, you did your best? If not, what would have helped you be able to say you did your best?
164
165
Gaining insight into self Many organizations and educational programs address the task of developing leaders. Although we encourage you to explore those and select those that meet your personal needs, our attempt here is to use broad concepts and readily available, and least costly, strategies to help develop your insight into self. You may choose to use each of these strategies or you may choose to use only one or two strategies. The key point is that resources exist to help you understand who you are and that capitalizing on the information those resources provide can help enrich your talents as a leader.
Reflection and Journaling Developing as a leader comes from knowing and understanding your authentic self (Kouzes & Posner, 2012), and learning from experience is a critical skill in developing your potential for leadership. In the exercises in the previous section, you were practicing the art of reflection about the core of leadership. Reflection, exploring the thoughts you have about your experiences, actions, and reactions, is an active process you can use to strengthen your ongoing professional growth. In his foundational work, Schön (1983) described reflection from two different perspectives: thinking- in-action and thinking-on-action. Thinking-in-action occurs when an individual employs existing knowledge to guide behaviors as a situation develops. Thinking-on-action is a recounting of the situation, inviting self-evaluation (Schön, 1983). We often think-in-action as we provide care. We are not as diligent about thinking-on-action (debrief or reflection). Adding that strategy can create new insights and lead to more effective performance.
Consider a cardiac arrest event in an acute care setting. The decision making occurring in the midst of cardiopulmonary resuscitation (CPR) is an example of thinking-in-action. A post-CPR debriefing, reviewing all aspects of the event, after the fact, is thinking-on-action—giving thoughtful consideration to individual and group performance as well as to any technical issues influencing the outcome. The same type of thinking occurs about leadership when you are in a situation in which you think a patient may be harmed and on the spot you intervene. How you decided to act and what you decided to do are thinking-in-action. After the fact, you consider the many factors leading up to the situation, what else you might have done (or done differently), and what you will do the next time such an event occurs. That is an example of thinking-on-action.
Reflection helps you assess the effect your choices have on both yourself and on those around you. Numerous models have been developed to guide reflection and reflective practice. Fig. 5.2 identifies four basic stages that are common to most reflective practice models: reflection, value, knowledge, and action.
166
FIG. 5.2 The impact of reflection.
Reflection, the thinking-on-action type, starts when you begin to think about the events of the day. You may choose to take a broad view or focus on a single specific event. The list of questions in Exercise 5.7 is not exhaustive, but you will notice that each experience you have invites other deeply personal questions as you explore the core of who you are as a leader.
E x e r c i s e 5 . 7 Think of what you did yesterday. You may have been in a clinical setting, or at a religious service, or out to dinner with friends, or at a meeting. As you do so, consider asking questions of yourself to guide the reflection: What happened? Why did I respond the way I did? What precipitated my behavior? Were my values in conflict with others? Did I honor the view of others?
In contemplating and grappling with probing questions, you release yourself to value specific aspects of each experience. Understanding develops about why you felt the way you did in the moment. You have the freedom to study the sources of input that swayed your behavior. You can contemplate different choices that might yield other outcomes. Over time, awareness is raised of your own conduct, and you begin to distinguish more effective patterns for interaction.
Awareness is essential; however, successful leaders go well beyond being aware. Building on self- awareness, leaders cultivate personal insight and new knowledge. A key question at this stage of
167
reflection is: What have I learned about myself and how can I take this knowledge into the future? Leaders embrace new knowledge, making sense of the events of the past and present to develop a plan of action for the future. For example, if you accept that learners learn in different ways, you do not simply tell your team something. You find ways to provide something from the key senses to engage each member in gaining the knowledge you are sharing. You may use a graph to show progress of a new intervention. You may talk with your team about the importance of this work. You might even ask them to manipulate equipment to develop the sensation of a psychomotor skill.
The ultimate goal of reflection is to bolster your leadership acumen. The final stage of the process is action—putting what you have learned into practice. The action stage of reflection is where you test the new knowledge you have gained about yourself. You may discover only incremental improvement toward the desired outcome. If this is the case, you need not worry. With each cycle of reflection you increase your understanding of the leader within. Reflection, as part of leadership development, is a lifelong iterative process. After you act, you recycle through the process again to learn more about what your values are, what knowledge you gained, and what action modifications or replacements you will test next.
A common outcome of reflection in your early stages of development is to focus on what not to do; actively considering what to do is equally beneficial and often more reinforcing to us. For example, think about when we started telling people to stop smoking. We did not tell them what to do, just what not to do. As a result, some people who smoked assumed the habit of using chewing tobacco. The point about the harmful effects of tobacco was buried in the focus on what to stop. The incorporation of reflection on a regular basis, however, allows us to move from a narrow thinking of what not to do to the broader thinking about possibilities and what fits with our values.
Reflection occurs through a variety of formats. Writing your thoughts helps make any learning that occurs more concrete (Kouzes & Posner, 2016). Thus journaling, also known as reflective journaling, is a method to support the ongoing development of self-confidence, professional practice, and critical thinking (Fig. 5.3). Journals allow you to retrace your thinking and also to see improvements in your thinking actions.
FIG. 5.3 Keeping a journal allows you to see your personal growth over time. (Copyright © Thinkstock/iStock.)
Because journaling is an individual exercise, you have flexibility to write in your journal at any time. You may choose to use a simple notebook or an e-journal. You might also choose from a variety of guided leadership journals that contain focused themes and questions designed to help
168
direct your thoughts. Box 5.2 describes basic considerations for an individual who is just beginning to journal.
Box 5.2
T i p s f o r C r e a t i n g a Pe r s o n a l J o u r n a l
1. Determine if you are going to use a hard copy journal or if you are going to do this electronically.
2. Consider how quiet the area might be where you wish to make an entry. 3. Create an entry as soon as possible after an important event so you can remember details,
including how you felt. 4. Write in the first person—it is your journal. And don't worry about spelling, etc. Be sure to
use abbreviations that are clear to you. 5. Focus on lessons learned. After you make an entry, you need to answer two questions: So
what? and What if? “So what” asks whether this was life-changing (or practice-changing) and what you will do. “What if” addresses the idea of alternative thinking so you consider different contexts, players, outcomes, and other ideas.
E x e r c i s e 5 . 8 Conduct an Internet search about professional journaling (or reflective journaling) and explore what apps are available to support professional journaling. What rationale for journaling made sense to you? What security was incorporated into any app you explored? Consider how a professional journal might be used to enhance individual leadership skills.
Regardless of the way that you choose to practice reflection, by committing time and energy to this practice you allow yourself an opportunity to grow in clarity around your own beliefs and values and your philosophies about nursing and the core of leadership. You become more adept at integrating the person you are into the professional role of nurse and leader. Reflection is a foundational skill needed to move each of us along the path from individual thought leader to nursing thought leader. Think about it!
Emotional Intelligence For years, we have focused on test scores, the most common being intelligence tests. Those tests, such as the GRE (Graduate Record Examination) or SAT (Scholastic Assessment Test), are typically used to determine a person’s ability to be successful in a graduate program or undergraduate program, respectively. Emotional intelligence (EI, or EQ as it is known by some) tests or assessments, however, are typically used by an individual, and to a lesser extent by an organization, to understand what abilities people have in understanding themselves and others. Furthermore, EI can improve and thus is a flexible view of your ability to relate to self and others (Bradberry, n.d.).
Emotional intelligence can be defined as understanding and managing our own emotions with the added social awareness of discerning the emotions of others. Knowing how to identify and use emotions to guide personal behavior and engagement with others is essential for leaders. The core elements of EI, as described in the now classic work, Emotional Intelligence 2.0 (Bradberry & Greaves, 2009), consist of understanding and then managing yourself (you) and social awareness and how to manage relationships (others). Why is this important to know? Several answers are possible, and one of the most important answers is that people with better EI scores are viewed as more successful. EI is viewed as the basis for numerous skills we use every day as humans, nurses, and leaders. EI is the “single biggest predictor of performance in the workplace and the strongest driver of leadership and personal excellence” (p. 21). Although some of us, at least at some point in our careers, may deny interest in being a leader, who of us wouldn’t want to be our personal best? Therefore knowing one’s EI would be of great value, and the even better news about EI is that it can be improved.
169
Being self-aware does not require a process of psychoanalysis. Rather, self-awareness refers to our ability to consider who we are as people. What would we say we do well? What makes us respond with a proverbial “knee jerk” response? What makes us feel confident? Thinking about our “good” and “bad” insights and responses is not geared to categorizing ourselves. It is geared to helping us understand who we are and what we do.
Self-management requires that we act independently for ourselves to strengthen those things we do well and to alter our approach to things we do not do so well. Although we may appreciate someone else pointing out something we need to do differently, our real source of making change is within us. Just knowing how we are is insufficient. We need to determine whether we are going to make adjustments or whether we want to maintain our current state. This aspect of EI is really about aligning ourselves with our goals, and sometimes delaying certain actions or satisfactions to advance toward our goals.
Social awareness now turns the awareness toward others. Think for a moment about Dr. Sheldon Cooper of The Big Bang Theory on television. In almost every episode, he is trying to figure out the people around him. He has secured equipment to help him “read people’s emotions” and he declares when he understands something is humorous—usually with the intent of garnering concurrence from one of the other members of the cast. Gaining the perspective of another person is what he lacks and what is critically important to working with others. Our observational and listening skills predispose us to being capable of determining what others are experiencing.
Relationship management pulls the first aspects (understanding and managing self and social awareness) together so that you can be effective at responding to people, being clear in expressing your personal assessment of a situation, and creating connections with others that allow you together to be more effective in the work you need to do. Being able to know yourself and others and then manage your own personal reactions allows you to direct energy toward managing a relationship.
E x e r c i s e 5 . 9 Conduct an Internet search using the term emotional intelligence assessments. What types of assessments are available? Did they identify reliability and validity information? What was the cost range? Were any that seemed useful available online? What could you do with the results of such an assessment?
E x e r c i s e 5 . 1 0 Go to https://hbr.org/2015/06/quiz-yourself-do-you-lead-with-emotional-intelligence and complete this online assessment of your E.2. Print or save your results. What did you learn about yourself?
Being able to consider each of these elements and how you can improve your abilities allows for greater success as a leader. Codier and Codier (2017) even suggest that emotional intelligence positively influences patient safety.
Strengths One of the most widely used self-assessment tools is StrengthsFinder 2.0 (Rath, 2007). Because it has been used worldwide, in numerous cultures, and across all sorts of personal characteristics, this is one of the most tested tools to help people determine their talents for developing strengths. The Research Perspective provides greater detail about the analyses of this tool. If you complete this assessment, you are given your top five strengths, or talents, out of the possible 34 themes. If you complete this assessment with others, you can identify how various themes contribute to the whole of a project or a relationship. Imagine if everyone in your group were deliberative, which is one of the 34 themes. This theme is described as careful, private, and cautious. What would the work look like? Likely, few timelines would be met and very little would be accomplished. However, what was done would have withstood multiple tests of thinking. Now imagine that everyone in your group were competitive. This group would be great to enter into tournaments to represent your
170
organization and, because they are so driven by the need to compete, might dim others’ prospects of participating. And we might wonder whether they could ever really reach agreement on a course of action or whether their competitiveness kept them focused on making their own individual points. Fortunately, this tool provides your top five strengths rather than only focusing on one. The authors point out that we can develop any of the strengths; however, our natural tendency is to respond in any given situation with one of our strengths.
R e s e a r c h Pe r s p e c t i ve Resource: Asplund, J., Lopez, S.J., Hodges, T, & Harter, J. (2007). The Clifton’s Strengths Finder 2.0 Technical Report: Development and validation. Princeton, NJ: The Gallup Organization.
Since the late 20th century, millions of people have used the tool StrengthsFinder (SF) to assess their talents for building certain strengths. This tool has been used worldwide in almost every type of business setting. People of various racial and ethnic backgrounds, living different lifestyles, of various ages and genders have participated in using this tool. Thirty-four themes are assessed via the 177-item online tool. Because all responses enter into the database, the reliability and validity of this tool can be assessed over time. The tool has been subjected to numerous statistical tests and has been found to be reliable and valid.
Implications for Practice Few people, including nurses, are likely to study the details of this tool. What is valuable for all to know is that the tool is reliable and valid and it is useful in helping people take their talents to a greater potential by focusing on making their strengths their greatest asset.
The key with strengths is to capitalize on those that are your talents and to surround yourself with people with other talents that “fill in” the total set of talents needed to accomplish work. No single strength is better than another, except as it relates to some specific activity and goal. You always have to meet the minimum performance expectations for any position in your career. How you will be deemed successful, however, typically derives from practicing and honing your talents so that they become great assets. Leaders need to help others develop their talents to their best potential rather than focusing on those aspects of work that are only acceptable if the goal is to make sure everyone is doing his or her best. As a result, people are focusing on what is positive about themselves and not on what is not among their best talents.
E x e r c i s e 5 . 1 1 Conduct an Internet search using the term personal strengths assessments. What types of assessments are available? Did they identify reliability and validity information? What was the cost range? Were any that seemed useful available online? What could you do with the results of such an assessment?
171
Becoming an authentic leader Earlier we discussed various leadership theories and models, some of which tend to be more applicable in situations where a person holds a formal title (see Chapter 1). To begin a solid advancement in leadership, one of the most direct models is that developed by George (2003). That model is authentic leadership. Although developing leadership skills is a lifelong journey, being authentic is a good introduction to thinking of oneself as a leader.
