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C H A P T E R

2

Introduction to
Management
and Management
Decision Making

The roles of the nurse manager and nurse

executive have evolved significantly in response

to changes in the healthcare industry in the last

20 years.

—Carol S. Kleinman

24

Throughout history, nursing has been required to respond to changing technological
and social forces. The new managerial responsibilities placed on organized nursing
services require nurse administrators who are knowledgeable, skilled, and competent
in all aspects of management. Now more than ever there is a greater emphasis on the
business of health care, with managers being involved in the financial and marketing
aspects of their respective departments. To confront expanding responsibilities and
demands, the manager’s role must take on new dimensions to facilitate quality out-
comes in patient care and meet other strategic institutional goals and objectives.

Although, management functions are similar in every discipline and across soci-
eties, changes in the healthcare industry in the last 20 years have been so dramatic
that nurse managers have had to bring a new cadre of skills into a dynamic and rap-
idly changing managerial role (Kleinman, 2003).

The relationship between leadership and management continues to prompt
some debate, although the literature demonstrates the need for both (Trent, 2003;
Zaleznik, 2004). Whereas management emphasizes control–control of hours, costs,
salaries, overtime, use of sick leave, inventory, and supplies–leadership increases
productivity by maximizing work force effectiveness.

Leadership is viewed by some as one of management’s many functions; others
maintain that leadership requires more complex skills than management and that
management is only one role of leadership; still others delineate between the two.
But if a manager guides, directs, and motivates others and a leader empowers oth-
ers, then it could be said that every manager is a leader.

Management and leadership are, however, first artificially separated in this
chapter so that there is a full understanding of the functions of management. The
following are some of the characteristics of managers:

• Have an assigned position within the formal organization
• Have a legitimate source of power due to the delegated authority that

accompanies their position
• Are expected to carry out specific functions, duties, and responsibilities
• Emphasize control, decision making, decision analysis, and results
• Manipulate people, the environment, money, time, and other resources to

achieve organizational goals
• Have a greater formal responsibility and accountability for rationality and

control than leaders
• Direct willing and unwilling subordinates

Historically, strong management skills were valued more than strong leadership
skills in the healthcare industry. This was true not only in nursing and health care
but throughout businesses in Western society. Only in the last 50 years has the
world shifted much of its research and interest onto leadership. Effective managers
need to be well grounded in management theory and to understand management
decision making. Leadership without management results in chaos and failure for
both the organization and the individual executive. The ultimate goal for all execu-
tives is to integrate management functions and leadership roles. This chapter will
focus on providing an historical overview of management theory development and
provide some tools for management decision making.

25CHAPTER 2 � Introduction to Management and Management Decision Making

HISTORICAL DEVELOPMENT OF MANAGEMENT THEORY

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

Scientific Management (1900–1930)

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

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

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

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

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

What was the result of scientific management? Productivity and profits rose
dramatically. Organizations were provided with a rational means of harnessing the
energy of the industrial revolution. Some experts have argued that Taylor was not a
humanist and that his scientific principles were not in the best interest of unions or
workers. However, it is important to remember the era in which Taylor did his
work. During the industrial revolution, laissez-faire economics prevailed, optimism
was high, and a Puritan work ethic was prevalent. Taylor maintained that he truly
believed managers and workers would be satisfied if increased productivity resulted
in adequate financial rewards.

26 UNIT 1 � A New Approach to Leadership and Management

As the cost of labor rose in the United States, many organizations took a new
look at scientific management. Healthcare organizations are using new technology,
such as video cameras and computers for time and motion studies, to enable indi-
viduals to find ways to “work smarter” (Russell, 2000). The implication is that
managers need to think of new ways to do traditional tasks so that work is more
efficient. Meltzer (1999) maintains that time and motion studies can be used to
improve performance, cut costs significantly, and improve the quality of care.

27CHAPTER 2 � Introduction to Management and Management Decision Making

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

Learning Exercise 2.1

Managers need to think
of new ways to do
traditional tasks so that
work is more efficient.

Bureaucracy

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

Management Functions Identified (1925)

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

The management process, shown in Figure 2.1, is this book’s organizing frame-
work. Brief descriptions of the five functions for each phase of the management
process follow:

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

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

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

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

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

In many ways, the management process is similar to the nursing process, as
shown in Figure 2.2. Both processes are cyclic, and many different functions may
occur simultaneously. Suppose that a nurse-manager spent part of the day working
on the budget (planning), met with the staff about changing the patient care man-
agement delivery system from primary care to team nursing (organizing), altered the
staffing policy to include 12-hour shifts (staffing), held a meeting to resolve a con-
flict between nurses and physicians (directing), and gave an employee a job perform-
ance evaluation (controlling). Not only would the nurse-manager be performing all
phases of the management process, but each function has a planning, implementing,
and controlling phase.

28 UNIT 1 � A New Approach to Leadership and Management

Planning

Controlling

Directing

Organizing

Staffing

Figure 2.1 The management
process.

Just as nursing practice
requires that all nursing
care has a plan and an
evaluation, so too does
each function of
management.

Human Relations Management (1930–1970)

During the 1920s, worker unrest developed. The industrial revolution had resulted
in great numbers of relatively unskilled laborers working in large factories on spe-
cialized tasks. Thus, management scientists and organizational theorists began to
look at the role of worker satisfaction in production. This human relations era
developed the concepts of participatory and humanistic management, emphasizing
people rather than machines.

Participative Management
Mary Parker Follett was one of the first theorists to suggest basic principles of what
today would be called participative decision making or participative management. In
her essay “The Giving of Orders” (1926), Follett espoused her belief that managers
should have authority with, rather than over, employees. Follett stated that to do so,
a need existed for collective decision making.

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

29CHAPTER 2 � Introduction to Management and Management Decision Making

Planning

Simplified Nursing Process Management Process Functions

Controlling
Directing
Organizing
Organizing
Staffing
Planning

ASSESSING

PLANNING

IMPLEMENTING

EVALUATING

Figure 2.2 Integrating nursing and management processes.

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

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

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

The human relations era of management science brought about a great interest
in the study of workers. Many sociologists and psychologists took up this challenge,
and their work in management theory contributed to our understanding about
worker motivation, which will be discussed in Chapter 18. Table 2.1 summarizes
the development of management theory up to 1970.

By the late 1960s, there was growing concern that the human relations approach
to management was not without its problems. Most people continued to work in
a bureaucratic environment, making it difficult to always apply a participatory

Table 2.1 Developers of Management Theory

Theorist Theory

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

30 UNIT 1 � A New Approach to Leadership and Management

approach to management. The human relations approach was time-consuming and
often resulted in unmet organizational goals. In addition, not every employee liked
working in a less-structured environment.

The evolution of management theory has affected how managers address workers’
concerns and needs. The early management theorists discounted workers’ needs and
focused on productivity and efficiency. Later the needs and motivation of workers
became the focal point of the work of the human relation theorist’s research into man-
agement science. It was not until the 1960s that it became apparent that management
was a complex issue that was intertwined with leadership. The following chapter will
focus on leadership and the relationship between leadership and management.

MANAGEMENT DECISION-MAKING TECHNOLOGY

As was discussed in Chapter 1, decision making is one of a manager’s primary
functions. Clancy (2003) maintains that even the most experienced manager can-
not eliminate all uncertainty when making decisions. However, to assist the man-
ager in making decisions, management analysts have developed tools that provide
order and direction in obtaining and using information or that are helpful in select-
ing who should be involved in making the decision. Because there are so many of
these decision aids, this chapter presents selected technology that would be most
helpful to a beginning manager. Some of these aids encourage analytical thinking,
others are designed to increase intuitive reasoning, and a few encourage use of both
hemispheres of the brain.

Quantitative Decision-Making Tools

Some management authors label management decision-making aids as models;
others use the term “tools.” It is only important to remember that any decision-
making aid always results in the need for the person to make a final decision and
that all aids are subject to human error.

Decision Grids
A decision grid allows one to visually examine the alternatives and compare each
against the same criteria. Although any criteria may be selected, the same criteria
are used to analyze each alternative. An example of a decision grid is depicted in
Figure 2.3. When many alternatives have been generated or a group or committee
is collaborating on the decision, these grids are particularly helpful to the process.
This tool, for instance, would be useful when changing the method of managing
care on a unit or when selecting a candidate to hire from a large interview pool.
The unit manager or the committee of nursing staff would evaluate all the alter-
natives available using a decision grid. In this manner, every alternative is evalu-
ated using the same criteria. It is possible to weight some of the criteria more
heavily than others if some are more important. To do this, it is usually necessary
to assign a number value to each criterion. The result would be a numeric value
for each alternative considered.

31CHAPTER 2 � Introduction to Management and Management Decision Making

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

If the instructor for the class costs $400, the in-service director would need to
charge each of the 20 participants $20 for the class, but for 40 participants, the class
would cost only $10 each. The in-service director would use attendance data from
past classes and the number of nurses potentially available to attend to determine
probable class size and thus how much to charge for the class. Payoff tables do not
guarantee that a correct decision will be made, but they assist in visualizing data.

Decision Trees
Because decisions are often tied to the outcome of other events, management
analysts have developed decision trees. Used to plot a decision over time, decision
trees allow visualization of various outcomes. The decision tree in Figure 2.4
compares the cost of hiring regular staff to the cost of hiring temporary employ-
ees. Here the decision is whether to hire extra nurses at regular salary to perform
outpatient procedures on an oncology floor or to have nurses available to the unit
on an on-call basis and pay them on-call and overtime wages. The possible con-
sequences of a decreased and an increased volume of procedures must both be
considered. Initially, costs would increase in hiring a regular staff, but over a
longer period of time, this move would mean greater savings if the volume of
procedures does not dramatically decrease.

Consequence Tables
Clancy (2003) used a consequence table to demonstrate how various alternatives
create different consequences. A consequence table lists the objectives for solving a

32 UNIT 1 � A New Approach to Leadership and Management

#1

#2

#3

#4

Financial
effect

Political
effect

Departmental
effect Time DecisionAlternative

Figure 2.3 A decision grid.

problem down one side of a grid and rates how each alternative would meet the
desired objective. For example, consider this problem: The number of patient falls has
exceeded the benchmark rate for two consecutive quarters. After a period of analysis the
following alternatives were selected as solutions:

• Provide a new educational program to instruct staff on how to prevent falls.
• Implement a night check to ensure that patients have side rails up and beds

are in a low position.
• Implement a policy requiring soft restraints orders on all confused

patients.

The decision maker then lists each alternative opposite the objectives for solving
the problem, which for this problem might be:

• Reduces the number of falls
• Meets regulatory standards
• Is cost effective
• Fits present policy guidelines.

The decision maker(s) then ranks each desired objective and examines each of
the alternatives through a standardized key, which allows a fair comparison
between alternatives and assists in eliminating undesirable choices. It is important

33CHAPTER 2 � Introduction to Management and Management Decision Making

POSSIBLE EVENT

S

Increased demand
for procedures

Decreased demand
for procedures

Increased demand
for staff

Decreased demand
for staff

Pay overtime and
on-call wages

Decision point
(Last event to occur)

ALTERNATIV

E

ACTIONS

Hire regular staff

Variable affecting the direction of the decision tree:
• Revenue from procedures • Net cash flow

• Costs • First year expected value

Figure 2.4 A decision tree.

to examine long-term effects of each alternative as well as how the decision will
affect others. See Table 2.2 for an example of a consequence table.

Program Evaluation and Review Technique

Program evaluation and review technique (PERT) is a popular tool to determine
the timing of decisions. Developed by the Booz-Allen-Hamilton organization
and the United States Navy in connection with the Polaris missile program,
PERT is essentially a flowchart that predicts when events and activities must
take place if a final event is to occur. Figure 2.5 shows a PERT chart for devel-
oping a new outpatient treatment room for oncology procedures. The number of
weeks to complete tasks is listed in optimistic time, most likely time, and pes-
simistic time. The critical path shows something that must occur in the sequence
before one may proceed. PERT is especially helpful when a group of people are
working on a project. The flowchart keeps everyone up-to-date, and problems are
easily identified when they first occur. Flowcharts are popular, and many people
use them in their personal lives.

34 UNIT 1 � A New Approach to Leadership and Management

Table 2.2 Consequence Table: An Example

Objectives for
Problem Solving Alternative 1 Alternative 2 Alternative 3

1. Reduces the number X X X
of falls

2. Meets regulatory X X X
standards

3. Is cost effective X X

4. Fits present policy X
guidelines

Decision Score

35CHAPTER 2 � Introduction to Management and Management Decision Making

Decision
to develop
a staffed
outpatient
treatment

room

5-7-9 2-3-4

2-3-4

Renovation
complete

Staff
recruited

Staff
hired

2-3-4
Staff

trained

4-5-6

1-2-3

Equipment
installed

Equipment
received

Equipment
ordered

Equipment
and staff

ready

3-4-5

1-2-3
2-3-4

10-12-14

Critical path

Number of weeks to complete task ranked from most optimistic,
to most likely, to most pessimistic finish times

Planning
complete

Room
gutted

Figure 2.5 An example of a PERT flow diagram.

Charting Workflow
Think of some project you’re working on; it could be a dance, a
picnic, remodeling your bathroom, or a semester schedule of activities
in a class.
Assignment: Draw a flowchart, inserting at the bottom the date activities
for the event are to be completed. Working backward, insert critical tasks
and their completion dates. Refer to your flowchart throughout the project
to see if you stay on target.

Learning Exercise 2.2

PITFALLS IN USING DECISION-MAKING TOOLS

Clancy (2003) maintains that there is a strong tendency for managers to favor first
impressions when making a decision and a second tendency called confirmation
biases often follows. A confirmation bias has a tendency to affirm one’s initial
impression and preferences as other alternatives are evaluated. So even using conse-
quence tables, decision trees and other quantitative decision tools will not guaran-
tee a successful decision.

It is also human nature to focus on an event that leaves a strong impression so
individuals may have preconceived notions or biases that influence decisions. Too
often managers allow the past to influence current decisions. Lastly, managers often
become too confident about their decision making ability and remember their good
decisions and forget the negative outcomes that resulted from some of their other
decisions (Clancy, 2003).

Minimizing Pitfalls

Many of these pitfalls can be reduced by choosing the correct decision making style
and involving others when appropriate. It is not always necessary to involve others
in decision making and frequently a manager does not have time to involve a large
group, but it is important to separate out decisions needing others from those a
manager can make alone.