Authentic leadership (Thacker, 2016) focuses on honest relationships (think of Ruiz’s statement about being impeccable with your word). How those relationships are formed may be artificial— you are assigned to an organizational task, know none of the people, and have a time frame to accomplish specific goals. In other words, at this point, you are not an organized whole; you are a group. Valuing what each person brings helps others develop trust in you and increases your potential for trusting the others in the group (think of Ruiz’s statement about not making assumptions). Exploring with each other what values you hold, how you see the assigned task unfolding, and who has what strengths and talents to contribute to the task are examples of how to build a cohesive team. Yet if we are not authentic in our approach, trust will be at a minimum.
Being truthful and open is critical to developing as an authentic leader. As George (2003, p. 11) said when he created this view of leadership, “It’s being yourself; being the person you were created to be.” He goes on to contrast this view of leadership with the idea of creating an image of what a leader is. Thus no matter what list of characteristics you might read, if they are not the real you, trying to adopt those only makes you look fake. That does not mean you should not explore those characteristics or styles. It simply means you will not look as real in leading as you would if you are being the real you. Brooks (2015) refers to these as character strengths. The authentic ones are eulogy virtues; the ones that match
L i t e r a t u r e Pe r s p e c t i ve Resource: Shirey, M.R. (2015). Enhance your self-awareness to be an authentic leader. https://www.americannursetoday.com/enhance-self-awareness-authentic-leader.
Authentic leadership can be assessed by the Authentic Leadership Questionnaire (ALQ) developed by Walumbwa et al. Four scales are used: self-awareness, relational transparency, balanced processing, and internalized moral perspective. Shirey focused on the first element. She identified eight approaches to consider in being better at self-awareness: explore personal strengths and fatal flaws, understand your limitations and seek others to complement you and the team, examine emotional intelligence, observe yourself and engage an observational partner, create down time for daily reflection, dig deep to gain insight, keep a reflective journal, and incorporate time for personal renewal and celebrate milestones.
Implications for Practice Being self-aware is critical to being an effective leader, especially one who is seen as authentic. Even though the idea of authenticity is being who you are, it is possible to increase skills and abilities in being authentic, and that process begins with being aware of self.
a list of characteristics are resume virtues. The former are the deep virtues you exhibit that you might want said at your funeral; the latter are the virtues that help others see a person–organization fit in a traditional sense.
Being the real you, however, is built on a true caring for others and a desire to help everyone maximize talents so that any group effort is as powerful as possible. As an example, being an authentic leader relies on having a true passion for people and the work in which they engage. Being able to respond to situations in an authentic manner promotes people’s personal values. Although this may seem somewhat concerning because some people do not necessarily have values that fit a mission or task, authenticity quickly filters people into those who can achieve a particular goal and those who cannot.
George (2003) developed the concept of authentic leadership having five dimensions: purpose, values, heart, relationships, and self-discipline. The corresponding developments are passion,
172
behavior, compassion, connectedness, and consistency, as Table 5.1 illustrates. Think, as an example, of someone who does not have real compassion. We say that person does not have heart or that person’s heart is not in the work.
Table 5.1
Behaviors and Developments of Leading Authentically
Dimensions Corresponding Developments Purpose Passion Values Behavior Heart Compassion Relationships Connectedness Self-discipline Consistency
Data from George, B. (2003). Authentic leadership: Rediscovering the secrets to creating lasting value. San Francisco, CA: Jossey Bass.
E x e r c i s e 5 . 1 2 Consider each of the developmental areas listed in Table 5.1 and think of messages we give ourselves (or others) that convey someone is really expert in one of the five dimensions or that ability is lacking. Use the example given for heart and compassion.
So, how does one become better at being an authentic leader? Shirey (2015) offers insight into one key aspect, that of self-awareness. The Literature Perspective captures the key points for consideration. If all we developed, as a skill, was awareness of self, think of the potential for further explorations of who we are and the actions we could take to be more—for our patients and ourselves.
173
Conclusion No matter where anyone is in his or her leadership trajectory, being complacent is not an option. Seeking new insights, using established tools (such as journaling), and wanting to do one’s best are lifelong skills that allow each of us to develop our full potential. If leadership is a journey expressed as a skill, each of us has the potential to contribute to the needed changes in health care by starting with a solid knowledge of and value for who we are and what we can become.
T h e S o l u t i o n Ellen Martin
Reflecting on that first week as a new home health nurse gave me some important insights. Although I did not feel particularly successful in the beginning, I recognized that I always strive to do my best. I considered how valuable my assessment and critical thinking skills would be in home health for monitoring the health status of people living at home with advanced chronic illnesses. At first, my reflections were focused on the superficial, such as considering each lesson learned the hard way and making a plan to make sure I did not make the same mistakes twice. It was the deeper reflection that allowed me to build on my strengths as a learner and achiever to develop a proactive learning plan to address my knowledge gaps. Beyond learning the tasks and paperwork, reflecting on relational competencies had the most impact on becoming an effective home health nurse.
One breakthrough in self-awareness related to my communication style, which I recognized had to change if I wanted to provide effective patient and family education. In the intensive care unit (ICU) environment, patients and their families are often in crisis, and they are highly dependent on the intense monitoring and frequent interventions provided by the healthcare team. In this context, the norm for patient education involved providing factual information using a directive approach. Although clear and direct communication is helpful in these situations, reflecting on those early encounters in patients’ homes made me aware of the ways in which my communication style and assumptions got in the way of therapeutic interactions. Patients and families depend on nurses to provide support and guidance based on nursing knowledge and experience. By engaging the patient and family in a dialogue, rather than a lecture, it became easier to elicit concerns and create a space for them to express concern, such as parts of the treatment plan that would be challenging. The shift to a conversational approach allowed an authentic, collaborative partnership to develop.
Caring for patients and families in their home is deeply personal because it offers a window into the private rhythms of their daily life. Each and every visit is an opportunity to practice deep listening and curiosity about the patient and family perspective on health, illness, and recovery. This is our access to providing truly person-centered care in a way that empowers patients and families to make positive healthcare choices long after discharge from home health services.
Would this be a suitable approach for you? Why?
174
Reflections Consider where you want to be in your career in 2 years. What do you need to consider in your personal and professional development? What are one to two first steps you can take to ensure you can reach this career stage? What do you need to learn about yourself? How will you intentionally use reflection to enhance your leadership skills to be the best nurse possible?
175
The evidence The successful nurse leader of the future will engage in practices that result in gains in personal insight. Recalling that only a small number of nurses hold official leadership positions, you can and will be called on to lead when a situation calls for one of your strengths. Leadership may find you when you are the only one of a small team and a decision needs to be made.
Leadership is not something that exists outside of you, but rather comes from the core of who you are. Developing as a leader is rooted in connecting with your most authentic self. Learning to be aware of how you act, react, and respond affords you the opportunity to integrate your full self into the roles of nurse and leader.
In pursuit of authenticity, reflection and journaling are valuable avenues to integrate your work experiences, decisions, and beliefs and values. Using reliable tools that help you identify your strengths will help you find the areas from which you can lead with your authentic self.
176
Tips for Gaining Personal Insight • Practice reflection daily. • Allow what you learn from your reflections to guide your next steps. • Participate in self-assessments and consider the results. • Strengthen your strengths.
177
References Bradberry, R. (ND). Emotional Intelligence-EQ.
http://www.forbes.com/sites/travisbradberry/2014/01/09/emotional- intelligence/#4cf302463ecb
Bradberry R., Greaves J. Emotional Intelligence 2.0. San Diego, CA: TalentSmart; 2009.
Brooks D. The road to character. New York: Random House; 2015. Codier, E., & Codier, D. D. (2017). Could emotional intelligence make patients
safer? American Journal of Nursing, 117(7), 58-62. https://doi.org/10.1097/01.naj.0000520946.39224.db.
George B. Authentic leadership: Rediscovering the secrets to creating lasting value. San Francisco: Jossey-Bass; 2003.
Kouzes J.M., Posner B.Z. The leadership challenge: How to make extraordinary things happen in organizations. San Francisco: Jossey-Bass; 2012.
Kouzes J.M., Posner B.Z. Learning leadership: The five fundamentals of becoming an exemplary leader. San Francisco: Jossey-Bass; 2016.
Rath T. StrengthsFinder 2.0. New York: Gallup Press; 2007. Ross C.A. The benefits of informal leadership. Nurse Leader. 2014;12(5):68–70.
doi:10.1016/j.mnl.2014.01.015. Ruiz D.M. The Four Agreements: A practical guide to personal freedom. White
Plains, NY: Peter Pauper Press; 1997. Schön D.A. The reflective practitioner. New York: Basic Books; 1983. Shirey, M.R. (2015). Enhance your self-awareness to be an authentic leader.
American Nurse Today, 10(8), 7. https://www.americannursetoday.com/enhance- self-awareness-authentic-leader.
Thacker K. The art of authenticity: Tools to become and authentic leader and your best self. Hoboken, NJ: Wiley & Sons; 2016.
178
Being an Effective Follower Amy Boothe
Copyright © Comstock images/iStock/Thinkstock.
LEARNING OUTCOMES
• Envision the goals of the Quadruple Aim in reference to the active follower. • Understand the difference between Leader, Effective Follower, and Ineffective Follower. • Define the characteristics and role of the Effective Follower within a healthcare team. • Compare different theories about followership between nursing and the business world.
KEY TERMS effective follower follower ineffective follower leader leader–follower relationship nursing theories Quadruple Aim transformational leadership model
179
T h e C h a l l e n g e Anonymous
I had only been a registered nurse (RN) for a few months when I encountered a situation with a patient that made me question the way his care had been handled by several different disciplines within our healthcare system. This patient was a Hispanic gentleman. I will call him “Mr. A.” He was being admitted to our facility for long-term acute care and was on a ventilator. While I was admitting him, I asked his wife all the normal questions and found that she wanted his code status to be do not resuscitate (DNR). I thought it was a little strange because when I received the report, the intensive care unit nurse told me he was a full code, noting that he had just been intubated the day before and placed on the ventilator. I probed, asking the wife more questions to fully appreciate the situation. His wife explained to me that the day before “Mr. A” had begun having more breathing problems. She said that the acute care unit nurse had told her he was getting worse and the oxygen mask was not enough, they would have to get a machine to help him breathe. The patient’s wife agreed and was asked to step out while they worked on him for a few minutes. When the wife returned to the room she was shocked to see they had put a tube down his throat and had him hooked up to a breathing machine. The wife told me she was so upset. (She thought they were going to put him back on the BiPAP machine with the mask that he had been on a few days prior.) She said her husband had told her before he did not want to be placed on any life support machines or have any CPR. She said she questioned the nurse and the nurse told her, “Well it is too late now it has already been done.” (It was hard to identify where the communication error occurred between the acute care unit staff and the patient’s wife because I was not present for the discussion.) I empathized with the wife’s situation and confusion. I explained to her she could change her mind at any time. Even if she had wanted him intubated yesterday and changed her mind today to make him DNR and did want him on the ventilator, she could still change her mind. I told her that I needed to discuss the situation with the charge nurse. I explained the situation with my charge nurse, who came in and talked with his wife. The doctor came in a few hours later and also talked to the wife. He told her since Mr. A was already intubated and had been through the trauma, we should give him 2 weeks and see whether they could eventually wean him off mechanical ventilation. At the end of 2 weeks they could explore options—get a tracheostomy and stay on the ventilator or remove the endotracheal tube. If the latter was chosen, he would either breathe on his own or pass away. The wife agreed, and the doctor left. I was very upset. I knew that was not what the wife wanted. I knew I needed to trust my instincts and find the courage to speak up.
What would you do if you were this nurse?
180
Introduction Following the leader is a concept that is learned at a very early age. Children follow the lead of their parents, schoolchildren follow the leader of the line, adolescents follow whom they perceive is the leader of the group, and adults follow the leaders within their organizations, social groups, and various encounters. This leader and follower concept is mirrored in the workplace as a hierarchy of command. Leaders are said to influence the followers into completing the tasks they are assigned. Educational studies and research projects are plentiful regarding what a leader is, how a leader influences others, what different leadership styles exist, and even what the innate characteristics of a “natural born leader” are. However, very little is known about the follower.
A leader does not have the ability to achieve the vision of the organization alone. A follower is defined as being a supporter, who is guided and told what to do. Being a follower is commonly associated with a negative connotation (Malak, 2016). This negative stigma includes words to describe the follower as passive, indecisive, devalued, and the obedient staff within the team. However, this could not be further from the truth. Being a follower does not place the person in a submissive position. The follower has the ability to create influence among other staff and among their leaders (Forbes, 2016); the follower can either advance the leader’s goals or divert and limit progress. Within nursing, the follower is often the direct care nurse who is trusted to think critically, ask probing questions about care, and advocate for the patient. Additionally, that probing and advocacy does not turn off in the presence of a patient. Those talents can advance the work of a group when they are acknowledged and used. This type of independent work is not in any way negative or passive.
181
Research on followership Literature consistently states the follower plays an important role within the team. Followers are at the bedside more than leaders tend to be, and they gain the trust of patients. In earning this trust, followers are often privy to information that the person in the leadership role does not know, and which may be of significant value in decision making or the plan of care (Malakyan, 2014; Gordon, Rees, Ker, & Cleland, 2015b; Sculli, 2015). Communication opens up the engagement of the leaders and followers and can also increase the trust and influence from and to the leaders and the followers. This open communication increases the confidence and decreases errors and negative outcomes (Gordon et al., 2015b, Malakyan, 2014; Sculli, 2015; Spriggs, 2016).
182
Followership theories Theories on followership have surfaced within the nursing profession and within the business profession. Nursing has maintained the healthcare hierarchy with limited exploration of the follower/direct care nurse. Within the business world the hierarchy has been challenged by those who have pointed out the importance of what the follower can contribute to the organization’s success.
Nursing Theories One theory on nursing care was developed by Dorothea Orem (1980). Orem addressed self-care of patients and described nursing as being needed when patients could not care for themselves or were limited in the care of themselves. Orem’s theory described nursing as an action of providing care and educating patients to provide their own care. Orem’s theory did not address leadership, but it did address the nurse (follower) as the person who intelligently participates in patient care and educates the patient when needed. Orem places the follower in an active, participatory role within his or her nursing career. The movement from novice nurse to experienced nurse can incorporate this theory into practice and hold the nurse accountable for the needs he or she identifies as lacking within the patient and the care provided.
Patricia Benner (1982) developed the now classic novice-to-expert theory about how nurses progress during their nursing careers. Novice and advanced beginner nurses (followers) rely on what they learned in nursing school to guide their practice, but as they move throughout their careers they also rely on their professional experiences. The leader can play an important role in how novice nurses move throughout the stages of their careers. Being flexible to new ideas through open communication allows nurses to gain even more knowledge by fully experiencing active learning on the job and gaining more experience to develop their expertise in patient care.
Ida Jean Orlando, a nursing theorist, developed a nursing practice model that incorporates both nursing practice and nursing leadership (Orlando, 1961). This theory requires nurses to incorporate their ideas and feelings and to investigate any assumptions they have about the patient. This is a huge step in having nurses (followers) think for themselves. Not only do nurses have instincts about patient care, but also nurses should investigate these instincts to figure out what might be harming or wrong with the patient. This is one of the first types of models that incorporates autonomy and active participation within nursing practice. Orlando called this the dynamic nurse– patient relationship model (Orlando, 1961).
Business Theories Robert E. Kelley decided in 1992 that the world of business needed to pay attention to followers. He stated that leaders do not live or thrive without followers. Kelley’s seminal work was to place followers as the central topic with leaders, organizations, peers, and everything else in the periphery. Kelley identified and defined five followership styles by asking questions about the way followers follow. Making use of the different styles, Kelley was able to help organizations understand behaviors and the actions taken by followers (Kelley, 1992).
Ira Chaleff propelled the idea of followership further by describing the courage it takes to become an effective follower within an organization. He strives to bring self-awareness to the ability of followers to courageously question or challenge leaders. Chaleff developed a self-assessment for followers to explain behaviors. The intent of the self-assessment is to identify behaviors among followers to provide reflection. Chaleff stated this is a way to develop followers and help them identify the style of follower they are and move into an effective follower role (Chaleff, 2017). (See the Literature Perspective box.)
Each of these theories contributes to valuing the importance of effective followership. Table 6.1 summarizes these theories.
Table 6.1
Theories on Followership
183
L i t e r a t u r e Pe r s p e c t i ve Resource: Chaleff, I. (2017). In praise of followership style assessments. Journal of Leadership Studies, 10(3), 45-48.
The roles of the leader and follower are not always roles that are solely one person’s and static. Most team members will occupy both roles interchangeably or simultaneously within the organizational setting. Chaleff describes the ability to move fluidly into and out of these roles as an area where self-assessment of behaviors should occur. These assessments can be individual, group, or culture. The result will help identify what is needed to know about followers and how they react within their environment.
Implications for Practice To be effective in any team work, the members of the team (followers) must be as effective at what they do as the leaders are at what they do. Additionally, because leadership is shared and fluid, a leader must be equally capable of transitioning into the role of follower as the follower is in transitioning into the role of leader.
184
Differences between leading and following Leading and following can be visualized within any organization, including and especially within healthcare organizations. However, if we look into the concepts behind each title of leader and follower, we can dive into how they are used within nursing practice. We can see some extreme differences in the characteristics of each one.
Leader The word leader refers to someone who has the ability to guide people toward a common goal and sets the tone within the unit (Gordon, Rees, Ker, & Cleland, 2015a). Within healthcare organizations and nursing practice, the word leader describes a person who does so much more. A leader within this context guides and gives direction to those who are perceived to be subordinate or reliant on them. The leader achieves this level of influence by using active listening and engaging in open communication (Gordon et al., 2015b). The nursing leader does the courageous act of releasing control to create an active learning environment. This release of control allows the leader to share the accountability of decision making with other people within their supervision. Sharing accountability fosters a partnership of trust between leaders and the team members they supervise by inspiring the team members to speak up and voice their opinions and concerns. The leader can handle and adapt to the unknown. Different leadership styles emerge during different crises and everyday situations.
Follower Followers have the ability to create influence among other staff and their leaders (Forbes, 2016). Within nursing, followers are often the direct care nurse who is trusted to think critically, ask probing questions about care, and advocate for the patient. This type of independent work is not in any way negative or passive. When we think about leadership, we often think only of one element of the equation—the leader. Yet without the follower role, leadership does not actually exist.
Thus the whole process of leadership can be thought of as Fig. 6.1 depicts.
FIG. 6.1 The huddle is a brief and precise communication exchange that engages team members to
185
identify any needs or safety issues. (Copyright © Uberimages/iStock/Thinkstock).
E x e r c i s e 6 . 1 Name five characteristics of a great leader. Think about a nursing leader you have observed. Does that person match those characteristics? Now, name five characteristics of a great follower. Have you seen a follower exhibit those characteristics? How are the two sets of characteristics similar? How are they different?
Effective Follower The phrase effective follower identifies an engaged and participating team member who thinks for himself or herself. Effective followers are able to communicate needs and concerns effectively and courageously (Sculli et al., 2015). Effective followers identify the practical aspects of nursing, provide input when needed, and ask questions to clarify. They are positive, and they support the leaders within their organization. Effective followers need leaders who foster professional growth, and in return effective followers can also influence the leader by using intelligent and experience- driven suggestions to solutions about patient care (Sculli et al., 2015). They practice autonomy with decision-making responsibilities and share accountability with their leaders (Mannion, McKimm, & O’Sullivan, 2015). Effective followers are loyal to the organizations and foster partnerships and support leadership in every area of nursing. Followers have the ability to self-manage; have commitment to their organizations; and have competence, focus, and courage (Everett, 2016). The effective follower has the potential to not only influence the leadership but also influence co- workers within the healthcare organization. Positive attitudes can be contagious and increase the morale of the entire unit. Fostering this type of atmosphere will most likely increase productivity and patient outcomes.
Ineffective Follower The term ineffective followers identifies static team members who rely solely on leadership for all direction and guidance (Malak, 2016). They do not question authority and have a hard time voicing their opinions or concerns because of the traditional hierarchy. The way ineffective followers communicate is through complaining and pointing fingers. They hardly ever offer solutions, only complain about problems. They have no control over their situation and have no loyalty to the healthcare organization in which they work (Forbes, 2016). Ineffective followers are not flexible, and their main concern is just putting in their required number of hours.
E x e r c i s e 6 . 2 Think of a time when you were involved in a great relationship. What made the relationship great? Was it hierarchical where one person was always the leader and the other was always the follower? Or was it “give and take” depending on the situation? What kind of trust was present? Were you afraid to voice your opinion? Did the other person value your opinion?
L i t e r a t u r e Pe r s p e c t i ve Resource: Malak, R. (2016). A concept analysis of “Follower” within the context of professional nursing. Nursing Forum 51(4), 286-294.
The leader and the follower are dynamic and intertwined in the leader–follower relationship. “Followers are practicing more in organizations where governance is shared and the organizational structure is flattened” (p. 286). The effectiveness of the followers and the advancement of the organization, increased trust, and leadership exchange were advanced as outcomes occurring within the leader–follower relationship. This increases the value of engaged and effective followers alongside effective leaders and is increasingly becoming recognized for improved team and organizational performance.
186
Followers have the expectation for leaders to be “accessible, trustworthy, empathetic, visionary, and to be invested in employee development” (p. 292). “Exemplary and engaged followers are those who show intelligence, commitment, integrity, independence, and courage” (p. 292-293). “Increasing the understanding of the follower and their many levels of impact on nursing practice will help guide how leaders are developed and how engaged followers are cultivated to achieve positive outcomes in all levels of health care” (p. 293).
Implications for Practice Nurse leaders at every level of the organization need to understand the dynamics of their followers to achieve the aligned vision and goals.
187
Leader–follower relationship For a long time within healthcare organizations, the hierarchy of leaders and followers did not permit the development of the leader–follower relationship. The leaders were the source of knowledge and power, and the followers were submissive. This was more like a dictatorship than a true relationship. Fortunately, a shift in thinking occurred away from hierarchies, because the relationship between nursing leaders and followers was defined as circular and not linear, with followers central to leaders, as seen in the Literature Perspective box (Malak, 2016). Simplifying this statement, leaders can become followers and followers can become leaders depending on the situation and expertise and experience of the nurse. With this knowledge, the emphasis on understanding the leader–follower relationship is more important to create a cohesive and productive team.
The relationship between leaders and followers is a true partnership built on trust and accountability. Leaders trust followers to make decisions and speak up about concerns, and followers trust leaders to actively listen and provide guidance and open communication (Forbes, 2016; Gordon et al., 2015b). Communication opens up the engagement, increases the trust, and increases the influence to and from both leaders and followers within this relationship (Malak, 2016).
A cohesive relationship between leaders and followers will reduce skill-based errors because followers are not afraid to ask needed questions, will reduce infection and mortality because the leader will trust the concerns of the followers in detrimental situations, and provide the patients with a better experience (Malak, 2016).
Importance to Nursing Practice Institute of Medicine/Robert Wood Johnson Foundation Report Nurses have always contributed to the health and well-being of the populations whom they serve by advocating for improved outcomes. The report conducted by the National Academy of Medicine (formerly known as the Institute of Medicine [IOM]) and the Robert Wood Johnson Foundation (RWJF) expanded the reach of nursing practice to assist with the need from the public for health care. This initiative included ideas such as nurses practicing to the full extent of their training and education and becoming full partners with physicians and other healthcare professionals in redesigning health care (IOM, 2010).
This initiative expands the view of the development of effective followership. Educated and well- trained professionals in nursing with limited experience can feel the weight of the hierarchy ladder on their shoulders. Becoming an effective follower in a learning institution and workforce organization elevates your position and acknowledgment of your skills among your team and gives your voice merit and the ability to be heard. The fact that the National Academy of Medicine is calling for the nursing workforce to be partners with physicians and other healthcare professionals changes the clinical ladder to a clinical round table where all voices can be heard and activated.
Quadruple Aim Nurses in leader or follower roles are expected to fulfill the expectations of the Triple Aim, which the Institute for Healthcare Improvement (IHI) developed in 2008 (Berwick, Nolan, & Whittington, 2008). The Triple Aim’s ultimate goal is to improve the health of the communities in which each healthcare organization serves (Bodenheimer & Sinsky, 2014). More recently, the list has increased to include another aim to decrease the incidence of healthcare provider burnout (Bodenheimer & Sinsky, 2014). Guiding healthcare professionals to achieve the quadruple aim will help achieve the goal of improved health while keeping the providers engaged and decreasing turnover. The Quadruple Aim guidelines include the following:
• Enhancing patient experience • Improving population health • Reducing costs • Improving the work life of care providers
188
The importance of achieving the Quadruple Aim can be emphasized with the engagement of the leader–follower relationship. The outcomes from promoting the leader–follower relationship can be seen in Table 6.2.
Table 6.2
How Leaders and Effective Followers Achieve the Quadruple Aim
A Followership Model The consensus in the literature is that within the leader and follower relationship, a lot of information is documented about developing and improving the role of the leader. Very little is known about the follower role, but the literature consistently states the follower plays an important role within the team. Identifying the follower as a strength within the relationship has yet to prove the need to actively engage and develop the follower into being an effective member of the team.
Many leadership programs and models have been developed over the years. One model is very close to addressing the leader-follower relationship. This model is the transformational leadership model. Taking this model and transforming it into a followership model (see Box 6.1) illustrates how the follower might be engaged to grow and be effective.
Box 6.1
C o n ve r t i n g t h e T r a n s f o r m a t i o n a l L e a d e r s h i p M o d e l I n t o a F o l l o we r s h i p M o d e l Leadership Model
• Focuses on leadership • Acts as a role model • Influences others • Demonstrates ethical actions • Promotes confidence in abilities • Inspires confidence in followers • Gives sense of purpose to followers • Motivates followers • Communicates well
189
• Emphasizes the positive • Values creativity and autonomy • Involves followers in decision-making process • Identifies the individual needs of the follower • Coaches individually • Mentors
Followership Model
• Focuses on followership • Acts professionally and ethically • Influences leaders and colleagues • Asks intelligent, thought-provoking questions • Speaks up when concerns arise • Inspires confidence in the care they provide • Demonstrates a sense of purpose • Motivates himself or herself • Communicates well • Demonstrates positive behaviors • Strives for autonomy but knows when to ask for assistance • Engages in decision-making process • Identifies the individual needs of the patient and relates them to leadership • Accepts criticism as a learning opportunity • Engages in open communication with the mentor • Transitions into leadership roles when needed • Advocates for patients • Commits to evidence-based, quality care • Engages in lifelong learning • Demonstrates active membership in shared governance
Based on Choi, S., Goh, C., Adam, M., & Tan, O. (2016). Transformational leadership, empowerment, and job satisfaction: The mediating role of employee empowerment. Human Resources for Health, 14(73), 1-14; and Schieltz, M. (2017). Four elements of transformational leadership. Small Business. www.smallbusiness.chron.com/four-elements-transformational- leadership-10115.html.
190
Conclusion Today, what is known about leaders is extensive. Developing the leader, expanding leadership knowledge and expertise, and transforming the individual into a productive leader are all well discussed within the literature. The followers play a very versatile and important role within the leadership–followership team. This is a stated fact among many writings; however, how to engage, motivate, and encourage the follower to become effective has not been well developed. Leaders need followers. Without followers, a leader is simply a team of one.