In addition to quantitative decision technology, management analysts have
developed models that assist managers in choosing the correct decision-making
style. A manager can be autocratic in making decisions and have little or no input
from others or can be democratic and involve others in the process. Some managers
develop patterns and use the same methods, rather than looking at the particular
situation and then concluding which type of decision making is needed. Vroom and
Yetton (1973) developed a useful approach in selecting an appropriate decision-
making style. They have identified five decision-making methods (Table 2.3).

Variables to Determine Decision-Making Style

Seven situation variables were identified by Vroom (1973). These situation vari-
ables determine which of the five decision-making styles is appropriate in a situa-
tion (Table 2.4).

1. The information rule. If the quality of the decision is important and the
leader does not possess enough information or expertise to solve the prob-
lem by himself or herself, AI is eliminated from the feasible set. (Its use
risks a low-quality decision.)

2. The goal congruence rule. If the quality of the decision is important and the
subordinates do not share the organizational goals to be obtained in solving
the problem, GII is eliminated from the feasible set. (Alternatives that elim-
inate the leader’s final control over the decision reached may jeopardize the
quality of the decision.)

36 UNIT 1 � A New Approach to Leadership and Management

3. The unstructured problem rule. When the quality of the decision is important,
if the leader lacks the necessary information or expertise to solve the prob-
lem alone, and if the problem is unstructured (i.e., he or she does not know
exactly what information is needed and where it is located), the method
used must provide a means not only to collect the information, but also to
do so in an efficient and effective manner. Methods that involve interaction
among all subordinates with full knowledge of the problem are likely to be
both more efficient and more likely to generate a high-quality solution to
the problem. Under these conditions, AI, AII, and CI are eliminated from the
feasible set. (AI does not provide for collection of the necessary information;
AII and CI represent more cumbersome, less-effective, and less-efficient
means of bringing the necessary information to bear on the solution of the
problem than methods that do permit those with the necessary information
to interact.)

4. The acceptance rule. If the acceptance of the decision by subordinates is critical
to effective implementation and it is not certain that an autocratic decision
made by the leader would receive that acceptance, AI and AII are eliminated
from the feasible set. (Neither provides an opportunity for subordinates to
participate in the decision, and both risk the necessary acceptance.)

5. The conflict rule. If the acceptance of the decision is critical, an autocratic
decision is not certain to be accepted, and/or subordinates are likely to be in

37CHAPTER 2 � Introduction to Management and Management Decision Making

Table 2.3 Types of Management Decision Styles

A1 You solve the problem or make the decision yourself, using information available
to you at that time.

A11 You obtain the necessary information from your subordinate(s), then decide
on the solution to the problem yourself. You may or may not tell your
subordinates what the problem is when getting the information from them.
The role played by your subordinates in making the decision is clearly one
of providing the necessary information to you, rather than generating or
evaluating alternative solutions.

C1 You share the problem with relevant subordinates individually, getting their ideas
and suggestions without bringing them together as a group. Then you make
the decision that may or may not reflect your subordinates’ influence.

C11 You share the problem with your subordinates as a group, collectively obtaining
their ideas and suggestions. Then you make the decision that may or may not
reflect your subordinates’ influence.

G11 You share a problem with your subordinates as a group. Together you generate
and evaluate alternatives and attempt to reach agreement (consensus) on a
solution. Your role is much like that of chairman. You do not try to influence
the group to adopt “your” solution, and you are willing to accept and
implement any solution that has the support of the entire group.

Reprinted by permission of publisher from Organizational Dynamics. Spring 1973. p. 74. New York: American Man-
agement Association. All rights reserved.

conflict or disagreement over the appropriate solution, AI, AII, and CI are
eliminated from the feasible set. (The method used in solving the problem
should enable those who disagree to resolve their differences with full
knowledge of the problem. AI, AII, and CI involve no interaction or only
“one-on-one” relationships and therefore provide no opportunity for those
in conflict to resolve their differences. Their use runs the risk of leaving
some of the subordinates with less than the necessary commitment to the
final decision.)

6. The fairness rule. If the quality of the decision is unimportant and accept-
ance is critical and not certain to result from an autocratic decision, AI, AII,
CI, and CII are eliminated from the feasible set. (The method used should
maximize the probability of acceptance because this is the only relevant
consideration in determining the effectiveness of the decision. In these cir-
cumstances, AI, AII, CI, and CII create less acceptance or commitment
than GII. To use them is to run the risk of getting less than the needed
acceptance of the decision.)

38 UNIT 1 � A New Approach to Leadership and Management

Table 2.4 Problem Attributes Used in the Vroom
Decision-Making Model

Problem Attributes Diagnostic Questions

A. The importance of the quality of the Is there a quality requirement such that
decision one solution is likely to be more rational

than another?
B. The extent to which the leader possesses Do you have sufficient information

sufficient information/expertise to make to make a high-quality decision?
a high-quality decision by himself or
herself

C. The extent to which the problem is Is the problem structured?
structured

D. The extent to which acceptance or Is acceptance of the decision by
commitment on the part of subordinates subordinates critical to effective
is critical to the effective implementation implementation?
of the decision

E. The prior probability that the leader’s If you were to make the decision by
autocratic decision will receive acceptance yourself, is it reasonably certain that
by subordinates your subordinates would accept it?

F. The extent to which subordinates are Do subordinates share the organizational
motivated to attain the organizational goals to be obtained in solving
goals as represented in the objectives this problem?
explicit in the statement of the problem

G. The extent to which subordinates are Is conflict among subordinates likely
likely to be in conflict over preferred in preferred solutions?
solution

Reprinted by permission of publisher from Organizational Dynamics. Spring 1973. p. 74. New York: American Manage-
ment Association. All rights reserved.

7. The acceptance priority rule. If acceptance is critical and not ensured by an
autocratic decision, and subordinates can be trusted, AI, AII, CI, and CII
are eliminated from the feasible set. (Methods that provide equal partner-
ship in the decision-making process can provide greater acceptance without
risking decision quality. Use of any method other than GII results in an
unnecessary risk that the decision will not be fully accepted or receive the
necessary commitment on the part of subordinates.

In later work, Vroom and associates (1976) demonstrated how a decision tree
could assist managers in deciding which decision-making style to use (Figure 2.6).
Vroom and Jago (1988) maintain that this model is able to deal with complexities
in situational demands more effectively than either McGregor’s Theory Y or Blake
and Mouton’s managerial grid, and they demonstrated its mathematical attributes
when the model was revised in the 1980s. Later work also demonstrated the effec-
tive use of a modified model for solving individual rather than group decisions.
However, the earlier model is less complex to use and for novice managers provides
a good basis for determining decision-making style appropriate for a manager
working with a group.

MANAGEMENT FUNCTIONS

No clear-cut lists of management functions are found in the current literature.
Kleinman (2003) lists the basic components of management functions to include
planning, organizing, delegating, problem solving, evaluating, and enforcing policies

39CHAPTER 2 � Introduction to Management and Management Decision Making

STATE
THE

PROBLEM

DOES THE PROBLEM POSSESS A QUALITY REQUIREMENT?
DO YOU HAVE SUFFICIENT INFORMATION TO MAKE A HIGH-QUALITY DECISION?
IS THE PROBLEM STRUCTURED?
IS ACCEPTANCE OF DECISION BY SUBORDINATES IMPORTANT FOR EFFECTIVE IMPLEMENTATION?
IF YOU WERE TO MAKE THE DECISION BY YOURSELF, IS IT REASONABLY CERTAIN
THAT IT WOULD BE ACCEPTED BY YOUR SUBORDINATES?
DO SUBORDINATES SHARE THE ORGANIZATIONAL GOALS TO BE ATTAINED IN SOLVING THIS PROBLEM?
IS CONFLICT AMONG SUBORDINATES OVER PREFERRED SOLUTIONS LIKELY?

A.
B.
C.
D.
E.

F.
G.

YES

YES

YES
YES
YES
YES

YES
YES

YES
YES
YES
YES

YES
YE

S
YES
YES
YES

NO

NO
NO
NO
NO

NO
NO

NO
NO
NO
NO
NO
NO
NO
NO
NO
NO

1: AI
2: GII

3: AI

4: AI

5: GII

6A: CII

6B: CI7: AII

9: CII
8: AII

10: CII

11: GII

12: CII

A

B

D

D
D
D
E
E
E
E

F

F
F
F
F

G
C

Figure 2.6 Decision tree governing group problems—Model A: Time efficient
(Vroom, Yetton, & Jago, 1976. Reprinted by permission of publisher from Organizational Dynamics.
Spring 1973. p. 74. New York: American Management Association. All rights reserved.)

and procedures. Nurse managers are expected to also manage day-to-day opera-
tions, empower staff, build productive work teams, maintain quality, and satisfy
customers. However, others describe empowerment as a role for nurse leaders
(Tourangeau, 2003; Trent, 2003 ) See Display 2.1 for a list of some of the functions
of management.

What soon becomes evident in reviewing the literature is that there is some
overlap in management functions with leadership roles. It does seem to become
increasing clear, however, that management functions are more concerned with the
day-to-day activity of the organization and with maintaining the status quo, and
therefore stability, for the organization while the role of leadership is more focused
on moving the organization forward toward the future and thereby changing the
status quo (Trent, 2003).

Throughout this text, leadership and management—the two very necessary
elements—are combined. Leadership is not merely one function of management,
nor management only one role of leadership. The two are forever symbiotic. How-
ever, by artificially separating the two components, leadership roles and manage-
ment functions, readers can see the differences in the two but also see the need for
an integrated leader manager. Zakeznik (2004) maintains that businesses must
find ways to train good managers and develop leaders at the same time. Adoption
of the integrated leader manager is critical for the healthcare industry.

40 UNIT 1 � A New Approach to Leadership and Management

Planning Empower staff Satisfy customers
Directing Maintain quality Organizing
Problem-solving Staffing Delegating
Enforcing policies Controlling

and procedures Evaluating
Manage day-to-day Build productive

operations work teams

Functions of ManagementDisplay 2.1

Questions on Management
Examine Display 2.1 and then recall your own experiences as a manager
or the experiences you have had working for a manager.
Assignment: Write a one-page essay, or discuss in a group, the following
questions.

What functions of management do you feel are the most critical?
What additional functions of management should be added to this list?
Do you feel empowering staff is a function of management or a

leadership role?

Learning Exercise 2.3
A

SUMMARY

Management has a unique purpose and outcome that is needed to maintain a
healthy organization. The history of management science provides managers with
a background into what came before so they are well grounded in the past. Man-
agers continue to use some past theories in coping with management problems
today. Since the earliest management studies, theorists have learned much about
human behavior; additionally society has changed remarkably, providing current
management theorists with new insights and challenges.

However, even today one of the most important functions for the manager
remains that of being a successful decision maker. Decision making takes place
throughout the management process and is one of the most critical functions
of management

The use of management tools and models to guide decision making will assist
the manager in making more effective decisions. Although there are many such
tools available, the successful manger knows that they are not foolproof and often
do not allow for the human element in management. Lastly, the manager is cog-
nizant that selecting the appropriate decision making style will influence the suc-
cess of the decision making.

❊ Key Concepts
• Management functions include planning, organizing, staffing, directing, and

controlling. These are incorporated into what is known as the management
process.

• Each management function has a planning and controlling phase.
• Classical, or traditional, management science focused on production in the

workplace and on delineating organizational barriers to productivity. Work-
ers were assumed to be motivated solely by economic rewards, and little
attention was given to worker job satisfaction.

• The human relations era of management science grew out of the Hawthorne
studies, which emphasized the needs of the worker for recognition. Concepts
of participatory and humanistic management emerged during this era.

• Management science has produced many tools to assist in management
decision making but all are subject to human error.

• Selecting an appropriate decision making style is critical in decision making.
• Management functions are not clear cut and are sometimes merged with

leadership roles.

41CHAPTER 2 � Introduction to Management and Management Decision Making

42 UNIT 1 � A New Approach to Leadership and Management

What’s Your Management Style?
Recall times when you have been a manager. This does not only mean a
nursing manager. Perhaps you were a head lifeguard or an evening shift
manager at a fast-food restaurant. During those times, do you think you
were a good manager? Did you involve others in your management deci-
sion making appropriately? How would you evaluate your decision-making
ability? What style of decision-making (from the Vroom and Yetton
model) did you use?
Assignment: Make a list of your management strengths and make a list of
management skills that you felt you were lacking.

Learning Exercise 2.4

What’s Your Decision Making Style?
You are the manager of a 30-bed medical unit. After consultation, you
recently implemented a system for incorporating nursing diagnoses on the
patient care plans. Although the system was expected to reduce report
time between shifts and improve the quality of patient care, to everyone’s
surprise, including your own, you find that the system is not working. You
do not think there is anything wrong with your idea. Many other hospitals
in the areas are using nursing diagnoses with success. You had a consultant
come from another hospital and give an update to your nurses on use of
the system. The consultant reported that your staff seemed knowledge-
able and appeared to understand their responsibilities in implementing
the system. You suspect that a few nurses might be sabotaging your
efforts for planned change, but your charge nurses do not agree; they
believe the failure may be lack of proper incentives or poor staff morale.

Your nursing administrator is anxious to implement the system in other
patient care units but wants it to be working well in your unit first. You
have just come from a manager’s meeting where your administrator told
you to solve the problem and report back to her within one week regard-
ing the steps you had taken to solve your problem. You share your admin-
istrator’s concern, but how should you solve this problem? Select the
most appropriate decision style.

Learning Exercise 2.5

More Learning Exercises and Applications

These exercises may be discussed individually or in groups, or used as written
assignments.

42

Using the decision-making guidelines developed by Vroom and Yetton, decide
what type of decision-making style should be selected for Learning Exercises 2.5,
2.6, and 2.7.

43CHAPTER 2 � Introduction to Management and Management Decision Making

Gathering the Facts—Stat!
You are the day shift charge nurse on a surgical unit. Because of your
related expertise, your supervisor has asked you to select a new type of
blood-warming unit. You want to be sure that you select the right one.
Several companies have provided your staff with trial units. You have not
received much feedback from the staff regarding their preferences.
Today, your supervisor tells you that your selection and its price must be
ready to accompany her budget, which is due in two days. What do you
do? Select the most appropriate decision style.

Learning Exercise 2.7

Who Should Go?
You are the evening shift charge nurse of the intensive care unit. Your
supervisor is sending two nurses from each shift to an upcoming critical
care conference in a nearby city. The supervisor wants each charge nurse
to submit names of the selected nurses in two weeks. All 12 of the full-
time evening shift nurses would like to go. From a staffing standpoint,
any of them could go. All are active in the local critical care organization.
Financial resources, however, limit your choice to two. How do you
resolve this situation? Select the most appropriate decision style.