Followers have a duty and a professional obligation to provide the highest standard of quality care for the patients whom they serve. Followers must step out of the negative shadows and into the positive light and drive leaders within the organization to promote the team as a whole. Followers must participate in the care of their patients, ask questions, voice concerns with intelligent communication, create trust from leadership in their abilities, provide advocacy to the patients, and have courage to make decisions and share them with the leadership team. Being an effective follower is an active role that requires participation. The act of following effectively contributes to the goal of advancing health.
T h e S o l u t i o n Anonymous
I was assigned to “Mr. A” again the next day. Early in my shift, I observed that his wife was crying. I sat down and offered comfort to her. She was upset because she said she had been attempting to talk with her husband and he was communicating with her that he did want to have the breathing tube and machine by shaking his head yes and no. She said when she would ask him he would shake his head no, he did not want it, and nod yes, he wanted to take it out. I asked her if she had communicated this new information to the physician. She stated, “He is the doctor, he is a man, and in my culture, we do not question the doctor. They know what is best.” Later that day the children came to visit. I had another nurse who was a certified interpreter come in and talk to everyone in Spanish to make sure we all understood what could and what would probably happen if they agreed with the patient’s wife about extubating the patient. The wife, the children, and most importantly the patient all understood that death was likely if the ventilator was removed because of the severity of his disease. I had a different charge nurse that day so I explained to her the entire situation. She called the physician to come by and talk to the family. Before entering the room, I informed the physician of my conversation with the family members. The interpreter was present for the conversation. After talking to the family, the physician agreed to extubate the patient. I knew that I had done what I was supposed to do, being an effective new nurse and trusting my instincts. I had to have the courage to speak up for the patient, and it was not easy as a new nurse.
There was a lot of miscommunication in this incident. The physician at our facility should have had an interpreter come in with him the first time he talked to the wife. He already knew there had been a miscommunication before at another facility. I got a call from one of my co-workers telling me that his wife had asked them to call me. She got on the phone and thanked me for helping them and that thanks to me her husband had died with dignity and got to enjoy his last hours with a few words, smiles, and a good-bye kiss. Being an effective staff nurse allowed me to trust my instincts, question leadership about the patient’s plan of care, and find the courage to speak up and communicate the concerns of the family under my care.
Would this be a suitable approach for you? Why?
191
Reflections Taking on the role of the effective follower is a continuous task. It involves all the characteristics described in this chapter, including active listening, open communication, trusting your own knowledge and instincts, and having the courage to speak up and voice any questions or concerns you may have in any situation. How effective are you as a follower?
Having the courage to take on this active role will improve the morale of the organization, help with increasing patient satisfaction and outcomes, and also provide leaders and peers the opportunity to view you as a “go to” person they can trust. How do you think others perceive you as an effective follower?
192
The evidence Little research has been completed related to the role of the follower in nursing. The greater emphasis has been placed on the idea that even new graduates are expected to lead, which is often related to intervening for patients as needed. As the idea of being an effective follower at any level grows, more data will be available to inform us about the role and impact of being an effective follower.
193
Tips on how to be an effective follower • Trust in your knowledge and instincts. • Do not be afraid to ask questions. • Have the courage to voice any concerns. • Be professional. • Stay up-to-date on evidence-based care. • Engage in open communication. • Do not hint and hope. • Take an active role within your organization.
194
References Benner P. From novice to expert. American Journal of Nursing. 1982;82(3):402–407. Berwick D., Nolan T., Whittington J. The triple aim: Care, cost, and quality. Health
Affiliate. 2008;27(3):759–769. Bodenheimer T., Sinsky C. From Triple to Quadruple Aim: Care of the patient
requires care of the provider. Annals of Family Medicine. 2014;12(6):573–576. doi:10.1370/afm.1713.
Chaleff I. In praise of followership style assessments. Journal of Leadership Studies. 2017;10(3):45–48. doi:10.1002/jls.21490.
Everett L. Academic-practice partnerships: The interdependence between leadership and followership. Nursing Science Quarterly. 2016;29(2):168–172. doi:10.1177/0894318416630106.
Forbes M.A. Followership: A critical shortfall in health leadership. Internal Medicine Journal. 2016;637–638. doi:10.111/imj.12993.
Gordon L., Rees C., Ker J., Cleland J. Dimensions, discourses and differences: Trainees conceptualizing health care leadership and followership. Medical Education. 2015a;49:1248–1262. doi:10.1111/medu.12832.
Gordon L., Rees C., Ker J., Cleland J. Leadership and followership in the healthcare workplace: Exploring medical trainees’ experiences through narrative inquiry. BMJ Open. 2015b;5:1–11. doi:10.1136/bmjopen-2015-008898.
Institute of Medicine (IOM). The future of nursing: Leading change, advancing health. Washington: DC; 2010. www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading- Change-Advancing-Health.aspx.
Kelley R.E. The power of followership: How to create leaders people want to follow and followers who lead themselves. New York: Doubleday/Currency; 1992.
Malak R. A concept analysis of “Follower” within the context of professional nursing. Nursing Forum. 2016;51(4):286–294. doi:10.1111/nuf.12158.
Malakyan P. Followership in leadership studies: A case of leader-follower trade approach. Journal of Leadership Studies. 2014;7:6–22. doi:10.1002/jls.21306.
Mannion H., McKimm J., O’Sullivan H. Followership, clinical leadership and social identity. British Journal of Hospital Medicine. 2015;76(5):270–274. doi:10.12968/hmed.2015.76.5.270.
Orem D. Nursing: Concepts of practice. 2nd ed. New York: McGraw Hill Company; 1980.
Orlando L.J. The dynamic nurse-patient relationship. New York: Putnam’s Sons; 1961.
Sculli G., Fore A., Sine D., Paull D., Tschannen D., Aebersold M., et al. Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork. Clinical Risk Management. 2015;35(1):21–30. doi:10.1002/jhrm.21174.
Spriggs D.A. Followership: A critical shortfall in health leadership. Internal Medicine Journal. 2016;637–638. doi:10.111/imj.12993.
195
Managing Self: Stress and Time Mary Ann T. Donohue-Ryan
LEARNING OUTCOMES
• Define self-management. • Define emotional intelligence. • Explore personal and professional stressors. • Analyze selected strategies to decrease stress. • Evaluate common barriers to effective time management. • Critique the strengths and weaknesses of selected time management strategies. • Evaluate selected strategies to manage time more effectively. • Assess the manager’s role in helping team members manage their time and deal effectively
with stress.
KEY TERMS burnout coping
196
delegation depersonalization employee assistance program fatigue general adaptation syndrome (GAS) information overload overwork perfectionism procrastination role stress self-management self-reflection time management
T h e C h a l l e n g e Savitra Sutton, MSN, MBA-HCN, RN Nurse Manager, Englewood Hospital Medical Center, Englewood, NJ
I was a nurse manager for more than 20 years at another facility and was promoted to supervisor and then director of nursing. When I came to this organization, I was administrative supervisor for 2 years. One of the biggest challenges I had in my nursing career was accepting this new position and learning the inpatient environment and covering the entire hospital. Then, after 2 years, I accepted an inpatient nurse manager position. Some of the challenges I faced were narrowing and decentralizing my thought process. I was no longer looking at the organizational picture; I had to refocus my views into just one inpatient unit. I had to focus on my quality indicators, my team members, their accountability, and communication with the patients and the families. Most importantly, I had to fit everything into an 8-hour day! It was difficult to do this; I didn’t have other leaders to assist me. When I was a nursing supervisor, I thought of myself as the liaison to all other leaders throughout the organization. However, when I assumed the nurse manager position, I had trouble with work–life balance. I found myself staying later and later, trying to accomplish everything I needed to do.
What would you do if you were this nurse?
197
Introduction What should you do when the skills you have usually deployed in a given situation do not seem to work and things are not going well? What needs changing? Where do you begin? Daniel Goleman (1995, 2017), considered by many to be the seminal author on emotional intelligence (EI), observed that those who are the most successful in organizations are not necessarily more intelligent. Rising stars are distinguished from their peers because they have learned how to master their own emotions as well as their relationships. Such individuals, with average IQs, clearly outpaced those with even the highest IQs when principles are learned and refined over time.
Managing EI, managing stress (or at least our response to it), and managing time when possible are three key strategies for self-management.
198
Emotional intelligence EI is a critical leadership competency, and it involves four skills, self-awareness, self-management, social awareness, and relationship management (Goleman, 2017). Briefly, self-awareness relates to how well we perceive our own emotions at the time we are experiencing them. This element is important because our emotions tell us how we are reacting to events and information. If you have an uncomfortable “gut” feeling and do not know what caused that sensation, you may want to practice deliberately thinking about events and information and your reactions so that you gain a better understanding of yourself. Self-management is your response to being self-aware. You either act or not. We all know people who blurt out something about a driver cutting them off on the road. That is an example of an immediate, although not productive, act. Being more self-aware may allow that individual to move from focusing on the other driver to focusing on better application of brakes, having a calm response, and so forth. Social awareness relates to “reading” people. Are they happy, angry, distressed, hurt? The purpose of being socially aware is to gain critical information, so listening and observing are two critical skills. The final element is relationship management. As you might suspect, it relies heavily on your abilities in the other areas. It combines your awareness of self and others in an effort to execute clear communication. Through solid relationship management, even with people we may not like, we can be more effective in reducing personal and sometimes even organizational stress. In times of crises, no matter what the origin is, clear communication is critical to being effective in resolving the issue.
Personal competence includes the skills of self-awareness and self-management (TalentSmart, 2017). Social competence involves the skills of social awareness and relationship management. The good news is that EI can be learned. EI is linked to improved self-performance, employee performance, and organizational performance (Basogul & Ozgur, 2016; TalentSmart, 2017). Emotionally intelligent managers possess greater insight into their staff and manage better because they provide support and guidance, frequent feedback, and, one might infer, a natural give-and- take that results in growth (Spano-Szekely, Griffin, Clavelle, & Fitzpatrick, 2016). Nurse leaders’ goals include growth and self-knowledge, learning to balance new as well as formerly held personal and professional objectives, and reorganizing time and activities to reach these goals. The literature suggests that nurses, because we are all human beings, cope with the complex stresses and crises of everyday life as well as unpredictable clinical situations (Scott, 2015). The so-called stress hardiness of nurses and leaders has long been thought to be essential to the survival of the nurse as well as overall staff recruitment and retention, giving rise to a professional alter-ego—the “supernurse culture” (Steege & Rainbow, 2017). In the past, seasoned nurses would pride themselves on being able to “take it,” meaning silently work without openly challenging unfavorable aspects of the workplace, however unacceptable they might be. Those who left nursing, either unable or unwilling to tolerate difficult conditions in the practice setting, were labeled as “weak,” “bad nurses,” or simply “not a good fit” for the organization. Historically, and even as recently as the mid-2000s, research on stress in the nursing workplace focused on the individual’s acceptance of demanding work environments, complex role requirements, and recurring staff shortages instead of proactive problem solving (Shirey, 2006). However, definitive hardiness, as described in the seminal work by Lambert and Lambert (1987), incorporates control, commitment, and challenge as tools in one’s personal repertoire to change what cannot easily be changed at the unit- and organization-wide levels. In fact, organizations that make a significant investment in leadership development connect and strengthen social support networks. Even the perception of transformational leadership mitigates against the toxic effects of burnout (Shi, Zhang, Xu, Liu, & Miao, 2015). Leaders in progressive and innovative thinking, called “thought leaders,” suggested that the cultivation of stress hardiness produces nurse managers with a leadership style and resilience that actually improves overall working conditions. Fortunately, stress management can be taught and personal hardiness can be acquired, and interventions at all organizational levels exist to mitigate against caregiver burnout and stress (Miller, 2016).
To develop stress hardiness, we must actively improve our skills related to stress management, adaptive coping, healthy communication, and problem solving. The three key strategies presented in this chapter—EI, time management, and stress management—are important ways to support one’s talents, energies, and creativity.
199
200
Understanding stress Time and stress are somewhat a chicken-and-egg phenomenon—trying to “fit everything in,” and not having enough time to complete tasks, further contributes to stress. Living a life without a break from stress further erodes efficiency and thus decreases one’s ability to contribute to quality outcomes. The key lies in our ability to take charge of our lives and strive to understand ourselves, and manage time and stress, both personally and professionally. Over time, the outcome of skillful self-management is hardiness and an improved ability to accomplish worthwhile goals, infused with our own unique style.
Nurses have learned about the effect of stress on patients and how to provide health teaching to manage its consequences. However, aspiring nurse leaders do not believe that their own skills adequately prepare them for dealing with competing needs and priorities—that is, being able to skillfully manage multiple sources of conflict at the same time. They may feel unprepared and thus reluctant to accept the demands of formal leadership roles (Dyess, Sherman, Pratt, & Chiang- Hanisko, 2016). Stress is defined as the uncomfortable gap between how we would like our life to be and how it actually is. Nurses are not immune to the effects of stress and, in fact, modern nursing is a very stressful occupation. Hospitals care for more and more critically ill patients, which requires advanced knowledge and skill to accomplish highly complex tasks, especially in the critical care setting (Nagel, Towell, Nel, & Foxall, 2016). Nurses need to recognize their unique stressors at home and on the job. The ubiquitous use of the Holmes-Rahe Stress Scale reinforces that everyone experiences stress—the exhilaration of a joyous event, as well as the negative feelings and unpleasant physical symptoms associated with a difficult life situation or even the anticipation of difficulty, such as meeting the parents of a new girlfriend, or taking an examination in a particularly tough subject area. Learning what stress is, its dynamics, and how we individually experience it and determining effective strategies to manage stress are part of the personal and professional maturation of all individuals. Because nurses tend to work in areas and in situations that are extremely stressful, stress management skills must be continuously adapted to new situations and strengthened over time.
201
Definition of stress In this chapter, stress and distress (Selye, 1965) are used interchangeably, although some writers regard stress as neutral and refer to positive attributes or perceptions of stress as eustress and negative attributes or perceptions of stress as distress. Stress is a consequence or response to an event or stimulus. Stress is not inherently bad. Rather, each individual’s interpretation determines whether the event is viewed as positive or threatening. In addition, stress management does not necessarily mean stress reduction or its outright elimination. More than 30 years ago, Kobasa, Maddi, and Kahn (1982) characterized successful stress management as the control of emotions and behaviors, perseverance, and a heightened sense of purpose, along with continuous challenge that is present in the face of stressful events. Stress management is an important nurse manager competency (American Organization of Nurse Executives, 2015), and to what degree leaders incorporate ways to mitigate stress in one’s leadership style is tied to employee stress (Fernandez, 2016). Effective stress management has important implications for the workplace because of its link to low absenteeism rates, improved quality, and increased productivity and characteristics associated with workforce flourishing (Schultze & Loi, 2014).
202
Sources of job stress Job stress can be defined as the physical and emotional responses that arise when job requirements do not seem to match the abilities, resources, or needs of the worker. Work-related stress can lead to poor physical and emotional health and injury. Job-related challenges (eustress), which motivate us to learn new skills, master our jobs, and manage new situations, differ from distress, which can lead to symptoms from fatigue to exhaustion, feelings of inadequacy and failure, or even complete and total indifference and burnout. For example, if you are involved in an oral interview for a job, you will benefit from a certain amount of stress (eustress). Stress provides the determination to land that new position and gives you the “edge” we all need to help us think quickly and clearly and to express our thoughts in ways that will be appropriate for the interview process. On the way to the interview, however, if your car breaks down or you miss the bus or if a hired driver misinterprets the correct address, these conditions certainly create a negative stress (distress) experience as you realize that you will most certainly be late for the appointment. Certainly, as more is learned about the relationship of stress to physiologic changes, as in its effect on sleep, eating, and social interactions, personal stressors will become even easier to identify. When one looks at job-related stressors, the stressors fall into one of two categories: external (working and living conditions) and internal (worker characteristics).
External Sources Work-related stressors, such as an ever-increasing workload; rotating shifts; high patient acuity; inadequate or unpredictable staffing; ethical conflicts; dealing with acute illness and death; role ambiguity; constant multitasking; work relationships; job insecurity; and the multiple, complex, and continually growing number of nursing responsibilities, have been associated with increased stress, all of which have been reported as stressors (Yu, 2016). Nurses spend more and more time at work, and their managers report 12- to 14-hour days as a normal way of life, with accountability 24 hours a day, 7 days per week. They, like most individuals in management, are tethered to cellphones or other electronic devices that can never be completely “powered down” without ramifications for that missed call, text, or important e-mail. However, some forward-thinking organizations are taking specific actions to avoid this feeling of always “being on.”
The needs and expectations of our consumers, patients and families, cannot be underestimated, as they are the reason healthcare organizations exist in the first place. The need to provide safe, effective health care is coupled with the need to provide an outstanding patient and family experience—because every patient has the right to expect it. Patient satisfaction scores are a source of stress, with initiatives linked to survey questions that appear to most closely tie to patient concerns. Recognizing this, many leaders freely provide personal cell and home phone information for their staff, administrators, donors, board members, and people with close ties to the community to allow for immediate communication should a need arise at any time of the day or night.
Role Expectations Although the distress that results from change takes many forms, two underlying patterns appear to be constant. Often, nurses feel overwhelmed by conflicting expectations to be accountable on many fronts: They are educationally prepared to furnish evidence-based clinical care; to meet their patients’ and families’ emotional needs; and to be warm, friendly, and supportive to their co- workers. Ultimately, organizations now require nurses to also be knowledgeable about their business unit, possess a keen financial awareness about how they contribute to overall organizational efficiency and cost-effectiveness, and to consistently earn highest marks on their patient satisfaction or experience scores. Because individuals—frontline direct care nurses, nurse managers, and chief nursing executives alike—cannot easily balance caring and clinical expectations with business and administrative expectations, it is completely normal to experience considerable role overload, frustration, chronic fatigue, and distress.
Relationships Interpersonal relations can buffer stressors or can in themselves become stressors. Outside the work setting, home may represent a refuge for harried nurses; however, stressors at home, when severe,
203
can impair work performance and relationships among staff or even include undesirable patterns that have the potential to invade the workplace and create an unhealthy work environment. When one parent in the home works hours other than daytime hours, for example, children and adolescents are more likely to demonstrate inferior cognitive and behavioral outcomes (Morsy & Rothstein, 2015). Therefore the cycle of work pressure and home pressure can at times seem insurmountable, especially to the nurse who may also be caring for an older parent, sick partner or sibling, or a child with special needs. Added to the mix may be the nurse who attends school to attain a degree, studies for a national board certification, or prepares for clinical ladder advancement—all common requirements of the contemporary work setting.
Changes in healthcare delivery systems, as well as the cycles in the nursing workforce supply and demand, have affected professional nursing in many ways. Some work settings may have a disproportionate representation of Generation X, Generation Y, or Millennials, or perhaps a larger percentage of older nurses, the Baby Boomer Generation. In situations in which the values of one generation of workers clash with those of another, conflict occurs unless the manager becomes aware of how to best maximize the positive behaviors of each generation. The wise leader will adapt to the best attributes of all members of the team (Diesing, 2016).
In geographic areas suffering from staffing shortages, inpatient settings may have minimally safe levels of professional caregivers. Because of the economy and changes in federal financial reimbursement in the form of reduced Medicare payments to US hospitals, strict adherence to unit budgets may result in rigid staffing patterns that are not realistically flexed to actual or perceived patient acuity and case mix index. Consequently, layoffs or early retirement buyouts may occur with the resultant struggle to maintain supportive, collegial relationships that were established over many years of working together. In nationally hard-to-recruit specialties, such as in perioperative and mother–baby areas, organizations have turned to supplemental staffing with agency or “traveling” nurses, thus creating a transient nursing staff for longer than desirable intervals. The practice of “floating” staff, when nurses are reassigned or “floated” to different patient care units, causes nurses to work with unfamiliar staff. They may feel isolated or become unwittingly involved in dysfunctional politics on the unit. Floating, by definition, means that nurses work with patients whose requirements for care may be different than the expected, resulting in further stress related to patient safety and professional practice concerns.
Persons in management-level positions may also become stressors. Mixed messages or, worse, multiple initiatives announced at the same time create confusion and stress about what constitutes the real organizational priority. Communication may come only from the top down, with scarce opportunity for nurses to participate in decisions that affect them directly and that they are required to implement without proper training or support. On units or in hospitals without a viable professional governance system of shared decision making, nurses may experience distress. This may arise from feelings of frustration and helplessness in settings without an opportunity to improve the clinical care and work environment with the active participation of the frontline direct care nurse.
Does stress management get any easier when nurses occupy the top job, chief nursing officer (CNO)? All nurses in an organization should care about what the CNO experiences, because that person is the official voice for nursing. One study concluded that although CNOs act with moral courage, they experience moral distress as they contribute to major decisions that affect those within the entire organization and, at the same time, attempt to uphold their moral values and professional responsibilities (see the Research Perspective).
The Position Upon entering nursing studies in a college or university, most students expect that caring for patients who are chronically or critically ill and their families will be stressful. The current environment in many healthcare agencies, however, is exponentially more complex and is often characterized by overwork, as well as by the stresses inherent in contemporary nursing practice. In some settings, direct care nurses have been expected to work beyond the designated assignment period, constituting mandatory overtime, often with little or no prior notice. Owing to the nature of stress and crisis, some patients and families may escalate in their own threatening behaviors and verbally or physically attack their own caregivers. Several states, in response to legislative efforts and pressure from their constituents, have enacted criminal laws to protect healthcare workers from such violence. Many healthcare institutions have established relationships with local police
204
departments to convey a zero tolerance policy to those who are violent toward their team members (see www.nursingworld.org/WorkplaceViolence.aspx). A zero-tolerance workplace means that acts of violence toward staff are not acceptable and will, in most cases, be prosecuted to the full extent of the law.
Another common stressor for nurses is the paradox of the presence and/or the lack of technology in the workplace. Technology is often anticipated as an assist to the nurse but often turns out to be far different. Therefore
R e s e a r c h Pe r s p e c t i ve Resource: Prestia, A., Sherman, R.O., Demezier, C. (2017). Chief nursing officers’ experiences with moral distress. Journal of Nursing Administration, 47(2), 101-107.
This is a study to qualitatively explore the phenomenon of moral distress in twenty chief nursing officers (CNO). Nurses who function as healthcare executives are required to uphold the tenets and beliefs of their respective profession, which is defined in the American Nurses Associations’ (ANA) Scope and Standards for Nurse Administrators. The study participants were asked to describe their experiences with moral distress, its effect, and the coping strategies that they used. Content analysis was used to identify themes, consistent with a phenomenologic approach. Moral distress occurred in the areas of salary and compensation; hiring practices; harmful and stressful relationships with peers and hospital presidents; and observations of questionable business practices and other improprieties. Emerging themes were identified that defined the experiences of moral distress. The six themes were (1) lacking psychological safety, (2) feeling a sense of powerlessness, (3) seeking to maintain moral compass, (4) drawing strength from networking, (5) having moral residue, and (6) living with the consequences. The researchers’ conclusion was that this is a rarely discussed aspect of chief nursing officers in acute care settings. Moreover, 8 out of the 20 study participants left their facility as a result of experiencing moral distress.
Implications for Practice Moral distress is a relentless experience that has the potential to undermine and derail careers. Those who suffer its consequences either deal with it in silence or discover alternatives as they transition out of the disruptive workplace. Networking with other CNOs and within one’s professional organizations were described as “invaluable,” and of “10-plus” benefit. In conclusion, psychological self-protection and professional discussion about moral distress would support the lives and careers of nursing executives. The descriptions and recommendations may readily apply to nurses in any leadership position.
nurses face stress as they attempt to learn and then integrate multiple systems that may lack sufficient interface, which often leads to frustration when they must toggle between multiple screens to complete critical patient documentation. When healthcare software is not designed well to be intuitive to the user, nurses wind up spending more and more time in front of a device instead of their patients. Nurses experience this as a burden because they are, so to speak, constantly feeding data hungry systems that were created and put into a production workflow to solve individually focused tasks, such as entering a patient’s blood pressure or blood glucose levels, without regard to the comprehensive effect on workflow and without regard for how time consuming computer tasks have become (Patterson et al., 2015; see http://ncbi.nlm.nih.gov/pubmed/10730596 and http://ncbi.nlm.nih.gov/pmc/articles/PMC61466). Nurses may need to bridge a staggering number of gaps to safely communicate with their internal and external colleagues whose workplaces are technologically different or who have separate and distinct rules about documentation, ordering tests, receiving results, and obtaining outcomes of care —all within the same hospital or setting!
Role stress is an additional stressor for nurses. Viewed as having three components (role ambiguity, role conflict, and role overload) (Iacobellis, 2015), role stress for new graduates has a positive correlation to burnout. Role stress is particularly acute for new graduates, whose lack of clinical experience and organizational skills, combined with new situations and procedures, may increase feelings of overwhelming stress. Conflict between what was learned in the classroom or limited clinical experience and the actual practice setting compounds the situation and increases
205
stress. This concept has been so historically common in nursing that the phenomenon gave rise to the term “reality shock” in Dr. Marlene Kramer’s (1974) seminal work. Unfortunately, transition to practice issues have endured to present day, because academic and practice leaders have not yet managed to completely eradicate its negative effects on successive generations of nurses. However, transition programs have had positive effects on helping new graduates transition.
Gender Roles Approximately 9.6% of the nation’s approximately 4 million licensed registered nurses in the United States are men (Health Resources and Services Administration, 2013). Most nurses are women who go home at the end of their shift to traditional responsibilities, including managing the household and caring for young children and aging parents while they balance their own needs. When added to the already stressful workday of the nurse, the additional responsibilities often contribute to a higher level of distress that may be experienced. Men may have those same experiences, because the “traditional” roles in society have changed to the extent that many men have those same stressors. Thanks to Generation Y’s (those born in the 1980s) and Millennials’ entry into the workforce, the importance of work–life balance has become increasingly emphasized, but this has not yet entirely translated into improvements in the American workplace, because at 18% (34% of the general workforce), they are underrepresented in the nursing workforce (Whitman, 2017). Owing to vagaries in the economy, spouses, partners, or children may be underemployed or experience sharply reduced work with reduced or nonexistent health benefits. Thus children or even grandchildren may have returned to live at home, and many nurses are shouldering the burden of another full- or part-time job or working overtime for additional income to contribute to overstretched household budgets. Lack of financial security means that in times of severe economic hardships, such as in a national economic recession or regional threats to the local economy, as in a severe hurricane or an industrial plant closing, living from paycheck to paycheck sharply reduces options for self-improvement through career advancement. Financial insecurity may actually curtail career opportunities. For example, some nurses may be too afraid to seek a better position because of concern for not succeeding in a new position, not liking a new job, losing health benefits, or experiencing layoffs in an uncertain economy. The key is to be open to asking for help in managing such stressors so they can be viewed as opportunities rather than setbacks. For example, seeking guidance from others will undoubtedly raise greater awareness and sensitivity to one’s patients and management team. The goal is always to maximize our abilities and talents so we can improve the health and lives of others.