Learning Exercise 2.6

Teamwork in Hiring
Six nurses have just applied for a position in the open heart unit. Working
with a group, develop an appropriate decision grid for selecting which
nurse to hire. Identify six criteria for hiring. You may give each criterion
weighted points so that the decision is a quantitative solution. For exam-
ple, level of education could be weighted 5 to 10 points and experience,
10 to 30 points.

Learning Exercise 2.8

Web Links

Guide to project management research sites:
http://www.amanet.org/index.htm
A Web site of the American Management Associates. They offer many free learning
resources.

Management Skills and Development: Interview with Warren Bennis.
http://www.managementskills.co.uk/articles.htm (under Leadership)
An interview with Leadership theorist Warren Bennis.

References
Argyris, C. (1964). Integrating the individual and the organization. New York: John Wiley

and Sons.
Clancy, T. R. (2003). The art of decision-making. Journal of Nursing Administration, 33(6),

343–349.
Fayol, H. (1925). General and industrial management. London: Pittman and Sons.
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business administration. Baltimore: Williams & Wilkins.
Gulick, L. (1937). Notes on the theory of the organization. In L. Gulick & L. Urwick

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Kleinman, C. S. (2003). Leadership roles, competencies, and education. Journal of Nursing
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Mayo, E. (1953). The human problems of an industrialized civilization. New York: Macmillan.
McGregor, D. (1960). The human side of enterprise. New York: McGraw-Hill.
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Russell, V. C. (2000). Working smart. Journal of Management in Engineering, 16(6), 5.
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Tourangeau, A. E. (2003). Building nurse leader capacity. Journal of Nursing Administra-

tion, 33(12), 624–626.
Vroom, V. H. (1973). A new look at managerial decision-making: Organizational decision-

making. Organizational Dynamics, 1(4), 66–80.
Vroom, V., & Jago, A. G. (1988). The new leadership. Englewood Cliffs, NJ: Prentice Hall.
Vroom, V., & Yetton, P. W. (1973). Leadership and decision-making. Pittsburgh: University of

Pittsburgh Press.
Vroom, V., Yetton, P. W., & Jago, A. G. (1976). Leadership and decision making: Cases and

manuals for use in leadership training (3rd ed.). New Haven, CT: Authors.
Zakeznik, A. (2004). Managers and leaders: Are they different? Harvard Business Review,

82(1), 74–81, 113.

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Curran, C. R. (2000). Musings on managerial excellence. Nursing Economic$, 15(6), 277.

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Grindel, C. G. (2003). Mentoring managers. Nephrology Nursing Journal, 30(5), 517–522.
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don), 10(5), 26–29.
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45CHAPTER 2 � Introduction to Management and Management Decision Making

Effective
Leadership and
Management in
Nursing
Ninth Edition

Eleanor J. Sullivan
PhD, RN, FAAN

330 Hudson Street, New York, NY 10013

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Names: Sullivan, Eleanor J., 1938- author.
Title: Effective leadership and management in nursing / Eleanor J. Sullivan,
PhD, RN, FAAN.
Description: Ninth edition. | Boston : Pearson, [2017] | Includes index.
Identifiers: LCCN 2016021687 | ISBN 9780134153117 | ISBN 0134153111
Subjects: LCSH: Nursing services—Administration. | Leadership.
Classification: LCC RT89 .S85 2017 | DDC 362.17/3068—dc23
LC record available at https://lccn.loc.gov/2016021687

1 17

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About the Author

Eleanor J. Sullivan, PhD, RN, FAAN, is the
former dean of the University of Kansas
School of Nursing, past president of

Sigma Theta Tau International, and previous edi-
tor of the Journal of Professional Nursing. She has
served on the board of directors of the American
Association of Colleges of Nursing, testified
before the U.S. Senate, served on a National Insti-
tutes of Health council, presented papers to
international audiences, been quoted in the Chi-
cago Tribune, St. Louis Post-Dispatch, and Rolling
Stone Magazine, and named to the “Who’s Who in
Health Care” by the Kansas City Business Journal.
She earned nursing degrees from St. Louis Community College, St. Louis University,
and Southern Illinois University and holds a PhD from St. Louis University.

Dr. Sullivan is known for her publications in nursing, including this award-
winning textbook, Effective Leadership & Management in Nursing, and Becoming Influential:
A Guide for Nurses, from Pearson Education. In addition, Dr. Sullivan has authored
numerous professional articles, book chapters, and books, including Creating Nursing’s
Future: Issues, Opportunities and Challenges, among others.

Today, Dr. Sullivan is also active in the mystery writing field. She served on the
national board of Sisters in Crime, chaired an award committee for the Mystery Writ-
ers of America, and is published in Mystery Scene Magazine and Ellery Queen Mystery
Magazine.

She has published five mystery novels. Her first three mysteries (Twice Dead,
Deadly Diversion, and Assumed Dead) feature nurse sleuth Monika Everhardt. The latter
two were bought by Harlequin, reissued in paperback, and are still available as e-books
(Deadly Diversion, Assumed Dead).

Her latest series, the Singular Village Mysteries, features 19th century midwife Ade-
laide Bechtmann and her cabinetmaker husband, Benjamin. Two books in the series
(Cover Her Body and Graven Images) are available in print, e-book, and audio formats.
The third book, Tree of Heaven, will be released in the fall of 2017. The series is set in the
Ohio village of Dr. Sullivan’s ancestors. Dr. Sullivan’s blog, found on her website,
reveals the history behind her historical fiction.

Connect with her at EleanorSullivan.com, Facebook, and LinkedIn.

This book is dedicated to my family
for their continuing love and support.

—Eleanor J. Sullivan

iii

Thank You

Our heartfelt thanks go out to our colleagues from schools of nursing across the
country who gave generously of their time, expertise, and knowledge to help
us create this exciting new edition of our text. We have reaped the benefit of

your collective experience as nurses and teachers, and this edition is vastly enriched
due to your efforts.

Contributors
Michael Bleich, PhD, RN, FAAN
President, Maxine Clark and Bob Fox Dean and Professor
Goldfarb School of Nursing
Barnes Jewish College
Chapter 2: Designing Organizations

Debra J. Ford, PhD.
Program Director, Leadership, and Research Assistant Professor
The University of Kansas Medical Center
Chapter 10: Communicating Effectively
Chapter 13: Handling Conflict

Rachel A. Pepper, RN, DNP, NEA-BC
Senior Director of Nursing
The University of Kansas Hospital
Chapter 15: Budgeting and Managing Fiscal Resources
Chapter 17: Staffing and Scheduling

Pamela Klauer Triolo, PhD, RN, FAAN
Former Chief Nursing Officer (Corporate) and Associate Dean
University of Pittsburgh Medical Center
Chapter 19: Evaluating Staff Performance
Chapter 20: Coaching, Disciplining, and Terminating Staff

Reviewers
Wendy Bailes, PhD, RN
Associate Director, Undergraduate Programs
University of Louisiana at Monroe
Monroe, Louisiana

Diane Daddario, MSN, ANP-C, ACNS-BC, RN-BC, CMSRN
Adjunct Faulty, College of Nursing
Pennsylvania State University
University Park, Pennsylvania

iv

Teresa Fisher, MSN, RN, PBT (ASCP)
Assistant Professor of Nursing
Arkansas State University
Jonesboro, Arkansas

Ruth Gladen, MS, RN
Associate Professor
RN Faculty & Director
North Dakota College of Science
Wahpeton, North Dakota

Lisa Harding, RN, MSN, CEN
Professor
Bakersfield College
Bakersfield, California

Mary Alice Hodge, PhD, CNL-C, RN
Director, Graduate Program
The University of South Carolina Upstate
Spartanburg, South Carolina

Mona P. Klose, MS, RN, CNE, CPHQ
Director of Quality Management
Assistant Professor of Nursing
University of Jamestown
Jamestown, North Dakota

Tara O’Brien, PhD, RN, CNE
Assistant Professor
The University of North Carolina
Charlotte, North Carolina

Jennifer O’Connor, RN, MS, CFCN, CNE
Instructor
Northeastern State University
Tahlequah, Oklahoma

Rose M. Powell, PhD, RN
Associate Professor
Stephen F. Austin State University
Nacogdoches, Texas

Joyce A. Shanty, PhD, RN
Associate Professor
Indiana University of Pennsylvania
Indiana, Pennsylvania

Deborah Smitherman, MSN, RN, CCM
Assistant Professor of Nursing
Belhaven University
Jackson, Mississippi

Thank You v

Preface

Never have nurses been more important to healthcare organizations than they
are today. Passage of the Affordable Care Act (ACA) in 2010 reversed decades
of focus on providing quantities of care to emphasize quality of care. Prevent-

ing illness and coordinating care are the cornerstones of the ACA, and nurses are key
to its success.

In addition, leading and managing are essential skills for all nurses in this radically
changed healthcare environment. New graduates find themselves managing unlicensed
assistive personnel, and experienced nurses are managing groups of healthcare providers
from a variety of disciplines and educational levels. All need to know how to manage.

This text is designed to provide new graduates or novice managers with the infor-
mation they need to become effective managers and leaders in healthcare. In addition,
a sidebar in each chapter illustrates how nurses can lead at the bedside. More than
ever before, today’s rapidly changing healthcare environment demands highly devel-
oped management skills and superb leadership.

Features of the Ninth Edition
Effective Leadership and Management in Nursing has made a significant and lasting con-
tribution to the education of nurses and nurse managers in its eight previous editions.
Used worldwide and translated into numerous languages, this award-winning text is
now offered in an updated and revised edition to reflect today’s healthcare arena and
in response to suggestions from the text’s users. The ninth edition builds upon the
work of previous contributors to provide the most up-to-date and comprehensive
learning package for today’s busy students and professionals.

Features of the ninth edition include the following:

• Implementation of the Affordable Care Act

• Evolving models of healthcare organizational structures and relationships

• Expanded content on cultural and gender diversity

• Emphasis on quality management

• Addition of emotional leadership concepts

• Use of social media in management

• Harassing, bullying, and lack of civility in healthcare

• Emergency preparedness for terrorism, disasters, and mass shootings

• Prevention of workplace violence

Two new chapters have been added to this award-winning text. Chapter 7, Under-
standing Legal and Ethical Issues, encompasses the myriad of issues confronting nurses
and managers today. Chapter 28, Imagining the Future, helps readers contemplate the
possibilities inherent in a fast-evolving environment.

Most notably, this text is available for the first time with a suite of digital resources
to enhance your learning. This digital program includes the MyLab Nursing program

vi

that lets you review the chapter materials, decision-making cases that allow you to
apply your learning, and the E-Text 2.0 digital text that is easy to navigate and gives
you tools for highlighting, note taking, and more.

Student-friendly Learning Tools
Designed with the adult learner in mind, the text focuses on the application of the con-
tent presented and offers specific guidelines on how to implement the skills included.
To further illustrate and emphasize key points, each chapter in this edition includes
these features:

• A chapter outline and preview

• A complete audio version of each chapter

• Key terms in pop-up boxes linked to their first appearance and defined in the
glossary at the end of the text

• Flashcards to self-test knowledge of new vocabulary

• What You Know Now summaries at the end of each chapter

• A Tool Box with a list of tools, or key behaviors, for using the skills presented in
the chapter

• Questions to Challenge You in an interactive journal format to help students relate
concepts to their experiences

• Up-to-date references

• Case Studies to demonstrate application of content, with discussion board
questions

Organization
The text is organized into five sections that address the essential information and key
skills that nurses must learn to succeed in today’s volatile healthcare environment and
to prepare for the future.

Part 1. Understanding Nursing Management
and Organizations
Part 1 introduces the context for nursing management, with an emphasis on chang-
ing organizational structures, ways that nursing care is delivered, the concepts of
leading and managing, how to initiate and manage change, providing quality care,
and how to use power and politics—all necessary for nurses to succeed and prosper
in today’s chaotic healthcare world. A new chapter addresses how to weigh legal
and ethical issues,

Part 2. Learning Key Skills in Nursing Management
Part 2 delves into the essential skills for today’s managers, including thinking
critically, making decisions, solving problems, communicating with a variety of
individuals and groups, delegating, working in teams, resolving conflicts, and
managing time.

Preface vii

Part 3. Managing Resources
Knowing how to manage resources is vital for today’s nurses. They must be adept at
budgeting fiscal resources; recruiting and selecting staff; handling staffing and sched-
uling; motivating and developing staff; evaluating staff performance; coaching, disci-
plining, and terminating staff; managing absenteeism, reducing turnover, and
retaining staff; and handling disruptive staff behaviors, especially harassing and bul-
lying behaviors. In addition, collective bargaining, preparing for emergencies and pre-
venting workplace violence are included in Part 3.

Part 4. Taking Care of Yourself
Nurses are their own most valuable resource. Part 4 shows how to manage stress and
to advance in a career.

Part 5. Looking Toward the Future
New to this edition, this chapter provides ways to consider the future, societal predic-
tions about the future, the future of healthcare, and the future of nursing.

Instructor Resources
The assignable and gradable assessments in MyLab Nursing provide educators with
insight into students’ preparation for class, students’ understanding of the material,
and clarity around areas in which additional instruction may be needed.

Additional Instructor Resources can be accessed by registering and logging in at
www.pearsonhighered.com/nursing and include the following:

• TestGen Test Bank

• Lecture Note PowerPoints

• Instructor’s Resource Manual

viii Preface

http://www.pearsonhighered.com/nursing

Part 1 Understanding Nursing
Management and Organizations

1 Introducing Nursing
Management 1

2 Designing Organizations 13

3 Delivering Nursing Care 33

4 Leading, Managing, Following 43

5 Initiating and Managing Change 60

6 Managing and Improving
Quality 75

7 Understanding Legal and
Ethical Issues 94

8 Understanding Power and
Politics 110

Part 2 Learning Key Skills
in Nursing Management

9 Thinking Critically, Making
Decisions, Solving Problems 125

10 Communicating Effectively 145

11 Delegating Successfully 163

12 Building and Managing Teams 178

13 Handling Conflict 198

14 Managing Time 211

Part 3 Managing Resources

15 Budgeting and Managing
Fiscal Resources 224

16 Recruiting and Selecting Staff 241

17 Staffing and Scheduling 260

18 Motivating and Developing Staff 271

19 Evaluating Staff Performance 283

20 Feedback and Coaching,
Disciplining, and Terminating
Staff 296

21 Managing Absenteeism,
Reducing Turnover, Retaining
Staff 307

22 Dealing with Disruptive
Staff Problems 323

23 Preparing for Emergencies 332

24 Preventing Workplace Violence 340

25 Handling Collective
Bargaining Issues 349

Part 4 Taking Care of Yourself

26 Managing Stress 356

27 Advancing Your Career 366

Part 5 Looking to the Future

28 Imagining the Future 382

Brief Contents

ix

Acknowledgments

The success of previous editions of this text has been due to the expertise of many
contributors. Nursing administrators, management professors, and faculty in
schools of nursing all made significant contributions to earlier editions. I am

enormously grateful to them for sharing their knowledge and experience to help
nurses learn leadership and management skills.