Internal Sources Personal stress “triggers” are events or situations that have an effect on specific individuals. A personal trigger might be a specific event such as the death of a loved one, an automobile accident, losing a job, or getting married or divorced. These events are in addition to daily personal stressors such as working in a noisy environment, experiencing job dissatisfaction, or having a long or difficult daily commute to work. Negative self-talk, pessimistic thinking, self-criticism, and overanalyzing situations can be significant ongoing stressors. These internal sources of stress usually stem from unrealistic self-beliefs (unrealistic expectations, taking things personally, all-or- nothing thinking, exaggerating, or rigid thinking), perfectionism, or a Type A personality.
An individual’s ability to deal with stress may be moderated by psychological hardiness, also called resilience. According to seminal researchers Lambert, Lambert, and Yamase (2003), psychological hardiness is a composite of commitment, control, and challenge. These form a constellation that (1) dampers the effects of stress by challenging the perception of the situation and (2) decreases the negative impact of a situation by moderating both cognitive appraisal and coping. Nursing resilience is a cultivated characteristic that occurs when individuals strategically use education and other practices in bad situations (Sanders, 2015).
Everyone needs to recognize that the human species require certain basic physiological needs (Maslow, 1943). According to Maslow, these needs govern our understanding of what constitutes homeostasis as well as the polar opposite, such as when we have an appetite for something that ties directly to a specific actual need or something else that is lacking (see the Theory Box). On the other hand, poor and unhealthy lifestyle choices, such as the overuse of caffeine, lack of an exercise schedule, consuming a fat-ridden diet, patterns of inadequate sleep and insufficient leisure time,
206
and drinking alcohol and cigarette smoking, all have a direct effect on the amount of one’s stress and have the potential to create a vicious lose-lose cycle. Unfortunately, according to the ANA Healthy Nurse, Healthy Nation website, nurses fail nearly every indicator of health compared with the average American (see http://anahealthynurse.org). The Healthy Nurse, Healthy Nation campaign promotes five constructs: calling to care; priority to self-care; opportunity to role model; responsibility to educate; and authority to advocate (see http://www.anahealthynurse.org).
207
Dynamics of stress Stress in organizations may result from unrealistic or conflicting expectations originating from oneself or others, the pace and magnitude of change, human behavior, individual personality characteristics, the characteristics of the position itself, or the culture of the organization. Other stressors may be unique to certain environments, situations, and persons or groups. Initially, increased stress produces increased performance. However, when stress continues to escalate or remains intense, overall performance suffers. Hans Selye’s (1956) mid–20th-century investigations to decode the nature of and reactions to stress have been very influential in our understanding of this human phenomenon. In his classic theory, Selye (1991) described the concept of stress, identified general adaptation syndrome (GAS), and detailed a predictable pattern of response (see the Theory Box and Fig. 7.1). The Theory Box also presents other key theories related to self- manangement.
208
209
FIG. 7.1 The stress diagram.
T h e o r y B o x Theories Applicable to Self-Management
Key Contributors Key Ideas Application to Practice
Maslow’s Hierarchy of Needs: Maslow (1943) identified five need levels of every human.
Although recent research shows the five levels are not always present or in order, it is reasonable that unmet needs motivate most employees most of the time.
Nurse wages should be sufficient to provide shelter and food. Job security and a social environment that rewards and recognizes nurse performance are important.
General Adaptation Syndrome: Selye (1956) is credited with developing this theory.
The “stress response” is an adrenocortical reaction to stressors that is accompanied by psychological changes and physiologic alterations that follow a pattern of fight or flight. The general adaptation syndrome includes an alarm, resistance, and adaptation or exhaustion.
Change, lack of control, and excessive workload are common stressors that evoke psychological and physiologic distress among nurses.
Complex Adaptive Systems: Plsek and Greenhalgh (2001).
This theory of unpredictable interactions between interdependent people and activities emphasizes the importance of innovation and rapid information sharing to improve performance.
Nurse engagement in self-managed groups and teams allows organizations to shape their environment through controlled “experimentation” using the rapid-cycle plan-do-study-act improvement method.
The Pareto Principle: Hafner (2001).
The “Pareto Principle” refers to a universal observation of “vital few, trivial many.” Pareto (1848–1923) studied distribution of personal incomes in Italy and observed that 80% of the wealth was controlled by 20% of the population. This concept of disproportion often holds in many areas. Although the exact values of 20% and 80% are not significant, the observation of considerable disproportion is important to remember.
The 80–20 rule can be applied to many aspects of health care today. For example, 80% of healthcare expenditures are on 20% of the population, and 80% of personnel problems come from 20% of the staff. In quality improvement, 80% of improvement can be expected by removing 20% of the causes of unacceptable quality or performance. A nurse can also expect that 80% of patient-care time will be spent working with 20% of his or her patient assignment. This concept may help explain sources of stress when nurses attempt to provide all of the patients in his/her assignment “equal time.”
More recent investigations of the relationship among the brain, the immune system, and health (psychoneuroimmunology) have generated models that challenge Selye’s (1956) GAS. Although Selye states that all people respond with a similar set of hormonal and immune responses to any stress, newer thinking, albeit using only male subjects, is that increased stress may connect humans to each other by increasing empathy and prosocial behavior (Tomova et al., 2016).
Critical of stress research using predominately male subjects, Taylor, Klein, Lewis, Gruenewald, Gurung, and Updegraff (2000) were the first to propose a model of the female stress response, the “tend and befriend,” as opposed to the male’s “fight or flight” model. The “tend and befriend” response is an estrogen and oxytocin–mediated stress response that is characterized by caring for offspring and befriending those around in times of stress to increase chances of survival.
Most nurses can easily recognize the origins of stress and its symptoms. For example, a healthcare agency may make demands on the nursing staff, such as excessive work, that its nurses regard as beyond their capacity to perform well, or at least in a healthy manner. When they are unable to resolve the problem through overwork, with more staff, or by looking at the situation in another way, nurses may experience decreased job satisfaction, become depressed, and have negative patient outcomes (Steege and Rainbow, 2017). They may also experience headaches, fatigue, inability to concentrate, or other physical symptoms that are associated with a low level of job performance. If the stress persists, such symptoms may escalate and manifest themselves in medication errors or musculoskeletal or needle-stick injuries. Nurses may attempt to cope by becoming completely apathetic, a sign of burnout. Box 7.1 on p. 108 gives physical, mental, and spiritual/emotional signs of overstress in individuals.
210
Box 7.1
S i g n s o f O ve r s t r e s s i n I n d i v i d u a l s Physical
Physical signs of ill health: • Increase in flu, colds, accidents • Change in sleeping habits • Fatigue
Chronic signs of decreased ability to manage stress: • Headaches • Hypertension • Backaches • Gastrointestinal problems
Unhealthy coping activities: • Increased use of drugs and alcohol • Increased weight • Smoking • Crying, yelling, blaming
Mental
• Dread going to work every day • Rigid thinking and a desire to go by all the rules in all cases; inability to tolerate any changes • Forgetfulness and anxiety about work to be done; more frequent errors and incidents • Returning home exhausted and unable to participate in enjoyable activities • Confusion about duties and roles • Generalized anxiety • Decrease in concentration • Depression • Anger, irritability, impatience • Blaming, negotiating
Spiritual
• Sense of being a failure; disappointed in work performance • Anger and resentment toward patients, colleagues, and managers; overall irritable attitude • Lack of positive feelings toward others • Cynicism toward patients, blaming them for their problems • Excessive worry, insecurity, lowered self-esteem • Increased family and friend conflict • Disconnection from family and friends and usual sources of support and love
A relationship exists between stress and the human immune system and a body of literature that ties unrelenting stress to immune dysregulation. The immune systems of those who are older or already sick are more prone to stress-related immune system changes such as inflammation, delayed wound healing, poor responses to vaccines, and increased susceptibility to infectious disease processes (Gouin, 2011). Physical illnesses linked to stress include visceral adiposity (increase in body fat), type 2 diabetes, cardiovascular disease (hypertension, heart attack, stroke), musculoskeletal disorders, psychological disorders (anxiety, depression), workplace injury, neuromuscular disorders (multiple sclerosis), suicide, cancer, ulcers, asthma, and rheumatoid arthritis. Stress can even cause life-threatening sympathetic stimulation.
211
212
Management of stress Individuals respond to stress by eliciting coping strategies that are a means of dealing with stress to maintain or achieve an improved sense of well-being or perceived work–life balance. Certain strategies may be ineffective because of reliance on excessive alcohol or prescription drug and substance use. Other methods, such as exercise, meditation, or professional counseling, may be quite effective in helping restore a greater sense of well-being and effectiveness. More examples of effective strategies are discussed here.
Workplace Stress Prevention One effective way to deal with stress is to determine and manage its source. Discovering the origin of stress in patient care may be difficult, because some environments have changed so rapidly that the nursing staff is overwhelmed trying to balance bureaucratic rules and limited resources with the demands of vulnerable human beings for whom they are caring. Labrague, McEnroe-Petitte, Gloe, Tsaras, Arteche, and Maldia (2016), in their study of nurses’ stress and burnout, found that positive correlations were identified between the perception of organizational politics and job stress, turnover intention, and job burnout. Therefore when in distress, nurses may need to step back and look at the moments that connect them more fully to their purpose and job enjoyment, as attending too much to the politics of the workplace may not do them any good. Identifying daily stressors and developing a plan of action for management of the stress includes making a plan. This plan may include eliminating the stressor, modifying the stressor, or changing the perception of the stressor (e.g., viewing mistakes as opportunities for new learning) and using the reframing technique.
Many of the day-to-day activities of nursing can create workplace stress. Consider the nature of acute care nursing and the potential for serious risk of injury to others. Staffing shortages create situations of caring for more patients with less help while pulling, moving, or pushing patients or their equipment. Nurses may have inadequate rest because of rotating shifts or irregular schedules or because they may come to work already tired from caring for other family members or working additional jobs and going to school. Nurses routinely give physical care to those who have potentially communicable diseases or may become verbally or physically abusive or assaultive. Nurses are highly engaged with patients and their families who suffer with acute pain and grief associated with either chronic or acute illness. Of course, such on-the-job stressors are often counterbalanced by the rewards of patient appreciation, the joy of seeing a healthy baby born, or seeing firsthand the relief brought by a nursing intervention such as appropriate pain medication or repositioning of an uncomfortable limb. However, given the nature of nursing practice, nurses must be alert to their own signs of stress and be able to develop self-awareness about work-life balance. Each of us has to understand how many hours in a day, how many shifts in a row, and conversely, how many hours or days between shifts is appropriate, all aimed at the goal of understanding what is a reasonable workload. Cultivating healthy lifestyle habits also helps reduce stress. Adequate sleep, a balanced diet, regular exercise, and frequent interactions with friends are excellent stress- buffering habits.
According to Fernandez (2016), the top leadership skills to develop are to (1) model and encourage well-being practices; (2) allow time to disconnect outside of work; (3) train the brain to deal with chaos; (4) emphasize “monotasking” for better focus; (5) be purposeful about “gap” or break time during the day; and (6) exercise empathy and compassion. Practicing these skills can be challenging.
E x e r c i s e 7 . 1 Identify what stress you experience and how you usually manage it. Create and complete the following log at the end of every day for 1 week. Review the log and note what situations (e.g., people, technology, values conflict) were the most common. Also identify how you most often react to stress: physically, mentally, or emotionally and spiritually. Keeping this diary for a week is helpful to determine what you respond to with stress and learn about your reactions. Enter a date, and describe a situation and your response. Ask yourself whether the stress was good stress
213
(eustress) or bad stress (distress). Then, with a trusted colleague, conduct a peer review about what more-positive strategies could be used to deal with a similar situation.
Date_____________________ Situation__________________ Your response___________ Good stress or bad_________________ Action (how you dealt with your response)__________________________ Evaluation_________________________
Look over your week of stressors. Are there some that you encounter on a regular basis? If so, try to formulate a plan to conquer the problems. You may need to role-play or get continuing education to improve a specific skill. You may need to simply break a task down into smaller pieces or to eliminate interruptions.
Symptom Management Unpredictable and uncontrollable change, coupled with immense responsibility and little control over the work environment, produces stress for nurses and other healthcare professionals. Consequently, nurses may develop emotional symptoms such as anxiety, depression, or anger; physical alterations such as fatigue, headache, and insomnia; mental changes such as a decrease in concentration and memory; and behavioral changes such as smoking, drinking, crying, and swearing. The important factor is not the stressor but, rather, how the individual perceives the stressor and what coping mechanisms are available to mediate the hormonal response to the stressor.
Multiple stress-buffering behaviors can be used to reduce the detrimental effects of stress. The stressor-induced changes in the hormonal and immune systems can be modulated by an individual’s behavioral coping responses. These coping responses include spending time developing a particular interest such as dancing or playing an instrument, leisure activities with friends and family, taking time for self, drinking water or decaffeinated liquids, positive social support, a strong belief system, a sense of humor, developing realistic expectations, reframing events, regular aerobic exercise, meditation, and the use of yoga for self-care (Alexander, Rollins, Walker, Wong, & Pennings, 2015).