I am especially grateful to the contributors to this edition. They revised and
updated content in the following chapters: Chapter 2: Michael Bleich, Chapters 10
and 12: Debbie Ford, Chapters 15 and 17: Rachel Pepper, and Chapters 19 and 20:
Pamela Triolo. All are excellent writers, and this edition would not exist without
their contributions. In addition, Michael Bleich lent his expertise to a review of the
eighth edition, and Rachel Pepper reviewed the previous edition and added specific
examples to demonstrate content for this edition as well.

At Pearson Education, I am grateful to continue to work with Executive Editor
Pamela Fuller, who has supported this text through many editions. For this edition,
Program Manager Erin Rafferty facilitated all aspects of the text’s progress, and Devel-
opment Editor Pamela Lappies’s expertise and fine attention to detail ensure that the
text will continue to be the first choice of faculty and students worldwide.

To everyone who has contributed to this fine text over the years, I thank you.

Eleanor J. Sullivan, PhD, RN, FAAN
www.EleanorSullivan.com

x

http://www.EleanorSullivan.com

Contents

About the Author iii
Thank You iv
Preface vi

Part 1 Understanding Nursing
Management and
Organizations

1 Introducing Nursing
Management 1

Introduction 2

Changes in Healthcare 2
Paying for Healthcare 2

Changes in Society 7
Cultural, Gender, and Generational Differences 7
Violence, Pandemics, and Disasters 8

Changes in Nursing’s Future 8
Current Status of Nursing 8
Institute of Medicine’s Recommendations
for Nursing 9
Adapting to Constant Change 9
What You Know Now 9

Questions to Challenge You 10

References 10

2 Designing Organizations 13

Introduction 14

Reductive and Adaptive Organizational Theories 15
Reductive Theory 15
Humanistic Theory as a Bridge 17
Adaptive Theories 18

Organizational Structures and Shared Governance 19
Functional Structure 19
Service-line Structure 20
Matrix Structure 21
Parallel Structure 21
Shared Governance 22

Healthcare Settings 22
Primary Care 23
Acute Care Hospitals 23
Home Healthcare 23
Long-term Care 23

Ownership and Complex Healthcare Arrangements 24
Ownership of Healthcare Organizations 24
Healthcare Networks 24
Interorganizational Relationships 26
Diversification 26
Managed Healthcare Organizations 27
Accountable Care Organizations 27

Redesigning Healthcare 28
Organizational Environment and Culture 29
What You Know Now 30

Questions to Challenge You 30

References 31

3 Delivering Nursing Care 33

Introduction 34

Traditional Models of Care 34
Total Patient Care 35
Functional Nursing 35
Team Nursing 35
Primary Nursing 35

Integrated Models of Care 36
Practice Partnerships 36
Case Management 36
Critical Pathways 37

Evolving Models of Care 38
Patient-centered Care 38
Synergy Model of Care 39
Patient-centered Medical Home 39
What You Know Now 41

Questions to Challenge You 41

References 41

4 Leading, Managing, Following 43

Introduction 44

Leaders and Managers 44
Leadership 45

Leadership Theories 45
Traditional Leadership Theories 45
Contemporary Leadership Theories 46

Followership: An Essential Component
of Leadership 49

xi

xii Contents

Traditional Management Functions 50
Planning 50
Organizing 51
Directing 51
Controlling 51

Nurse Managers in Practice 52
Nurse Manager Competencies 52
Staff Nurse 52
First-level Management 54
Charge Nurse 54
Clinical Nurse Leader 56
What You Know Now 57

Tools for Leading, Managing, and Following 57

Questions to Challenge You 58

References 58

5 Initiating and Managing
Change 60

Introduction 61

The Nurse as Change Agent 62

Change Theories 62

The Change Process 64
Step 1: Identify the Problem or
Opportunity 64
Step 2: Collect Necessary Data and
Information 65
Step 3: Select and Analyze Data 65
Step 4: Develop a Plan for Change, Including
Time Frame and Resource 65
Step 5: Identify Supporters and Opposers 66
Step 6: Implement Interventions to Achieve
Desired Change 66
Step 7: Evaluate Effectiveness of the Change
and, if Successful, Stabilize the Change 66

Change Strategies 67
Power–Coercive Strategies 67
Empirical–Rational Model Strategies 67
Normative–Reeducative Strategies 67

Resistance to Change 68

The Nurse’s Role 69
Initiating Change 69
Implementing Change 71
Unplanned Change 71
Handling Constant Change 72
What You Know Now 73

Tools for Initiating and Managing Change 73

Questions to Challenge You 73

References 74

6 Managing and Improving
Quality 75

Introduction 76

Quality Management 76
Total Quality Management 76
Continuous Quality Improvement 77
Components of Quality Management 77
Six Sigma 78
Lean Six Sigma 79
DMAIC Method 79

Improving the Quality of Care 80
National Initiatives 81
Evidence-based Practice 82
Electronic Health Records 82
Dashboards 82
Rounding 82
Reducing Medication Errors 83

Risk Management 83
Nursing’s Role in Risk Management 84
Incident Reports 84
Examples of Risk 85
Root-cause Analysis 87
Peer Review 87
Role of the Nurse Manager 87
Creating a Blame-free Environment 90
What You Know Now 90

Tools for Managing and Improving Quality 91

Questions to Challenge You 91

References 92

7 Understanding Legal
and Ethical Issues 94

Introduction 95

Law and Ethics 95

Ethical Decision Making 96
Autonomy 96
Beneficence and Nonmaleficence 97
Distributive Justice 97

The Legal System 97
Sources of Law 97
Types of Law 98
Liability 99

Legal Issues in Nursing 100
Nursing Licensure 100
Patient Care Rights 100
Management Issues 105

Employment Issues 107
What You Know Now 108

Questions to Challenge You 109

References 109

8 Understanding Power
and Politics 110

Introduction 111

Power and Leadership 111
Power: How Managers and Leaders Get
Things Done 111

Using Power 114
Image as Power 114
Using Power Appropriately 116

Shared Visioning as a Power Tool 117

Power, Politics, and Policy 118
Nursing’s Political History 118
Using Political Skills to Influence Policies 119
Influencing Public Policies 121

How Nurses Can Influence the Future 123
What You Know Now 123

Tools for Using Power and Politics 124

Questions to Challenge You 124

References 124

Part 2 Learning Key Skills
in Nursing Management

9 Thinking Critically,
Making Decisions,
Solving Problems 125

Introduction 126

Critical Thinking 126
Critical Thinking in Nursing 127
Using Critical Thinking 127
Creativity 128

Decision Making 130
Types of Decisions 130
Decision-making Conditions 131
The Decision-making Process 132
Decision-making Techniques 133
Group Decision Making 135

Problem Solving 135
Problem-solving Methods 135
The Problem-solving Process 137
Group Problem Solving 140

Stumbling Blocks 141
Personality 141
Rigidity 141
Preconceived Ideas 141

Innovation 142
What You Know Now 142

Tools for Making Decisions and Solving
Problems 143

Questions to Challenge You 143

References 143

10 Communicating Effectively 145

Introduction 146

Communication 146
Transactional Model of Communication 147
Channels of Communication 148
Nonverbal Messages 149
Directions of Communication 150
Effective Listening 150

Effects of Differences in Communication 151
Gender Differences in Communication 151
Generational and Cultural Differences
in Communication 152
Differences in Organizational Culture 152

The Role of Communication in Leadership 153
Employees 153
Administrators 154
Coworkers 156
Medical Staff 156
Other Healthcare Personnel 156
Patients and Families 157

Collaborative Communication 157

Enhancing Your Communication Skills 158
What You Know Now 160

Tools for Communicating Effectively 160

Questions to Challenge You 161

References 161

11 Delegating Successfully 163

Introduction 164

Delegation 164

Benefits of Delegation 165
Benefits to the Nurse 166
Benefits to the Delegate 166
Benefits to the Manager 166
Benefits to the Organization 166

The Five Rights of Delegation 166

Contents xiii

The Delegation Process 167
Steps in the Delegation Process 168
Key Behaviors for Successful
Delegation 170
Accepting Delegation 171

Ineffective Delegation 172
Organizational Culture 172
Lack of Resources 172
An Insecure Delegator 172
An Unwilling Delegate 174
Underdelegation 174
Reverse Delegation 175
Overdelegation 175
What You Know Now 176

Tools for Delegating Successfully 176

Questions to Challenge You 176

References 177

12 Building and Managing
Teams 178

Introduction 179

Groups and Teams 179
Group Interaction 182
Group Leadership 182

Group and Team Processes: Homans
Framework 182

Norms 184
Roles 185

Building Teams 186
Assessment 186
Team-building Activities 187

Managing Teams 187
Task 187
Group Size and Composition 188
Productivity and Cohesiveness 188
Development and Growth 190
Shared Governance 190

The Nurse Manager as Team Leader 190
Communication 190
Evaluating Team Performance 191

Leading Committees and Task Forces 192
Guidelines for Conducting Meetings 192
Managing Task Forces 193
Patient Care Conferences 195
What You Know Now 196

Tools for Building and Managing Teams 196

Questions to Challenge You 196

References 196

13 Handling Conflict 198

Introduction 199
Conflict 199

Interprofessional Conflict 199
Conflict Process Model 200

Antecedent Conditions 200
Perceived and Felt Conflict 202
Conflict Behaviors 203
Conflict Resolved or Suppressed 203
Outcomes 203

Managing Conflict 204
Conflict Responses 206
Alternative Dispute Strategies 208
What You Know Now 209

Tools for Handling Conflict 209

Questions to Challenge You 209

Resources 209

References 210

14 Managing Time 211

Introduction 211

Time-wasters 212

Setting Goals 214
Determining Priorities 215
Daily Planning and Scheduling 216
Grouping Activities and Minimizing
Routine Work 216
Personal Organization and Self-discipline 217

Controlling Interruptions 217
Phone Calls, Voice Mail, Email, and
Text Messages 218
In-person Interruptions 220
Paperwork 220

Controlling Time in Meetings 221

Respecting Time 222
What You Know Now 222

Tools for Managing Time 222

Questions to Challenge You 223

References 223

Part 3 Managing Resources

15 Budgeting and Managing
Fiscal Resources 224

Introduction 225

The Budgeting Process 225
Timetable for the Budgeting Process 227

xiv Contents

Approaches to Budgeting 227
Incremental Budget 228
Zero-based Budget 228
Fixed or Variable Budgets 229

The Operating Budget 229
The Revenue Budget 229
The Expense Budget 230

Determining the Salary and Nonsalary Budget 230
The Salary Budget 230
The Supply and Nonsalary Expense
Budget 233

The Capital Budget 234

Monitoring and Controlling Budgetary
Performance During the Year 234

Variance Analysis 235
Position Control 237

Staff Impact on Budget 237
Improving Performance 237
What You Know Now 239

Tools for Budgeting and Managing Resources 240

Questions to Challenge You 240

References 240

16 Recruiting and
Selecting Staff 241

Introduction 242

The Recruitment and Selection Process 242

Recruiting Applicants 243
Where to Look 244
How to Look 245
When to Look 245
How to Promote the Organization 245
Cross-training as a Recruitment Strategy 246

Selecting Candidates 247

Interviewing Candidates 248
Principles for Effective Interviewing 248
Involving Staff in the Interview Process 252
Interview Reliability and Validity 253

Making a Hire Decision 253
Education, Experience, and Licensure 253
Integrating the Information 254
Making an Offer 255

Legality in Hiring 255
What You Know Now 258

Tools for Recruiting and Selecting Staff 259

Questions to Challenge You 259

References 259

17 Staffing and Scheduling 260

Introduction 261

Staffing 261
Patient Classification Systems 262
Determining Nursing Care Hours 263

Planning FTE Workforce 263
Determining Staffing Mix 264
Determining Distribution of Staff 264

Scheduling 266
Self-staffing and Scheduling 266
Shared Schedule 267
Open Shift Management 267
Weekend Staffing Plan 267
Automated Scheduling 268

Supplementing Staff 268
Internal Pools 268
External Pools 269
What You Know Now 269

Tools for Handling Staffing and Scheduling 269

Questions to Challenge You 270

References 270

18 Motivating and
Developing Staff 271

Introduction 272

A Model of Job Performance 272
Employee Motivation 273
Motivational Theories 273

Staff Development 275
Orientation 276
On-the-job Instruction 276
Preceptors 277
Mentoring 278
Coaching 278
Nurse Residency Programs 279
Career Advancement 279
Leadership Development 280

Succession Planning 281
What You Know Now 281

Tools for Motivating and Developing Staff 281

Questions to Challenge You 282

References 282

19 Evaluating Staff Performance 283

Introduction 284

Performance Management 284

Contents xv

The Performance Evaluation Process 284
Management Responsibilities 287
Components of the Annual Performance
Evaluation 287
Developing Evaluation Tools 288

Methods for Collecting Performance Data 288
Peer Review 288
Self-evaluation 289
Skill Competency 290
Manager’s Evaluation 291

Facing the Challenges of Performance Review 291
Conducting the Annual Performance Review 292

What You Know Now 294

Tools for Evaluating Staff Performance 294

Questions to Challenge You 295

References 295

20 Feedback and Coaching,
Disciplining, and
Terminating Staff 296

Introduction 297

Feedback 297

Coaching 297

Feedback versus Coaching 299

Confronting Behavior 299

Discipline 299

Termination 303
What You Know Now 305

Tools for Feedback and Coaching,
Disciplining and Terminating Staff 305

Questions to Challenge You 305

References 306

21 Managing Absenteeism,
Reducing Turnover,
Retaining Staff 307

Introduction 308
Absenteeism 308

A Model of Employee Attendance 308
Managing Employee Absenteeism 311
Absenteeism Policies 312
Selecting Employees and Monitoring
Absenteeism 313
Family and Medical Leave 313

Reducing Turnover 314
Cost of Nursing Turnover 314
Causes of Turnover 315
Understanding Voluntary Turnover 315

Retaining Staff 316
Job Satisfaction 316
Improving Salaries 317
Retention Strategies 318
What You Know Now 320

Tools for Reducing Turnover, Retaining Staff 320

Questions to Challenge You 321

References 321

22 Dealing with Disruptive
Staff Problems 323

Introduction 323

Harassing Behaviors 324
Bullying 324
Lack of Civility 324
Horizontal Violence 325

How to Handle Problem Behaviors 326
Marginal Employees 327
Disgruntled Employees 327

The Employee with a Substance Abuse Problem 327
State Board of Nursing 329
Strategies for Intervention 329
Reentry 330
The Americans with Disabilities Act
and Substance Abuse 330
What You Know Now 330

Tools for Managing Staff Problems 331

Questions to Challenge You 331

References 331

23 Preparing for Emergencies 332

Introduction 332

Types of Emergencies 333
Natural Disasters 333
Man-made Disasters 333
Levels of Disasters 334

Hospital Preparedness for Emergencies 334
All-hazards Approach 334
Emergency Operations Plan 334
Surge Capacity 335
Disaster Triage 336
Continuation of Services 336

Staff Utilization in Emergencies 336
What You Know Now 338

Tools for Preparing for Emergencies
and Preventing Violence 338

Questions to Challenge You 338

References 339

xvi Contents

24 Preventing Workplace
Violence 340

Introduction 340

Violence in Healthcare 341
Incidence of Workplace Violence 341
Horizontal Violence 341
Consequences of Workplace Violence 342
Factors Contributing to Violence
in Healthcare 342

Preventing Violence 343
Zero-tolerance Policies 343
Reporting and Education 343
Environmental Controls 343

Dealing with Violence 344
Verbal Intervention 344
A Violent Incident 344
Other Dangerous Incidents 345
Post-incident Follow-up 345
What You Know Now 347

Tools for Preventing Violence 347

Questions to Challenge You 347

References 347

25 Handling Collective
Bargaining Issues 349

Introduction 349

Laws Governing Unions 350

Process of Unionization 350

Handling Grievances 351
Unfair Labor Practices 351
The Grievance Process 352

Collective Bargaining and Nurses 352
Legal Issues of Supervision 353
The Future of Collective Bargaining
for Nurses 354
What You Know Now 354

Tools for Handling Collective Bargaining Issues 355

Questions to Challenge You 355

References 355

Part 4 Taking Care of Yourself

26 Managing Stress 356

Introduction 356

The Nature of Stress 357

Causes of Stress 358

Organizational Factors 358

Interpersonal Factors 358

Individual Factors 359

Consequences of Stress 360

Managing Stress 361

Personal Methods 361

Organizational Methods 362

What You Know Now 364

Tools for Managing Stress 364

Questions to Challenge You 364

References 365

27 Advancing Your Career 366

Introduction 366

Envisioning Your Future 367

Acquiring Your First Position 367

Applying for the Position 368

The Interview 368

Accepting the Position 373

Declining the Position 373

Progressing in Your Career 373

Tracking Your Progress 375

Identifying Your Learning Needs 376

Finding and Using Mentors 378

Considering Your Next Position 379

Finding Your Next Position 379

Leaving Your Present Position 379

Adapting to Change 380

What You Know Now 380

Tools for Advancing Your Career 381

Questions to Challenge You 381

Online Resources 381

References 381

Part 5 Looking to the Future

28 Imagining the Future 382

Introduction 382

Ways to Consider the Future 383

Possible Future 383

Plausible Future 383

Probable Future 383

Preferable Future 383

Contents xvii

Societal Predictions About the Future 383

The Future of Healthcare 384
Technological Innovations 384
Healthcare Legislation 385
Demands of Consumerism 385

The Future of Nursing 386
Institute of Medicine Recommendations 386
New Careers in Nursing Project 386

What You Know Now 388

Questions to Challenge You 388

References 388

Glossary 390

Credits 398

Index 401

xviii Contents

Chapter 1

Introducing Nursing
Management

Learning Outcomes

After completing this chapter, you will be able to:

1. Explain changes to healthcare over the past decade,
including those resulting from implementation of the
Affordable Care Act; demands to reduce errors and improve
patient safety; and evolving medical and communication
technology.

2. Describe how nursing management is influenced by changes
in society.

3. Identify the changes and challenges that nurses face now and in
the future.

Key Terms
accountable care organization

(ACO)

Affordable Care Act (ACA)

benchmarking

Centers for Medicare & Medicaid
Services (CMS)

electronic health records
(EHRs)

evidence-based practice (EBP)

health home

Leapfrog Group

Magnet Recognition Program

Changes in Healthcare
Paying for Healthcare

Changes in Society
Cultural, Gender, and Generational Differences

Violence, Pandemics, and Disasters

Changes in Nursing’s Future
Current Status of Nursing

Institute of Medicine’s Recommendations
for Nursing

Adapting to Constant Change

1

2 Chapter 1

medical errors

medical home

Quality and Safety Education for
Nurses (QSEN)

quality management

robotics

telehealth

Introduction
Today, all nurses are managers. And leaders. And followers. Whether you work in an
urgent care center, an ambulatory surgical center, a critical care unit in an acute care
hospital, or in hospice care for a home care agency, you interact with staff, including
other nurses and unlicensed assistive personnel, who work with you and for you. You
must be able to collaborate with others, as a leader, a follower, and a team member.
More than ever before, today’s rapidly changing healthcare environment demands
highly refined management skills and superb leadership.

Leading at the Bedside: Management Skills
You may think you don’t need this text. After all, you’re a
staff nurse. You take care of patients in a hospital or clinic.
You’re neither a designated manager nor an identified leader.

But you would be wrong.
For every plan you make, every time you instruct an

assistant, every interaction with a patient or family member,

you use management skills. Don’t you manage patient
safety? Solve problems? Handle conflict? And—my
favorite—manage time? These are just a few of the skills
you will learn in this text. Good luck!

Changes in Healthcare
Healthcare continues to change at a rapid rate. Reimbursement for care, demands for
safe care, and evolving technology are affecting every aspect of care. In addition, soci-
etal changes, including cultural, gender, and generational differences, as well as an
increase in violence, pandemics, and disasters force the healthcare system to adapt
quickly. In turn, these changes challenge nursing and nurses to adapt.

Paying for Healthcare
In the past, healthcare providers were paid for the amount of care they gave patients.
The more care they provided, the more money they received. There was no provi-
sion for the effectiveness of that care. Also, if mistakes were made, healthcare orga-
nizations were reimbursed for whatever care they provided to ameliorate those
mistakes. That system is being replaced by reimbursement for the quality of the
care provided and not reimbursing healthcare organizations for the cost of correct-
ing mistakes.

AffordAblE CArE ACt Implementation of the Affordable Care Act (ACA)
in 2010 radically changed how healthcare is delivered and compensated in the

Introducing Nursing Management 3

United States. Such healthcare reform was desperately needed to fix a system
that rewarded more care and discouraged preventive care. In addition, the cost of
medical care continued to soar while many Americans lacked access to basic care
(Centers for Medicare & Medicaid Services [CMS], 2015). Although the ACA has
undergone numerous court challenges that remain unsettled, implementation is
proceeding.

The ACA was designed to provide quality, affordable healthcare for all Ameri-
cans (Emanuel, 2015). Its emphasis is on preventing disease and coordinating
care, and it provides mechanisms for the uninsured to acquire health insurance by
enrolling in state or federal exchanges of health insurance companies (Blumenthal
& Collins, 2014). Through incentives and penalties, the ACA encourages health-
care organizations to establish accountable care organizations (ACO), consisting
of hospitals and healthcare providers who agree to provide care to a designated
population.

Also changed is how primary care providers offer care via a health home (previ-
ously called a medical home) (U.S. Department of Health and Human Services, 2015a).
Instead of serving as gatekeepers to specialty care in order to contain costs, primary
care providers facilitate access to specialty care when needed and monitor that care
using electronic health records (Russell, 2014). Regular follow-ups by care providers
monitor chronic health conditions and reinforce treatment regimens. Patients, too,
have access to their medical records and are encouraged to participate in decisions
about their care.

Whether the ACA will remain as it is, be changed by legislation, or be repealed
entirely remains to be seen. What is apparent, however, is that access, cost, and
quality of care will continue to concern providers, insurers, state and federal gov-
ernments, and the American people.

COSt Of MEdiCAL ERRORS Another factor affecting the healthcare system is the
cost of medical errors (Andel, Davidow, Hollander, & Moreno, 2012). Since the Insti-
tute of Medicine (IOM) reported that 98,000 deaths occur each year from preventable
medical mistakes (Institute of Medicine, 1999), both healthcare providers and insur-
ers have mounted efforts to prevent such errors, including falls, wrong site surgeries,
avoidable infections, pressure ulcers, and adverse drug events. In spite of numerous
efforts to prevent mistakes, the cost of medical errors has continued to climb. In addi-
tion to loss of life or diminished quality of life, actual dollar estimates put such costs
at $17.1 billion annually (Den Bos et al., 2011).

To incentivize hospitals to reduce medical mistakes, the Centers for Medicare &
Medicaid Services (CMS), the agency that oversees government payments for care,
changed its reimbursement policy to no longer cover costs incurred by medical mis-
takes. If medical mistakes occur, the hospital must absorb the costs. Thus, pay for per-
formance became the norm, and performance is now measured by the quality of care
(Milstein, 2009).

dEMANd fOR QuALity In an effort to ameliorate medical mistakes, a number of
quality initiatives have emerged. These include quality management, the Leapfrog
Group, benchmarking, evidence-based practice, the Magnet Recognition Program,
and Quality and Safety Education for Nurses.

Quality Management. Quality management is a preventive approach designed to
address problems before they become crises. Although quality management was

4 Chapter 1

originally designed for manufacturing, the healthcare industry has adopted various
quality management strategies from the airline industry and other fields. Good man-
agement techniques can often be transferred from one use to another.

Leapfrog Group. The Leapfrog Group is a consortium of public and private pur-
chasers that uses its mammoth purchasing power by rewarding healthcare organi-
zations that demonstrate quality outcome measures. Today, the Leapfrog Group
compares hospitals’ performance on preventing errors, accidents, injuries, and
infections. In 2014, the Leapfrog Group assessed 1,501 hospitals (Leapfrog Group,
2015).

Benchmarking. Benchmarking is a comparison of an organization’s data with simi-
lar organizations. Outcome indicators are compared across disciplines or organiza-
tions. Once the results are known, healthcare organizations can address areas of
weakness and enhance areas of strength (Nolte, 2011).

Evidence-based Practice. Evidence-based practice (EBP) has emerged as a strat-
egy to improve quality by using the best available knowledge integrated with clini-
cal experience and the patient’s values and preferences to provide care (Houser &
Oman, 2010).

Similar to the nursing process, the steps in EBP are as follows:

1. Identify the clinical question.

2. Acquire the evidence to answer the question.

3. Evaluate the evidence.

4. Apply the evidence.

5. Assess the outcome.

Research findings with conflicting results puzzle consumers daily, and nurses are
no exception, especially when they search for practice evidence. Hader (2010) suggests
that evidence falls into several categories:

• Anecdotal—derived from experience

• Testimonial—reported by an expert in the field

• Statistical—built from a scientific approach

• Case study—an in-depth analysis used to translate to other clinical situations

• Nonexperimental design research—gathering factors related to a clinical
condition

• Quasi-experimental design research—a study limited to one group of subjects

• Randomized control trial—uses both experimental and control groups to deter-
mine the effectiveness of an intervention

While all forms of evidence are useful for clinical decision making, randomized
control design and statistical evidence are the most rigorous (Hader, 2010).

Magnet Recognition Program. More than 25 years ago, the Magnet Recognition Pro-
gram was designed to recognize excellence in nursing. The purpose was to improve
patient care by focusing on nurses’ qualifications, work life, and participation within
the organization. The program designated 14 factors that indicated a culture of

Introducing Nursing Management 5

excellence, resulting in an environment for quality patient care. Institutions that met
the stringent guidelines for nurses were credentialed by the American Nurses Creden-
tialing Center (ANCC) as Magnet-certified hospitals.

In 2007, the Magnet program was redesigned to provide a framework for the
future of nursing practice and education (American Nurses Credentialing Center,
2008). To focus on outcome measures, the 14 factors from the original program were
reconfigured into five components:

• Transformational leadership

• Structural components

• Exemplary professional practice

• New knowledge, innovations, and improvement

• Empirical outcomes

Magnet hospitals are those organizations that are recognized for “quality patient
care, nursing excellence and innovations in professional nursing practice.” (American
Nurses Credentialing Center, 2016). To qualify for recognition as a Magnet hospital,
the organization must demonstrate that they are achieving the following:

• Promoting quality in a setting that supports professional practice

• Identifying excellence in the delivery of nursing services to patients/residents

• Disseminating “best practices” in nursing services (ANCC, 2015)

In 2013, the US News Best Hospitals in America Honor Roll included 15 medical
centers of the 18 recognized as holding Magnet certification (ANCC, 2015).

Quality and Safety Education for Nurses. Based on recommendations of the Institute
of Medicine (IOM, 2003), a national advisory board of experts developed quality and
safety competencies, designating targets of knowledge, skills, and attitudes (KSAs) for
nursing education known as Quality and Safety Education for Nurses (QSEN;
Cronenwett et al., 2007).

The six prelicensure KSAs are as follows:

• Patient-centered care

• Teamwork and collaboration

• Evidence-based practice

• Quality improvement

• Safety

• Informatics (Quality and Safety Education for Nurses Institute, 2015)

These competencies are being used as guides for nursing education, to assist nurses
transitioning to practice, and for nurses continued lifelong learning (Amer, 2013).

EvOLviNG tECHNOLOGy Rapid changes in technology seem, at times, to over-
whelm us. Hospital information systems (HIS); electronic health records (EHRs); com-
puterized physician/provider point-of-care data entry (CPOE); barcode medication
administration; dashboards to manage, report, and compare data across platforms;
telehealth provided from a distance; and robotics—to name a few of the many

6 Chapter 1

evolving technologies—both fascinate and frighten us simultaneously. At the same
time, communication technology—from smartphones to social media—continues to
march into the future. It is no wonder that people who work in healthcare complain
that they can’t keep up! The rapidity of technological change promises to continue
unabated (Huston, 2013).