Everyone needs to balance work and leisure in his or her life. Leisure time and stress are inversely proportional. If you find that time for work is more than 60% of awake time or if self-time is less than 10% of awake time, and you find that stress levels increase accordingly, it may be time to take a look at your own work/self-time ratio. Changes should be made to relieve stress, such as decreasing the number of work hours or finding more time for leisure activities. Caffeine is a strong stimulant and, in itself, a stressor. Slowly weaning off caffeine should result in better sleep and more energy. Positive social support can offer validation, encouragement, or advice. By discussing situations with others, one can reduce stress. A great deal of stress comes from our belief systems, which cause stress in two ways. First, behaviors result from them, such as placing work before rest or pleasure. Second, beliefs may also conflict with those of other people, as may happen with patients from different cultures. Articulating beliefs and finding common ground will help reduce anger and stress. Humor is a great stress reducer and laughter a great tension reducer. Other activities may include self-reflection in the form of guided imagery, journaling, or debriefing with a mentor or peer.
A common source of stress is unrealistic expectations. Realistic expectations can make life feel more predictable and more manageable. Reframing is changing the way you look at things to make you feel better about them or to obtain a different perspective. For example, an individual who is difficult to deal with may be viewed instead as someone who lacks understanding about how to make an assignment. A situation can be seen in multiple ways, and it is less stressful to take the view that there is always an aspect of our lives (including the rapidly changing health care environment) that is bound to be unpredictable and remain a mystery at times. Plsek and Greenhalgh (2001) observed that according to Complex Adaptive Systems (see the Theory Box), all systems are nested within other systems, and all are in a state of constant interaction. Therefore it would seem that taking one aspect of a situation out of proportion and fretting about it does little to
214
achieve one’s overall understanding. Regular aerobic exercise is a logical method of dissipating the excess energy generated by the
stress response. Numerous studies cite the value of such exercise, including stress reduction.
E x e r c i s e 7 . 2 This systematic relaxation technique can be used in the middle of a working day, the last thing at night, or at any time you feel tense or anxious. Review the information and strategies at the Mayo Clinic website: www.mayoclinic.com/health/meditation/HQ01070. Make a short list of steps to take, and put it in your smartphone or notepad.
Social support in the form of positive work relationships, as well as nurturing family and friends, is an important way to buffer the negative effects of a stressful work environment. Although friendships may be formed with colleagues, the workload and the shifting of staff from one unit to another make it difficult sometimes to establish and maintain close relationships with peers. For many people at work, the time spent with their managers and co-workers represent one of the strongest sources of community in their lives. The Gallup Organization, in its study of more than 80,000 managers to better understand the relationship of great managers to a quality workplace, created the Q-12 survey question: I have a best friend at work. Strong friendships with co-workers who will help people get through rough spots positively correlates with employee retention, customer metrics, productivity, and profitability (Miller & Adkins, 2016). Leaders can provide regular recognition feedback, in the form of personal notes that are mailed to their team members’ homes; annual Nurses’ Week celebrations; or participation in the DAISY Foundation, a not-for- profit organization that formally recognizes the extraordinary contributions of nurses (see the Daisy Foundation website at http://daisyfoundation.org). All of these help shape the organization’s culture in a way that patients, families, and nurses value.
Young nurses in their first position, those who find themselves in an unfamiliar geographic area, or nurses who switch employers after a long tenure at another hospital all want to anticipate that they will be part of a work group that will furnish emotional support and a sense of belonging to an endeavor that is greater than themselves. Too often, nurses overlook the benefits of active membership in their professional association or specialty associations. Connections established at the beginning of one’s career will serve the nurse with an unending lifelong source of enthusiastic colleagues who are as passionate about their individual professional careers as they are about serving their profession. Opportunities to become active members help nurses discover and refine brand-new leadership skills in a warm, comfortable setting. Ongoing mentorship by seasoned nursing leaders from academia, private practice, and organizational sectors is often free for the taking and adds dimension and a valuable perspective to nurses at every level. Such efforts may help nurses cope with workplace demands that seem to exceed their capabilities through mentoring and coaching.
Stress applies to all positions. Direct care nurses may experience stress from a patient’s deteriorating condition or lack of ability to function independently. Nurse managers may experience role conflict when they must function as representatives of both the corporate culture and the professional nursing culture. For example, a leader may be stressed about the potential for downsizing or a plan to open a new service or a new unit. The stress (distress) experienced by one group can affect another. The challenge is how to manage individual reactions to stress so that it results in growth rather than inhibiting it and in how to manage the effects of stress on others (see the Research Perspective).
215
Burnout Sometimes individuals cannot manage stress successfully through their own efforts and require assistance. Examples of behavior related to stress that feels overwhelming are found in Box 7.1 on p. 108. Coping strategies, such as those described previously, may furnish temporary relief or none at all. With this level of distress, one can feel overwhelmed or helpless and may be at greater risk for mental or physical illness. This constellation of emotions is commonly called burnout.
The classic view of burnout, a psychological term to describe the effects of prolonged emotional and physical exhaustion and diminished interest caused by an unrelenting workload without relief was described by Maslach and Leiter in 1997. The sources of the stressors may exist in the environment, in the individual, or in the interaction between the individual and the environment. Some stressors, such as employment termination, serious illness or death in the family, or the breakup of a relationship, appear to be universal, whereas other
R e s e a r c h Pe r s p e c t i ve Resource: Van Bogaert, P., Peremans, L., Van Heusden, D., Verspuy, M., Kureckova, V., Van de Cruys, Z., & Franck, E. (2017). Predictors of burnout, work engagement and nurse reported job outcomes and quality of care: A mixed method study. BioMed Central, 16(1), 1-14.
This is a mixed-method study, using a quantitative approach to retest previously existing models as well as two follow-up qualitative studies to better understand the findings. Workload influenced staff nurses’ feelings of stress, negativity, and feelings of failure. Conversely, positive nurse– physician relationships and a supportive, dynamic team seemed to serve as a protective barrier that served nurses well: They balanced their workloads better, served with vigor and determination, and intended to stay within the nursing profession longer when in the presence of management and organizational support.
Implications for Practice This study seemed to confirm the results of prior studies related to the American Nurses Credentialing Center (ANCC) Magnet® status and demonstrated the effectiveness of a healthy nursing work environment upon key indicators and outcomes.
stressors, such as meeting a work deadline, are more personal. For example, some individuals thrive on goals and timetables, whereas others feel constrained and frustrated and experience distress. Sometimes, stress is experienced when others around the individual have a dominant personality style and the relationships are not complementary to one another. Burnout is not an objective phenomenon as if it were the accumulation of a certain number and type of stressors. How stressors are perceived and how they are mediated by an individual’s ability to adapt are crucial variables in determining one’s levels of distress.
Nurses who are burned out feel as though their resources are depleted to the point that their well-being is at risk. A self-analysis usually uncovers the characteristics of burnout. First, a feeling of physical, mental, and emotional exhaustion can be recognized. Historically, Greenglass, Burke, and Fiksenbaum (2001) found that emotional exhaustion was directly related to workload. For example, recent graduates may value total, detailed care for individuals and may have little experience in caring for more than two or three patients simultaneously. When confronted with the responsibility of caring for a group of six to eight acutely ill patients, they may have difficulty adapting to the realities of the workplace. Coupled with fear of failure, emotional exhaustion ensues. Emotional exhaustion in turn has a direct effect on levels of cynicism and somatization. A second characteristic of burnout is depersonalization, a state characterized by distancing oneself from the work itself and developing negative attitudes toward work in general (Greenglass et al., 2001). Depersonalization is commonly described as a feeling of being outside one’s body, feeling as if one is a machine or robot, an “unreal” feeling that one is in a dream or that one “is on automatic pilot.” Generally, subjective symptoms of unreality make the nurse uneasy and anxious. Others may view this as callousness. Nurses pushed to do too much in too little time may distance themselves from patients as a means of dealing with emotional exhaustion. Also, nurses’
216
personality characteristics may lean too heavily on the caregiving dimension, which often carries over into one’s personal life. For example, caregiving individuals may be further challenged by life partners who demand a disproportionate amount of time and energy, either because of physical disabilities or because of latent personality disorders or even alcoholism, so renewal and safe havens are unlikely in such cases.
A decreased sense of professional accomplishment and competence is the third hallmark of burnout. Low professional efficacy has been found to be a function of higher levels of cynicism (Greenglass et al., 2001). Efficacy is one’s belief in his or her capabilities to organize and execute goal-oriented activities. Nurses are more inclined to take on a task if they believe they can succeed. Lower levels of efficacy can lead nurses to believe tasks are harder than they actually are. This can lead to a sense of failure, perceived helplessness, and eventually crisis. At this point, one’s coping skills are no longer effective. Immediate referral to mandated employee assistance program (EAP) counseling and perhaps a medical leave of absence may be recommended. At its best, a healthy peer discussion, whether it is formal or informal, can help to identify when a nurse is troubled. However, assistant nurse managers, nurse managers, or nursing supervisors often have the task of addressing and referring nurses to seek help for themselves, before the stress escalates to a state of personal crisis.
217
Resolution of stress Resolution of stress in its early stages can be accomplished through a variety of techniques. Nurses must be able to reach a balance of caring for others and caring for self. Box 7.2 summarizes physical, mental, and emotional and spiritual strategies. When stress rises to unacceptable or even dangerous levels, colleagues can be supportive and perhaps even point out the stress level or recommend appropriate help (Fig. 7.2).
Box 7.2
S t r e s s - M a n a g e m e n t S t r a t e g i e s Physical
• Accept physical limitations • Modify nutrition: moderate carbohydrate, moderate protein, high in fruits and vegetables, low
caffeine, low sugar • Exercise: participate in an enjoyable activity five times a week for 30 minutes • Make your physical health a priority • Nurture yourself by taking time for breaks and lunch • Sleep: get enough in quantity and quality
Mental
• Learn to say “no!” • Use cognitive restructuring and self-talk • Use imagery • Develop hobbies or activities • Plan vacations • Learn about the system and how problems are handled • Learn communication, conflict resolution, and time-management skills • Take continuing education courses
Emotional/Spiritual
• Relax: use meditation, massage, yoga, or biofeedback • Seek solace in prayer • Seek professional counseling • Participate in support groups • Participate in networking • Communicate feelings • Identify and acquire a mentor • Ask for feedback and clarification
218
FIG. 7.2 Peers and followers can be supportive and help reduce stress.
E x e r c i s e 7 . 3 Using the items in Box 7.2, identify what strategies you most commonly use. Then find at least one strategy you never or rarely use and consider what prevents your using that strategy more effectively.
Social Support Peers and followers can be supportive and help reduce stress by assisting with problem solving and by presenting different perspectives. Family and friends can provide an affirming, loving perspective and much-needed respite from stress in the form of celebrations around birthdays, graduations, and seasonal holidays. Social isolation increases stress. When nurses find themselves in a never-ending cycle of work, sleep, school, and conflicting calendars with escalating pressures at home, relief must be actively sought. True social support allows us to relax, be playful, have fun, laugh, vent emotions, and enjoy life to the fullest.
Counseling Persistent, unpleasant feelings; problem behavior; helplessness; and withdrawal during prolonged stress may suggest the need for assistance from a mental health professional. Examples of problem behaviors include tearfulness or angry outbursts over seemingly minor incidents, traffic violations, major or subtle changes in eating and/or sleeping patterns, frequent unwillingness or lack of desire to go to work, chronic complaining and negativity, passive-aggressive behaviors, and even substance abuse. In such cases, the aforementioned coping strategies afford only temporary relief; nurses with this level of distress feel overwhelmed or paralyzed and may believe that they simply cannot go on this way. In these stressful situations, individuals may feel helpless and see no way out. They may require professional assistance from an advanced practice psychiatric nurse, clinical psychologist, psychiatrist, or another mental health professional.
In some organizations, leaders may refer their peers, subordinates, or themselves to EAPs. EAPs are a source of free, voluntary, confidential, short-term professional counseling and other services for employees either via in-house staff or through a contract with a separate mental health agency.
219
This type of counseling can be effective because the counselors are usually already well aware of organizational issues and stressors in the workplace. Some nurses may have confidentiality concerns when using employer-recommended or employer-provided counseling services. However, mental health professionals are bound by their professional standards of confidentiality. Additionally, it is in the nurse’s best interest to sign a release of information, such as when seeking employer accommodation for a certain physical or emotional problem.
Those who seek counseling outside of the workplace may be guided in their selection of mental health professionals by a personal provider (physician or nurse practitioner), a knowledgeable colleague in the human resources department, or the most recent edition of their health insurance referral book. A phone call to the state nurses’ association and an inquiry for lists of advanced practice registered nurses in adult psychiatric–mental health practice in your region will often yield significant results. When the problem underlying the distress is ethical or moral, a trained pastoral counselor or spiritual director may be very helpful. Some clergy and mental health professionals are certified in pastoral care or have earned a degree in another discipline such as psychology or spiritual direction counseling. Referrals can be obtained from hospital pastoral care departments or places of worship that affiliate with regional centers where certified counselors are available. When private counseling is being arranged, the health insurance contract should be checked to determine mental health benefits and the payment limitations and types of providers eligible for reimbursement.
Leadership and Management Although social support and counseling can alter how stressors are perceived, effective leadership that is shared and time management that supports involvement at the level of direct care nurse in the unit can certainly modify or remove stressors. Historically, nurses have had limited formal authority as individuals in most organizations. Shared governance, defined by Tim Porter-O’Grady when he first described the pioneer efforts of Vanderbilt University Medical Center in the 1980s, “is a professional practice model, founded on the cornerstone principles of partnership, equity, accountability and ownership” that embraces the concepts of professional governance (Porter- O’Grady, 2013, 2017). Organizations that implement shared governance systems are either “on the bus or off the bus,” according to Dr. Robert Hess, creator of the only measurement tools designed to analyze organizational readiness and level of participation in shared governance activities (Mouro, Tashijian, Bachir, Al-Ruzzeih, & Hess, 2013). In Hess’s early study (2011), Magnet® hospitals reported 37%, non-Magnet® hospitals reported 16%, and hospitals pursuing Magnet® designation reported 32% of involvement in shared governance activities that bring policymaking to the nurses whose job it is to implement them. Hess has since observed that although the current conversation is about the inclusion of other professionals, such as pharmacists, physicians, and allied health personnel, professional governance is hardly a new construct (Hess, 2017). It may simply be a good idea whose time has become much more in the here and now. Chief nursing executives and the managerial and administrative groups at which tables they sit continually advocate for nursing resources and certainly influence policy and resource allocation. Nurse managers can and must continue to articulate clinical and workplace issues as they work to control existing environmental stressors on their own units. In addition, managers ought to examine their own behavior as a source of their subordinates’ stress via peer review, coaching, and regularly scheduled leadership rounds.