Electronic Health Records. Electronic health records (EHRs) reduce redundancies,
improve efficiency, decrease medical errors, and lower healthcare costs. Continuity of
care, discharge planning and follow-up, ambulatory care collaboration, and patient
safety are just a few of the additional advantages of EHRs. Furthermore, fully inte-
grated systems allow for collective data analysis across clinical conditions and between
and among healthcare organizations, and they support evidence-based decision
making. Federal incentives (e.g., reimbursement and grants) encourage the expanded
use of EHRs, which is expected to continue (Amer, 2013).

Telehealth. telehealth has evolved as technologies to assess, intervene, and moni-
tor patients remotely continue to improve. The technology to diagnose and treat
patients from a distance, along with patient-accessible EHRs and mobile devices
such as smartphones, enables providers to interact with patients regardless of their
location.

Nurses, for example, can watch banks of video screens miles away from the hospi-
tal monitoring ICU patients’ vital signs. Electronic equipment, such as a stethoscope,
can be accessed by a healthcare provider in a distant location. Such systems are espe-
cially useful in providing expert consultation for specialty care (Zapatochny-Rufo,
2010). This technology, too, is expected to grow (Amer, 2013).

Robotics. Another technological advance is robotics. In the hospital, supplies can be
ordered electronically. Next, laser-guided robots fill orders in the pharmacy or central
supply and deliver them to nursing units via dedicated elevators—and do so more
efficiently, accurately, and in less time than individuals can. Robot functionality will
continue to expand, limited only by resources and ingenuity.

Communication Technology. Communication technologies are evolving just as rap-
idly as clinical and data technology, changing forever the ways people keep informed
and interact (Sullivan, 2013). Information (accurate or inaccurate) is disseminated with
lightning speed, while smartphones capture real-time events and broadcast images
instantaneously.

Social media have revolutionized communication beyond the realm of possibili-
ties of just a few years ago. Social media connect diverse populations and encourage
collaboration by way of the exchange of images, ideas, and opinions in online forums,
blogs, wikis, podcasts, RSS feeds, Instagram, Pinterest, YouTube, Twitter, Facebook,
and LinkedIn, among others (Sullivan, 2013).

Like other enterprises, most healthcare organizations maintain a website as
well as a presence on social media sites such as Facebook, Twitter, and blogs. Units
within the organization may maintain Facebook pages as well, with staff designated
to post on those sites. These opportunities for information sharing and relationship
building also come with risks. Patient confidentiality, the organization’s reputa-
tion, and recruiting efforts can be enhanced or put in jeopardy by posts to the site
(Sullivan, 2013).

Introducing Nursing Management 7

Changes in Society
Societal change is occurring as rapidly as healthcare is changing. Changes include dif-
ferences in the composition of today’s population, including the nursing population,
as well as demands on the healthcare system resulting from increasing violence,
threats of pandemics, and challenges of potential disasters.

Cultural, Gender, and Generational Differences
The population mix in the United States, the number of men entering nursing, and
the average age of practicing nurses all affect nursing. All require nursing to adjust
and adapt.

CuLtuRAL diffERENCES According to the U.S. Census Bureau (2013), the
minority population in the United States is projected to rise to 56% of the total by
2060, compared with 38% in 2014 (U.S. Census, 2015). This includes Hispanic, Asian,
and African American populations, but the fastest growing minority group in the
United States are people who identify themselves as two or more races (U.S. Cen-
sus, 2015). In addition, the recognition that lesbian, gay, bisexual, and transgender
(LGBT) populations are part of communities across the United States challenges
healthcare providers to offer appropriate care and services (Budden, Zhong,
Moulton, & Cimiotti, 2013).

The nursing profession, however, does not reflect the cultural diversity seen in the
general population. A 2013 survey of registered nurses found that only 17% are minor-
ities (Budden et al., 2013). Efforts to increase diversity in nursing are recommended
(IOM, 2010).

GENdER diffERENCES The gender mix found in nursing also differs from the gen-
eral population, with men greatly outnumbered by women. While only 7% of the
nursing population is male, only 5% in the profession were male in 2000 (Budden et
al., 2013). Cultural and gender diversity challenge nurses to consider such differences
when working with staff, colleagues, and administrators as well as mediating conflicts
between individuals.

GENERAtiONAL diffERENCES Generational differences in the nursing popula-
tion challenge interactions and relationships between workers and patients alike.
Three generational cohorts (baby boomers, generation X, and generation Y) are cur-
rently working together (Keepnews, Brewer, Kovner, & Shin, 2010) and a fourth (gen-
eration Z) will soon join them (Levit, 2015).

Each generational group has different expectations in the workplace. Baby
boomers value professional and personal growth and expect that their work will
make a difference. Generation X members strive to balance work with family life
and believe that they are not rewarded given their responsibilities. Generation Y
(also called millennials) are technically savvy and expect immediate access to infor-
mation electronically. Generation Z, born in the mid-1990s to early 2000s, will soon
graduate and join their older coworkers. Generation Z members are curious, pas-
sionate, and diverse, and willing to pursue nontraditional options in their futures
(Levit, 2015).

The challenge for nurses in dealing with different generations is similar to that of
dealing with cultural and gender differences: to avoid stereotyping within the

8 Chapter 1

generations, to value the unique contributions of each generation, to encourage
mutual respect for differences, and to leverage these differences to enhance team
work (Murray, 2013).

Violence, Pandemics, and Disasters
Sadly, violence invades today’s workplaces, and healthcare is no exception. Verbal
threats, physical attacks, and violent assaults can and do occur in healthcare set-
tings (Papa & Venella, 2013). As those who work closely with patients, nurses are
vulnerable to attack from patients, family members, coworkers, or others. To reduce
the incidence and impact of workplace violence, the organization must establish
clear guidelines to prevent it, and staff must be adequately trained to respond to
incidents of violence.

A pandemic is a disease outbreak that spreads rapidly, usually because the
infecting virus is new, and humans have little or no immunity to it. The H1N1 virus
of 2009 is an example (U.S. Department of Health and Human Services, 2015b). Pan-
demics are public health emergencies that require healthcare organizations to have
in place the necessary protocols to respond rapidly in the event of a pandemic
(Fineberg, 2014).

Both natural and human-caused disasters have increased in recent years and
require healthcare organizations to prepare for the influx of mass casualties that may
occur. Natural disasters, such as earthquakes, floods, and tornadoes, may damage not
only communities but hospitals as well (e.g., the 2012 tornado in Joplin, Missouri).
Human-caused disasters may occur accidentally (e.g., industrial accidents, bridge
collapses, power outages), but intentional harm from acts of terrorism are unfortu-
nately common today. All hospitals and other healthcare organizations must have
emergency plans in place and have staff adequately trained to respond to these all-too-
common events.

Changes in Nursing’s Future
As healthcare organizations are restructuring to implement the ACA, scrambling
to improve outcomes to meet safety and quality benchmarks, and struggling to
adapt to constantly evolving technology, nurses ask, “What does this mean for our
future?”

Current Status of Nursing
Slightly more than 3 million nurses are currently licensed as registered nurses in the
United States, with 2.6 million practicing in the profession (U.S. Bureau of Labor Sta-
tistics, 2014). To meet both anticipated increases in population and an aging populace
(U.S. Census Bureau, 2015), more than 500,000 additional nurses will be needed by
2022 (U S. Bureau of Labor Statistics, 2014). Unfortunately, as the population ages,
nurses, too, are growing older (Budden et al., 2013). The average age of nurses practic-
ing today is 50 years or older, up from 45 a few years ago (Health Resources and Ser-
vices Administration [HRSA], 2013).

Introducing Nursing Management 9

Institute of Medicine’s Recommendations
for Nursing
The IOM’s report on the future of nursing makes sweeping recommendations for the
profession, including that “nurses should be full partners, with physicians and other
healthcare professionals, in redesigning healthcare in the United States” (IOM, 2010,
p. 3). Also, the IOM posits that today’s healthcare environment necessitates better-
educated nurses and recommends that 80% of nurses be prepared at the baccalaureate
or higher level by 2020.

In addition, the report recommends that barriers limiting the scope of practice for
advanced practice nurses be eliminated, and that racial, ethnic, and gender diversity
among the nursing workforce should be increased to better care for a diverse patient
population. While nurses are consistently ranked as the most trusted profession in the
United States (Gallup, 2014), few nurses hold positions of leadership in healthcare, and
the IOM recommends an increase in their numbers. Progress on meeting the recommen-
dations of the IOM report is substantial and ongoing (Hassmiller & Reinhard, 2015).

Adapting to Constant Change
What does the future hold for nursing? Change is the one constant! The challenge for
nurses is how to manage in this continually fluctuating system.

Nurses are charged with monitoring and improving the safety and quality of care,
managing with limited resources, participating in organizational decision making,
working with teams of professionals and nonprofessionals from various generations
and cultures, adapting to technological advances, and preparing for constant environ-
mental changes. This is no small task. It requires that nurses be committed, involved,
enthusiastic, flexible, and innovative; above all else, it requires that they have good
mental and physical health. The nurse of today must be a coach, a teacher, and a facili-
tator. Most of all, the nurse must be able to live with ambiguity and be flexible enough
to adapt to the changes it brings.

That is a tall order, but nurses are up to the challenge. This text is designed to pre-
pare you to meet that challenge.

What You Know Now
• The Affordable Care Act, which may be changed

or repealed, altered how healthcare is provided
and compensated.

• Reducing medical errors is a priority, and organi-
zations are scrambling to achieve outcomes better
than benchmarks.

• The Magnet Recognition Program certifies hospi-
tals that meet rigorous standards and provide
excellent nursing.

• Electronic health records, robotics, and telehealth
are just a few of the many technologies continu-
ing to evolve.

10 Chapter 1

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• Communication technologies will continue to
evolve, offering opportunities and challenges to
healthcare organizations.

• Cultural, gender, and generational diversity will
continue to shape the nursing workforce and
patient populations.

• Threats of natural disasters, terrorism, and pan-
demics require all healthcare organizations to
plan and prepare for mass casualties.

• More than a half million new nurses will be needed
in the near future.

• The Institute of Medicine recommends that nurses
be better educated to participate as full partners
in redesigning healthcare.

• Nurses must be able to adapt to rapid and ongo-
ing changes in healthcare.

Questions to Challenge You
1. Name three changes that you would suggest to

reduce the cost of healthcare without compromis-
ing patient safety. Specify how you could help
make these changes.

2. What mechanisms could you suggest to improve
and ensure the quality of care? (Don’t just suggest
adding nursing staff!)

3. How could you help reduce medical errors? What
can you suggest that a healthcare organization
could do?

4. What are some ways that nurses could take
advantage of emerging technologies in healthcare
and information systems? Think big.

5. Have you participated in a disaster drill? Did
you notice ways to improve the organization’s
readiness for mass casualties? Name at least one.

6. What steps can you take to transfer the knowl-
edge and skills you learn in this text into your
work setting?

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Introducing Nursing Management 11

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch,
J., Johnson, J., Mitchell, P., . . . Warren, J. (2007).
Quality and safety education for nurses. Nursing
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Den Bos, J., Rustagi, K., Gray, T., Halford, M.,
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Emanuel, E. J. (2015). Reinventing American health care:
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Hader, R. (2010). The evidence that isn’t . . .
interpreting research. Nursing Management,
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Hassmiller, S. B., & Reinhard, S. C. (2015). A bold
new vision for America’s health care system: The
Future of Nursing report becomes a catalyst for
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Health Resources and Services Administration.
(2013). The U.S. nursing workforce: Trends
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Houser, J., & Oman, K. S. (2010). Evidence-
based practice: An implementation guide for
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Keepnews, D. M., Brewer, C. S., Kovner, C. T., & Shin,
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Milstein, A. (2009). Ending extra payment for
“never events”—Stronger incentives for patients’
safety. New England Journal of Medicine, 360(23),
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Murray, E. J. (2013). Generational differences: Uniting
the four-way divide. Nursing Management, 44(12),
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12 Chapter 1

Sullivan, E. J. (2013). Becoming influential: A guide for
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Chapter 2

Designing
Organizations

Learning Outcomes

After completing this chapter, you will be able to:

1. Differentiate between reductive and adaptive organizational theories.

2. Describe traditional and emerging structures in healthcare
organizations.

3. Choose a practice setting based on a preferred professional practice
model.

4. Explain how the ownership of and complex relationships among
healthcare organizations impact nursing.

5. Discuss how the organizational environment and culture affect
workplace conditions.

Reductive and Adaptive Organizational
Theories

Reductive Theory

Humanistic Theory as a Bridge

Adaptive Theories

Organizational Structures and Shared
Governance

Functional Structure

Service-line Structure

Matrix Structure

Parallel Structure

Shared Governance

Healthcare Settings
Primary Care

Acute Care Hospitals

Home Healthcare

Long-term Care

Ownership and Complex Healthcare
Arrangements

Ownership of Healthcare Organizations

Healthcare Networks

Interorganizational Relationships

Diversification

Managed Healthcare Organizations

Accountable Care Organizations

Redesigning Healthcare
Organizational Environment and Culture

13

14 Chapter 2

Key Terms
accountable care organization (ACO)

bureaucracy

capitation

chain of command

diversification

Hawthorne effect

health home

horizontal integration

integrated healthcare networks

line authority

medical home

mission

organization

organizational culture

organizational environment

philosophy

redesign

retail medicine

service-line structures

shared governance

span of control

staff authority

throughput

values

vertical integration

vision statement

Introduction
When individuals come together to fulfill a common aspiration, organizations are
formed. Some organizations are as small as two individuals with simple structures
guiding the business relationship. Others may be large and complex. In healthcare,
individuals form organizations to care for the ill and infirm or to advance health and
well-being, yet they use different approaches to achieve these aims. A home care orga-
nization may focus less on the use of diagnostic technologies in favor of delivering
hands-on and psychosocial support services where the patient resides. Other organi-
zations may prefer to focus on technology usage, such as outpatient imaging services
where patients go for care. Still other organizations may combine the two and add
other aims, such as teaching future health providers. For these reasons, individuals
studying to be healthcare providers will benefit from realizing early on that they will
choose not only an area of clinical interest for a career but also a practice setting that
aligns with their beliefs about organizations.

Organizations almost always begin small, with structures that are easy to navi-
gate. A nurse practitioner with a rural independent practice may provide clinic ser-
vices with one or two others, but most organizations tend to grow in size and
complexity. If the clinic grows in volume and scope of services offered, the time comes
when more care providers are needed. At some point, a business manager is needed to
specialize in billing and collecting revenues to offset the cost of providing services.
Leaders begin to differentiate organizations into functions, divisions, and service lines,
among other ways of structuring work discussed later in this chapter.

In the earliest stages, especially during in an era when a business plan is needed to
establish an organization in order to gain needed capital, organizational partnerships
have a defined mission, purpose, and goals. Leaders shape their organizational struc-
ture based on what they want the organization to achieve.

The philosophy is a sometimes written statement that reflects the organizational
values, vision, and mission (Conway-Morana, 2009). Values are the beliefs or attitudes

Designing Organizations 15

one has about people, ideas, objects, or actions that form a basis for the behavior that
will become the culture. Organizations use value statements to identify those beliefs or
attitudes esteemed by the organization’s leaders.

A vision statement is often written; it describes the future state of what the orga-
nization is to become through the aspirations of its leaders. The vision statement is
designed to keep stakeholders intent on why they have come together and what they
aspire to achieve. “Our vision is to be a regional integrated healthcare delivery system
providing premier healthcare services, professional and community education, and
healthcare research” is an example of a vision statement for a healthcare system.

The mission of an organization is a broad, general statement of the organization’s
reason for existence. Developing the mission is the necessary first step to forming an
organization. “Our mission is to provide comprehensive emergency and acute care
services to the people and communities within a 200-mile radius” is an example of a
mission statement that guides decision making for the organization. Purchasing a
medical equipment company, therefore, fails to meet the current mission, nor does it
contribute to the vision of improving the community’s health.

Reductive and Adaptive
Organizational Theories
The purpose of a theory-derived organization is to design work and optimize human
talent in a manner that best accomplishes the aspirational goals of the organization.
Most healthcare organizations have theoretical foundations stemming from the late
1800s to the early to mid 1900s, an era during which family-based industries such as
farming were replaced with manufacturing plants developed in urban settings to
accommodate mass production. Building on management principles derived from
Adam Smith in 1776, who studied how organizations specialize and divide labor into
piecework, new theories emerged. On analysis, these theories began to address work
design, individual and group motivation to improve performance outputs, and the
hypothesis that different situations may require adaptive strategies for the organiza-
tion to remain viable.

Reductive Theory
Reductive theory, or classical approaches to organizations, focuses heavily on (a) the
nature of the work to be accomplished, (b) creating structures to achieve the work, and
(c) dissecting the work into component parts. The premise is to enhance people’s effi-
ciency through thoughtfully designed tasks. Leaders who use this model aim to subdi-
vide work, specify tasks to be done, and fit people into the plan. Reductive theory has
four elements: division and specialization of labor, organizational structure, chain of
command, and span of control.

DiVisiOn AnD speCiAlizAtiOn Of lAbOr Dividing work reduces the number
of tasks that each person carries out, with the intent to increase efficiency by assigning
repetitive tasks to dedicated workers and improve the organization’s product. This
concept ties proficiency and specialization together such that the division of work and
specialization economically benefit the owner. When work is designed in such a stan-
dardized manner, managers exert greater control over productivity expectations.

16 Chapter 2

OrganizatiOnal Structure Organizational structures delineate work group
arrangements based on the concept of departmentalization as a means to maintain
command, reinforce authority, and provide a formal communication network.

Stated earlier, structures evolve over time, especially as organizations grow in
size. The term bureaucracy is defined as the ideal, intentionally rational, most efficient
form of organization. Today this word has a negative connotation, suggesting long
waits, inefficiency, and red tape, yet its tenets continue to serve a purpose.

chain Of cOmmand The chain of command is depicted on a table of organiza-
tion (called the organizational chart) through job titles listed in magnitude of authority
and responsibility. Those jobs that ascend to the top reflect increased authority and
represent the right or power to direct the activities of those of lesser rank. Those
depicted at the lower end of the chart have the obligation to perform certain functions
or responsibilities and yield less authority and power.

The organizational chart gives the appearance of orderliness and clarity around
who is in charge. Positions with line authority are depicted in boxes on the organiza-
tional chart, with the person holding supervisory authority over other employees
located at the top. In Figure 2-1, line authority is illustrated by the chief nurse execu-
tive holding supervisory authority over nurse managers and the acute care nurse prac-
titioner. Another type of authority is known as staff authority, in which individuals
yield considerable expertise to advise and influence others; they possess influence
that, without supervisory power, provides important direction and persuasion, minus
supervisory status. In Figure 2-1, the nurse managers and acute care nurse practitioner
possess staff authority with one another. This means that no nurse is responsible for
the work of the others, yet they respect and collaborate to improve the efficiency and
productivity of the unit for which the nurse manager bears responsibility.

Chief nurse executive

Staff nurse Staff nurse Staff nurse

Acute
care nurse
practitioner

Nurse
manager

Nurse
manager

Nurse
manager

Figure 2-1 Chain of authority.

Span Of cOntrOl Span of control addresses the issue of effective supervision
expressed by the number of direct reports to someone with line authority. Complex
organizations have numerous highly specialized departments; centralized authority
results in a tall organizational structure with small differentiated work groups. Less
complex organizations have flat structures; authority is decentralized, with several
managers supervising large work groups. Figure 2-2 depicts the differences.

Reductionist theory uses the mission of the organization to structure and design
work, which is then subdivided into parts. The traditional design of medicine is based
on this model, where a primary care physician oversees the holistic concerns of the
patient, but specialists are called in to detail each subcomponent part of medical

Designing Organizations 17

treatment. Similarly, most hospital organizations still orchestrate their clinical services
and departments using this model. This classical view of organizations has strength,
but also real limitations. The way clinical work is carried out is dependent upon
bureaucratic work design, yet clinicians often create work-arounds when necessary to
achieve patient care objectives.

Humanistic Theory as a Bridge
Between reductive and adaptive organizational theory development is a movement
from the 1930s that addresses how people respond to working in large organizations
brought on by the industrial revolution. A major premise of humanistic theory is that
people desire social relationships, respond to group pressure, and search for personal
fulfillment in work settings. A series of studies conducted by the Western Electric Com-
pany at its Hawthorne plant in Chicago unexpectedly advanced knowledge about
human responses to the workplace. The first study coexamined the effect of illumination
(improved or diminished) on productivity but failed to find any relationship between
the two extremes. In most groups, productivity varied at random, and in one study pro-
ductivity actually rose as illumination levels declined. These contradictory results led
researchers to conclude that unforeseen psychological factors could be at play.

Further studies of working conditions, such as varied positive and negative
experiences linked to rest breaks and workweek length, similarly failed to impact

Tall

Flat

Figure 2-2 Contrasting spans of control.

From Longest, B. B., Rakich, J. S., & Darr, K. (2000). Managing health services organizations and systems (4th ed.).
Baltimore: Health Professions Press, p. 124. Reprinted by permission.

18 Chapter 2

productivity. The researchers concluded that the social attention and interactions
created by the research itself—that is, the special human attention given to workers
participating in the research—met a social need that enhanced productivity. This
tendency for people to perform in an expected manner because of special attention
and focused, unintentional interactions became known as the Hawthorne effect, a
term now used most commonly in research but which emanated from organiza-
tional science.

Although the findings are controversial, organizational theorists shifted focus to
the social aspects of work and organizational design. One important assertion of this
theory was that individuals cannot be coerced or bribed to do things they consider
unreasonable; formal authority does not work without willing participants.

Adaptive Theories
During the great social changes that occurred following World War II and Vietnam,
organizational theorists began to observe ways that organizations adapt to change.
The interplay among structure, people, technology, and environment led to perceiving
organizations as adaptive systems; consequently, rules developed about how organi-
zations thrived or were challenged.

SyStemS tHeory Concurrent thoughts about biologic and nursing science also led
to breakthrough knowledge known as systems theory (Mensik, 2014).

An open-system organization draws on resources—known as inputs—from out-
side its boundary. Inputs can include materials, money, and equipment as well as
human capital with particular expertise. These resources are transformed when pro-
cesses are designed, animated, and coordinated with the mission of the organization in
mind—a process known as throughputs—to create the goods and services desired,
which are called outputs. Each healthcare organization—whether a hospital, ambula-
tory surgical center, home care agency, or something else—requires human, financial,
and material resources. Each also designs services to treat illness, restore function, pro-
vide rehabilitation, and protect or promote wellness, thereby influencing clinical and
organizational outcomes.

throughput today is commonly associated with access to care and how patients
enter and leave the healthcare system. Hospitals measure the throughput of patients,
beginning with emergency department services and, if necessary, patients diverted
away from the hospital based on resource availability; how long a patient has to wait
for a bed; and the number of readmissions (Handel et al., 2010). Readmissions that
occur within fewer than 120 days from discharge create financial penalties for
hospitals as a measure of inadequate discharge planning. Using information techno-
logy, bed management systems are a tool to monitor patient throughput in real time
(Gamble, 2009). The Joint Commission accreditation, a national accreditation pro-
gram, requires hospitals to show data on throughput statistics (Joosten, Bongers, &
Janssen, 2009).

ContingenCy tHeory Another adaptive theory is contingency theory, which
was developed to explain that organizational performance is enhanced when leaders
attend to and interact directly with the unique characteristics occurring in a changing
environment. Through these interactions leaders match an organization’s human and
material resources in creative ways to respond quickly to social and clinical needs. The
environment defined here includes the people, objects, and ideas outside the

Designing Organizations 19

organization that influence or threaten to destabilize the organization. Although some
environmental factors are easily identified in healthcare organizations (regulators,
competitors, suppliers of goods, and so on), the boundaries become blurred when a
third-party payer or a physician controls a patient’s access to care. In these cases, the
physician or payer appears to be the customer, or gatekeeper.

CHAOs tHeOry The final adaptive theory, known as chaos theory, is linked to the
field of complexity science, inspired by quantum mechanics. Chaos theory chal-
lenges us to look at organizations through a lens that strips away notions of the com-
mand and control structures found in reductive theories. Complexity scientists
observe in nature that nonlinear problems cannot be solved with the linear
approaches tied to reductionism. The concept of cause and effect is rarely predictable
in work settings where the stakes are high, multiple variables interact, and predic-
tive outcomes are not feasible. Complexity science informs organizational leaders
that all systems will self-regulate over time, that change is plausible from the bot-
tom-up or through the organization, and that leadership aims to establish simple
rules that promote adaptation in concert with environmental agents, rather than
believing that the command and control methods found in reductionist models are
sufficient (Ray, Turkel, Cohn, 2011).

Chaos theory and complexity science refute permanent organizational structures
as useful. Rather, principles that ensure flexibility, fluidity, speed of adaptability, and
cultural sensitivity are emerging, such as those found in virtual organizations (Norton
& Smith, 1997). In social media, Facebook is an example of a leaderless organization,
created and managed by its communities of interests, serving its users through a broad
set of principles that are self-monitored.

Organizational Structures and Shared
Governance
Implementing organizational theory is best accomplished with guiding principles to
orchestrate roles and responsibilities linked to the mission, purpose, and goals of the
organization; accommodate its size; and consider technology and other environmental
factors. The structures named in the following sections are used in healthcare organi-
zations today.

Functional Structure
In functional structures, employees are grouped in departments by specialty, and
groupings of similar tasks are performed by groups of like-minded or trained indi-
viduals operating out of the same department along with similar types of departments
reporting to the same manager. In a functional nursing structure, all nursing tasks fall
under nursing service. Functional structures tend to centralize decision making
because the functions converge at the top of the organization.

A functional nursing structure enjoys the benefit of having like individuals per-
forming common work close together, but coordination between and among other
functional areas, such as the pharmacy or laboratory, may be limited. Decision making
can become too centered on a single manager who may lack a broad perspective of
organizational dynamics.

20 Chapter 2

Service-line Structure
More common in healthcare organizations today are service-line structures (Nugent,
Nolan, Brown, & Rogers, 2008). Service-line structures also are called product-line or
service-integrated structures. In a service-line structure, clinical services are organized
around patients with specific conditions (see Figure 2-3). For instance, there may be an
oncology, cardiac, or mother–infant service line.

Nursing Dietary

Oncology

CEO

Pharmacy Storeroom

Nursing Dietary Pharmacy Storeroom

Cardiology

Nursing Dietary

Burn unit

Pharmacy Storeroom

Figure 2-3 Service-line structure.

Service-line structures are sometimes preferred in large and complex organiza-
tions because the same activity (e.g., hiring) is assigned to several self-contained units.
In theory, service lines respond rapidly to the service’s patient populations because
nursing, pharmacologic, diagnostic, and other services work in tandem. This structure
is appropriate when environmental uncertainty is high, the populations serviced are
high volume and have specific needs, and the organization requires frequent adapta-
tion and innovation to distinguish itself.

A service-line structure designs its resources for rapid response in a changing
environment. Because each service line specializes and strategically aligns resources,
its outputs can be tailored to keep patient satisfaction high.

Service lines coexist with functional structures. A nurse may work in a service line
as an oncology nurse but also have ties to the functional area of nursing. This requires
coordination across function settings (nursing, dietary, pharmacy, and so on) and takes
effort among leaders to ensure that functional and service goals are achieved. Service
goals receive priority under this organizational structure because employees see the
service outcomes as the primary purpose of their organizational position.

As in all structures, organizations with multiple service lines face challenges,
including possible duplication of resources (such as duplicating advertisements for
new positions), lack of identity with one’s professional discipline, and inconsistent or
duplicative process design across services, creating multiple demands on support ser-
vice areas, such as pharmacy or environmental services where expectations can differ
enough to create confusion and inefficiencies in those areas. In addition, some service

Designing Organizations 21

lines (e.g., pediatrics, obstetrics, bariatric surgery, and transplant centers) present spe-
cial challenges due to low usage or the need for specialized personnel (Page, 2010).

Service-line structures are the most common structures found in academic health
science centers and larger urban organizations (Kaplow & Reed, 2008). As noted, this
type of structure can present a challenge to nurse leaders to maintain nursing stan-
dards across service lines (Hill, 2009).

Armstrong, Laschinger, and Wong (2009) found that improved patient safety in
Magnet hospitals was related to nurses’ perception of empowerment. This can be
explained, possibly, by Magnet standards that encourage staff participation in deci-
sion making.

Leading at the Bedside: Organizational Structures
What does it matter how your unit or practice or institu-
tion is structured? You can’t do anything about that, you
say. However, nursing doesn’t exist in isolation; it is part
of a larger entity—from your organization to your state
(e.g., licensing of nurses and institutions) to your country
(e.g., healthcare policies). All of those components affect
your practice.