In some cases, a controlling or autocratic style of management is appropriate, such as in emergency or disaster situations and when working with a large percentage of new and inexperienced team members. For the most part, however, professional nurses need, want, and deserve the latitude to direct their activities within their sphere of competence. “Letting go” of autocratic power and learning more about the power in delegating important functions to team members means that the nurse leader trusts the personal integrity and professional competence of the entire team. It does not mean abdicating accountability for achieving accepted standards of patient care and agreed-on outcomes. Such an attitude provides ample opportunity to provide invaluable coaching that has the potential to teach, motivate, and guide others toward reaching their full potential.
Assistance with problem solving is another way to reduce environmental stressors. Nurse leaders may provide technical advice, refer staff to appropriate resources, or mediate conflicts. Often, nurse leaders enable staff to meet the demands of their work more independently by providing time for continuing education and preparation for national board certification. Such nurse leaders make it
220
possible for frontline staff to attend internal and external professional meetings to enhance their clinical competence and exert control over their own workplace.
Another way in which nurse leaders can reduce stress is to be supportive of staff. Support is not equated with being a friend or buddy; rather, it is helping one’s peers accomplish good care, develop professionally, and feel valued personally. Leaders can ensure that the expected workload is in line with the nurses’ capabilities and resources. They can work to ensure meaningfulness, stimulation, and opportunities for nurses to use their skills. Nurses’ roles and responsibilities need to be clearly and publicly defined. Work schedules should be posted as far in advance as possible and should be compatible with what is known about patient safety and respect for their team members’ private lives and educational schedules. Encouraging innovation and experimentation, as in self-scheduling, for example, can motivate staff and give them a sense of greater control over their environment. Affirming a good idea, finding resources for further study, or implementing a promising new procedure or proposal by a direct care nurse are all characteristic of supportive leadership. It is possible to be supportive even when things are not necessarily going well. For example, when staff members struggle with their methods of coping with overwork and other stressors, supportive leadership behaviors include helping staff members recognize the need to avoid passive coping strategies that fuel helplessness and lower the standards of care through active, engaged coaching. Nurse leaders must be sensitive to the distress of the nursing staff and acknowledge it without themselves becoming therapists or counselors, which would present a role conflict. Support may involve raising the staff’s knowledge of counseling resources and truly getting to know each and every staff member.
Nurse leaders also must be careful to avoid diagnostic labels and to maintain strict confidentiality. This is difficult to do, for example, when a nurse’s practice is impaired by alcohol or drug use. Sometimes the staff on the entire unit and even staff on other units may already be aware of the impairment. When distress relates to the personal life of subordinates, managers should focus on the effect of such situations on workplace performance and ask for outside assistance, if necessary, to help the members of the team work through the events. The individual who has produced the stress can then hopefully be welcomed back to the job after recovery in a goal- directed program designed to aid the person in appropriate coping approaches.
In addition, leaders can enhance the workplace by dealing effectively with their own stressors. Maintaining a sense of perspective as well as a sense of humor is important. Some stressors, in fact, can be ignored or minimized by posing three questions:
1. Is this event or situation important? Stressors are not all equally significant. Do not waste energy on minor stressors.
2. Does this stressor affect me or my unit? Although some situations that produce distress are institution-wide and need group action, others target specific units or activities. Do not borrow stressors from another unit. Individuals can “cross-pollinate” stressors by spreading gossip about the misfortunes of other units’ team members.
3. Can I change this situation? If not, then find a way to cope with it, or if the situation is intolerable, make plans to change positions or employers. This decision may require gaining added credentials that may produce long-term career benefits or contacting a search firm to simply discover “what’s out there.”
Keeping stressful situations in perspective can enable nurses to conserve their energies to cope with stressful situations that are important, that are within their domain, or that can be changed or modified.
221
Management of time A very close relationship exists between stress management and time management. Time management is one method of stress prevention or reduction. Stress can decrease productivity and lead to poor use of time. Time management can be considered a preventive action to help reduce the elements of stress in a nurse’s life.
Everyone has two choices when managing time: organize or “go with the flow.” Everyone has only 24 hours in every day, and it is clear that some people make better use of time than others do. How people use time makes some people more successful than others. The effective use of time- management skills thus becomes an even more important tool to achieve personal and professional goals. Time management is the appropriate use of tools, techniques, and principles to control time spent on low-priority needs and to ensure that time is invested in activities leading toward achieving desired, high-priority goals. More simply, time management is the ability to spend your time on the things that matter to you and your organization. However, it does take time to plan daily time-management strategies! By setting goals and actively working to reduce time stealers, you will have the extra time to accomplish them. Table 7.1 presents a classification scheme for time- management techniques. Table 7.2 provides ways to make applications of time-management strategies to practice.
Table 7.1
Classification of Time-Management Techniques
Technique Purpose Actions Organization Promotes efficiency and productivity Organize and systematize things, tasks, and people.
Use basic time-management skills. Keep focused on goals Focuses on goal achievement Assemble a prioritized “to do” list daily, based on goals. Tool usage Uses the right tool for planning and preparation Use tools such as a smartphone. Time-management plan Helps refocus, gain control, and use information Develop a personal time-management plan appropriately.
Table 7.2
Time-Management Applications to Practice
Key Idea Definition Application to Practice Losing track of time Absorption in one aspect of a task, or even
distractions that prevent focus on a task, preventing successful resolution in a time- effective manner
Concentrate on results. Identify common “time stealers” and guard against them. Do not get caught up with the technology such as answering e-mails or responding to instant message alerts. Minimize distractions. Use an alarm or stopwatch feature on your smartphone or other device. Take a class on time management.
Doing too much Competing priorities that vie for attention Reduce the number of important projects that are due at the same time. Be realistic and limit major commitments. Give each major activity your undivided attention. Avoid multitasking whenever possible! Make a daily “to do” list and tick them off as each is accomplished. Engage with a supervisor or mentor for advice/guidance on which project needs the most attention.
Learning to say “no” or “not now, please”
Politely declining requests for an additional project or assignment
Agreeing to tasks that are not in alignment with your individual personal/professional priorities may translate into frustration and resentment. Consider whether this task may be easily delegated to another individual. Discuss the request in detail so you may better understand the nature: Is it in alignment with the organization’s overall goals or your family’s primary needs at this time? Or, is it someone else’s “emergency” and they need a favor?
Procrastination Putting off important tasks because they may not be enjoyable or involve a level of difficulty
Identify the reason for procrastination. Develop a PERT (Program Evaluation and Review Technique) chart or a Gantt chart (see Table 7.3) to help parse out complex assignments. Make that specific task your number one priority for the next opportunity. Select either the least attractive component or the easiest; tackle that part first. Reward yourself after you complete the task.
Complaining/whining Expressing dissatisfaction or annoyance Stop and ask yourself, “What would the ideal resolution be?” and then, take the risk to act on it.
222
Discuss the scenario with a trusted friend/co-worker/mentor or supervisor. Bring potential solutions so that you can move beyond complaining to effective problem solving. Spend time speaking with the parties involved or those with the power to improve the overall situation. Write yourself a letter describing the situation as well as options for correction. Look for solutions that are very simple or “outside the box” for you.
Perfectionism The tendency to never completely finish a project or assignment because it is not yet acceptable
Continue to do your best. Find and share feedback with others who have similar assignments or projects or are in situations like yours. Once you receive feedback on your project, move quickly to incorporate it into your final submission and move on to the next assignment.
Interruptions Avoidable or unavoidable occurrences that distract from one’s ability to complete a prioritized task
Set workplace rules to limit lengthy e-mails and other distractions (see Box 7.3). Mentally, dive right back into the immediate task at hand.
Information overload Proliferation of data that occurs too quickly to be able to interpret the information in an effective manner
Form or join study groups or other forms of knowledge communities. Learn to appreciate podcasts, e-mail capsules of weekly healthcare news, or other professional organizations’ and specialty associations’ online news summaries.
Table 7.3
Sample Gantt Chart
The unifying theme is that each activity undertaken should lead to goal attainment and that goal should be the number one priority at that time.
Goal Setting The first steps in time management are goal setting and developing a plan to reach the goals. Set goals that are reasonable and achievable. Do not expect to reach long-term goals overnight—long- term means just that. Give yourself time to meet the goals. Determine many short-term goals to reach the long-term goal, giving you a frequent sense of goal achievement. Give yourself flexibility. If the path you chose last year is no longer appropriate, change it. Write your goals, date the entry, keep it handy, and refer to it often to give yourself a progress report. Very often, goals are an important discussion point of the annual performance evaluation process. The time for reviewing goals ought not to be the period immediately preceding this year’s discussion, yet unfortunately too often this is the case. Savvy nurse leaders will refer to mutually set goals frequently throughout the year and address, encourage, and recognize progress toward achievement during monthly meetings and at specific hallmark times.
Setting Priorities Once goals are known, priorities are set. They may, however, shift throughout a given period in terms of goal attainment. For example, working on a budget may take precedence at certain times of the year, whereas new staff orientation to a brand-new electronic medical record system is a higher priority at other times. Knowing what your goals and priorities are helps shape the “to do” list. On a nursing unit or as you work in a community setting, you must know your personal goals and current priorities. How you organize work may depend on geographic considerations, patient acuity, or some other schema.
A particular strategy to assist in prioritization suggests that people generally focus on those things that are important and urgent. Clarity is enhanced about priorities by placing the elements of importance and urgency in a grid (Fig. 7.3 on p. 117) or by using the Covey Matrix, also known as the Eisenhower’s Urgent-Important Principle (Mueller, 2015).
223
FIG. 7.3 Classification of priorities.
Typically, we tend to focus on those items in cell A because they are both important and urgent and therefore command our attention. Making shift assignments is an A task because it is both important to the work to be accomplished and commonly urgent, because a time frame is specified during which data about patients and qualifications of staff can be matched. Conversely, if something is neither important nor urgent (cell D), it may be considered a waste of time, at least in terms of personal goals. An example of a D activity might be reading “junk” e-mail or attention- grabbing department store or vacation advertisements. Even if something is urgent but not important (cell C), it contributes minimally to productivity and goal achievement. An example of a C activity might be responding to a memo that has a specific time line but is not important to goal attainment. The real key to setting priorities is to attend to the B tasks, those that are important but not urgent. Examples of B activities are reviewing the organization’s strategic plan or participating on organizational committees.
Organization A number of simple routines for organization can save many minutes over a day and enhance your efficiency. Keeping a workspace neat or arranging things in an orderly fashion may be a powerful time-management tool. Rather than a system of “pile management,” use “file management.” Although the historical view was of physical paper
Box 7.3
T i p s t o P r e ve n t I n t e r r u p t i o n s a n d W o r k M o r e E f f e c t i ve l y
• Ask people to put their comments in writing in an e-mail—do not let them catch you “on the run.” On the same note, do not use others as you would a Post-it note!
• Let the office or unit secretary know what information you need immediately. • Conduct a conversation in the hall to help keep it short or in a separate room to keep from
being interrupted. • Be comfortable saying “no” and “not yet.” • When involved in a long procedure or home visit, ask someone else to cover your other
responsibilities. • Break projects into small, manageable pieces. • Get yourself organized. • Minimize interruptions—for example, allow voicemail to pick up the phone; shut the door. • Keep your work surface clear. Have available only those documents needed for the task at
hand. • Keep your manager informed of your goals. • Plan to accomplish high-priority or difficult tasks early in the day. • Develop a plan for the day and stick to it. Remember to schedule in some time for
224
interruptions. • Schedule time to meet regularly throughout the shift with staff members for whom you are
responsible. • Make an effort to round with the night and weekend team; conduct early morning breakfasts
so that night staff can meet with you away from their unit. • Recognize that crises and interruptions are part of the position. • Be cognizant of your personal time-wasting habits, and try to avoid them.
and desk surface, the same concepts apply to a laptop or mobile phone. The following are a few hints:
• Plan where things should go: your desk or your disk • Keep a clean workspace • Create a “to do” folder • Use a “to be filed” folder for any papers • Schedule time to work your way through the folders
If you don’t have a physical desk at work, you typically use something—a designated space, a tablet, a clipboard, or your phone. Consider how to translate this list into a nondesk format.
Determine your priority goals for the next day, and have the materials ready to work on when you start the next day. If you are fortunate to have the resources of a secretary or administrative assistant, even for very limited periods of the day, be sure to discuss with this individual how creative scheduling has the power to either maximize your day or sap your energy and strength to deal with your obligations.
E x e r c i s e 7 . 4 Create a goal statement related to some competency you wish to achieve or improve. Using a Gantt chart approach, designate timelines and activities to meet this goal. Print the chart or enter it in your phone to track your progress.
Time Tools Sometimes, the real problem is that the events of the day become the driving force, rather than a planned schedule. Days may become so tightly scheduled that any little interruption can become a crisis. If you do not plan the day, you may be responding to events rather than prioritized goals. If you think you are a reactor rather than a proactiv