Also, are you career minded? Do you want to advance
in your profession? You may be undecided about that. After
all, you’re still a student or a beginning staff nurse. Wouldn’t
you like to have that option available to you? If so, pay

attention to the reporting relationships between and among
various departments, divisions, or service lines in your
organization, especially when something goes wrong.
Errors identify problems in either the person in the position
or the structure. Sometimes both the individual and struc-
ture are unworkable. Notice, too, when everything goes
smoothly.

You are correct; you can’t change your organization’s
structure. Paying attention to how it works, though, offers
you a learning experience that you can tuck away for the
future. Remember it!

Matrix Structure
The matrix structure integrates both service-line and functional structures into one
overlapping structure. In a matrix structure, a manager is responsible for both the func-
tion and the product line. For example, the nurse manager for the oncology clinic may
report to the vice president for nursing and the vice president for outpatient services.

Matrices tend to develop where there are strong outside pressures for a dual orga-
nizational focus on product and function. The matrix is appropriate in a highly uncer-
tain environment that changes frequently but also requires organizational expertise
(Galbraith, 2009).

A major weakness of the matrix structure is its dual authority, which can frustrate
and confuse departmental managers and employees. Respect and strong interpersonal
skills are required from the leaders in this structure, who will spend extra time in joint
problem solving and conflict resolution. These leaders must share organizational
vision beyond their individual functional areas and be willing to act based on this
broader vision. If this does not happen, one function may become more dominant.

Parallel Structure
Parallel structure is unique to healthcare. The field of medicine contends that it
requires its own organizational structure because of the complexity of its field and the
desire to self-monitor its own members. Most hospitals today continue to have

22 Chapter 2

hospital structures while the medical staff has its own structural unit, with its own
leaders and departments that coexist with the hospital’s structures, with both struc-
tures reporting to the board of trustees. For a department like nursing, this poses the
dilemma of being exposed to two lines of authority—to the hospital and the medical
governance structure. Parallel structures are becoming less successful as healthcare
organizations integrate into newer models that incorporate physician practice under
the organizational umbrella.

Shared Governance
shared governance is a nursing response to organizational structures that represents
the voice of the nursing profession in healthcare agencies. It can be considered a modi-
fied parallel structure to that of medicine, ensuring that matters of clinical practice are
influenced by those who are closest to care delivery. One key difference in shared gov-
ernance is that its structures complement organizational design.

Shared governance gives nurses a forum in which to shape nursing practice within
the healthcare organization. Shared governance requires nurses to be accountable to
the latest standards and knowledge in the field. Nurses gain experience in using their
voice in decision making at the organizational level. So important is this structure that
Magnet standards require shared governance and—as part of its review process,
including peer review—examine the influence of nursing in organizational decision
making. Nurses participate in unit-based councils that interface with divisional coun-
cils, specialty councils, and a leadership council, consisting of nurse managers and
administrators (Hafeman, 2015).

In this structure, decisions are made by consensus rather than by the manager’s
order or majority rule, allowing staff nurses an active voice in problem solving. Unit
councils make decisions for that unit, while divisional councils address issues impact-
ing multiple units, with a hospital-wide council addressing profession-wide issues
linked to patient care standards. Appropriate councils address clinical quality and
safety issues, professional competencies and development, and the implementation of
evidence-based practices into the organization.

Although nursing practice councils have operated for several decades, changes in
healthcare and in organizational structures have led to council modifications, a pro-
cess not without difficulty (Moore & Wells, 2010). Staffing shortages, patient demands,
and unfamiliarity with shared governance concepts or its benefits may discourage
participation. In addition, not all shared governance models are successful (Ballard,
2010). Human factors—such as lack of leadership, lack of staff or manager understand-
ing of shared governance, or the absence of knowledgeable mentors—can impede
implementation of the model. Structural factors—such as a known structure for deci-
sion making, time available for meetings, and staffing support for attendance—also
affect the success of shared governance. Still, as a Magnet standard, shared governance
will continue into the future (McDowell et al., 2010).

Healthcare Settings
Settings for the delivery of healthcare include primary care, acute care hospitals, home
healthcare, and long-term care organizations. While these are the most common, note
that nursing care is also provided in schools, rehabilitation, hospice, correctional, and
other settings not addressed in this section.

Designing Organizations 23

Primary Care
Primary care is considered to be the location where the patient goes for preventive and
basic care services and is the gatekeeper for access to specialized services. Primary care
is delivered in neighborhood clinics, provider offices, ambulatory care, emergency
departments, public health clinics, and some sites found in retail shopping.

Retail medicine is now available in many pharmacies and large retail chains as a
convenient walk-in clinic for treating low-acuity illnesses, immunizations, or school
physicals. Staffed heavily by nurse practitioners with physician backup, these clinics
address the ease that consumers want outside of traditional bureaucratic agencies.
While groups such as the American Medical Association have questioned the quality
of care provided in these clinics (Costello, 2008), other studies refute this claim, reveal-
ing comparable levels of care (Bauer, 2010; Rohrer, Augstman, & Furst, 2009).

Acute Care Hospitals
Hospitals are frequently classified by length of stay and type of service. Most hospitals
are acute (short-term or episodic) care facilities, and they may be classified as general
or special care facilities, such as pediatric, rehabilitative, and psychiatric facilities.
Many hospitals also serve as teaching institutions for nurses, physicians, and other
healthcare professionals; these are known as academic health centers.

The term teaching hospital commonly designates a hospital associated with a medical
school that maintains physician or medical resident availability on-site 24 hours a day.
Nonteaching hospitals, in contrast, have private physicians (not medical students) on
staff. Both academic teaching and nonteaching hospitals have made greater use of a new
physician specialty known as hospitalists. A hospitalist manages the care of hospitalized
patients on behalf of the primary care provider while that patient is hospitalized or
works to complement the private physician by being available for emergency care.
Whatever the model, the role of the nurse shifts based on physician availability. Like-
wise, some hospitals are employing acute care nurse practitioners to support the clinical
management of hospitalized patients. These specialty-trained nurses have the authority
to manage clinical incidents and write orders to manage clinical events (Hravnak, 2014).

Home Healthcare
Home healthcare is the intermittent, temporary delivery of healthcare in the home
by skilled (nurses) or unskilled providers (home health aides). With the expanded
use of minimally invasive and adjunctive treatments, coupled with safety concerns,
today patients are rapidly discharged to recuperate at home. The primary service
provided by home care agencies is nursing care, yet physical or occupational thera-
pists and durable medical equipment technicians who support ventilators, hospital
beds, home oxygen equipment, and other medical supplies are also on the team,
along with social workers.

Long-term Care
Long-term care facilities constitute a range of service levels known as assisted living
services. Included in these services are professional nursing care and rehabilitative
services. Most long-term care facilities are freestanding, but it is not uncommon for
them to be part of a hospital or aligned with a hospital system. Assisted living services

24 Chapter 2

used to be almost exclusively for residential care. Today, many long-term care facilities
maintain both apartment-like living for those who are independent and more clini-
cally oriented facilities to accommodate the aging process. Many of these facilities are
now a bridge from acute care to home, with a limited length of stay.

Given the range of services provided, the long-term care industry is heavily regu-
lated. There are exemplars for outstanding senior services, but some facilities lack pro-
fessional staff and adequate support staff. Thus, many patients with conditions of aging
may require resources beyond what is available. Particularly vulnerable are the frail
elderly. Challenges in providing care to the elderly include addressing the tendency to
stigmatize older, frail adults and to provide continuity of care across settings.

Ownership and Complex Healthcare
Arrangements
As federal regulations and payment shifts from a fee-for-service model to population
health management systems, hospitals are consolidating or becoming part of larger
systems that cover geographic expanses. Further, health systems are restructuring to
provide a range of pre- and post-acute care services.

Ownership of Healthcare Organizations
Ownership can be either private or government, voluntary (not for profit) or investor
owned (for profit), and sectarian or nonsectarian (see Figure 2-4). Private organiza-
tions are usually owned by corporations or religious entities, whereas government
organizations are operated by city, county, state, or federal entities, such as the Indian
Health Service. Voluntary organizations are usually not-for-profit, meaning that sur-
plus monies are reinvested into the organization. Investor-owned, or for-profit, corpo-
rations distribute surplus monies back to the investors, who expect a profit. Sectarian
agencies have religious affiliations.

Healthcare Networks
integrated healthcare networks originally emerged as organizations sought to sur-
vive in today’s cost-conscious environment. The results of the Affordable Care Act
have led to even further integration as the health of populations must not be managed
across the continuum of care services (Soto, 2013). The earliest definition for popula-
tion health was based on health outcomes distributed over a group of individuals.
Today this includes interventions around lifestyle, prevention, and risk avoidance, all
aimed at reducing the need for acute care services. Integrated systems encompass a
variety of model organizational structures, but certain characteristics are common.
Network systems provide the following:

• A continuum of care

• Geographic or population coverage for the buyers of healthcare services

• Acceptance of the risk inherent in taking a fixed payment in return for providing
healthcare for all persons in the selected group, such as all employees of one
company

To provide such services, networks of providers evolved to encompass hospi-
tals and physician practices. Most important, the focal point for care is primary care

Designing Organizations 25

and care management rather than using the hospital for the continuum of services.
The goal is to interact with and keep patients in the setting that incurs the lowest cost,
promotes health, and reduces expensive hospital stays. A variety of other arrange-
ments have emerged, varying from loose affiliations or collaborations between hospi-
tals and hospital systems to complete mergers of hospitals, clinics, and physician
practices. As changes in healthcare reimbursement unfold, nurses are playing
expanded roles in primary care, transitional care, and community-based wellness
initiatives.

PRIVATE (NONGOVERNMENT) OWNERSHIP

Voluntary
(not for profit)

Roman Catholic,
Salvation Army,
Lutheran, Methodist,
Baptist, Presbyterian,
Latter-day Saints, Jewish

Community

Industrial (railroad,
lumber, union)
Kaiser-Permanente Plan
Shriners hospitals

Investor-
owned
(for profit)

Individual owner
partnership
corporation

Single hospital
(Investor-owned
hospitals)

Sectarian

Nonsectarian

GOVERNMENT OWNERSHIP

Federal

State
Long-term psychiatric, chronic,
and other
State university medical centers

Army
Navy
Air Force

Public Health Service
Indian Health Service
Other

Local

Hospital district or authority
County
City-county
City

Department of
Defense

Department of
Veterans Affairs

Department of
Health and
Human Services

Department of
Justice—prisons

Figure 2-4 Types of ownership in healthcare organizations.

From Longest, B. S., Rakich, J. S., & Darr, K. (2000). Managing Health Services Organizations and Systems
(4th ed.). Baltimore: Health Professions Press, p. 173. Reprinted by permission.

26 Chapter 2

Interorganizational Relationships
At the onset of this chapter, the reasons why organizations form and re-form were
addressed. With increased competition for resources and public and governmental
pressures for better efficiency and effectiveness, organizations are choosing to estab-
lish expanded relationships with one another for their continued success. Multihospi-
tal systems and multiorganizational arrangements, both formal and informal, are
exploring their mission, purpose, and goals, and whether or not alignments through
new mechanisms are beneficial.

Arrangements between or among organizations that provide the same or similar
services are examples of horizontal integration. For instance, all hospitals in the net-
work provide comparable services (see Figure 2-5).

Hospital
A

Hospital
B

Hospital
C

Hospital
D

Hospital
E

Hospital
F

Hospital
G

Figure 2-5 Horizontal integration.

Vertical integration, in contrast, is an arrangement between or among dissimilar
but related organizations to provide a continuum of services. An affiliation of a health
maintenance organization with a hospital, pharmacy, and nursing facility represents
vertical integration (see Figure 2-6).

Numerous arrangements using horizontal and vertical integration can be found
today. Examples of such arrangements include affiliations, consortia, alliances,
mergers, consolidations, and agencies under the umbrella of a corporate network
(see Figure 2-7).

Hospital
Imaging
center

Home care
services

Medical
group

practice

Skilled
nursing
facility

Ambulatory
surgical
center

Long-term
care

Corporate board

Figure 2-7 Corporate healthcare network.

Diversification
Diversification is the expansion of an organization into new arenas. It provides
another strategy for survival in today’s economy. Two types of diversification are com-
mon: concentric and conglomerate.

Concentric diversification occurs when an organization complements its existing
services by expanding into new markets or broadening the types of services it cur-
rently has available. For example, a children’s hospital might open a daycare center for
developmentally delayed children or offer drop-in facilities for sick child care.

Acute care hospital

Long-term care facility

Home health agency

Ambulatory care clinic

Sports medicine clinic

Hospice care

Figure 2-6 Vertical
integration.

Designing Organizations 27

Conglomerate diversification is the expansion into areas that differ from the original
product or service. The purpose of conglomerate diversification is to obtain a source of
income that will support the organization’s product or service. For example, a long-
term care facility might develop real estate or purchase a company that produces dura-
ble medical equipment.

Another type of diversification common to healthcare is the joint venture. A joint
venture is a partnership in which each partner contributes different areas of expertise,
resources, or services to create a new product or service. In one type of joint venture,
one partner (general partner) finances and manages the venture, whereas the other
partner (limited partner) provides a needed service. Joint ventures between healthcare
organizations, physicians, researchers, and others are becoming increasingly common.
Integrated healthcare organizations, hospitals, and clinics seek physician and/or prac-
titioner groups they can bond (capture) in order to obtain more referrals. The health-
care organization as financier and manager is the general partner, and physicians are
limited partners.

Managed Healthcare Organizations
The managed healthcare organization is a system in which a group of providers is
responsible for delivering services (that is, managing healthcare) through an orga-
nized arrangement with a group of individuals (e.g., all employees of one company, all
Medicaid patients in the state). Different types of managed care organizations exist:
health maintenance organizations (HMOs), preferred provider organizations (PPOs),
and point-of-service plans (POS).

An HMO is a geographically organized system that provides an agreed-on pack-
age of health maintenance and treatment services provided to enrollees at a fixed
monthly fee per enrollee, called capitation. Patients are required to choose providers
within the network.

In a PPO, the managed care organization contracts with independent practitioners
to provide enrollees with established discounted rates. If an enrollee obtains services
from a nonparticipating provider, significant copayments are usually required.

Point-of-service (POS) is considered to be an HMO—PPO hybrid. In a POS, enroll-
ees may use the network of managed care providers to go outside the network as they
wish. However, use of a provider outside the network usually results in additional
costs in copayments, deductibles, or premiums.

Accountable Care Organizations
Effective January 2012, accountable care organizations have been able to contract with
Medicare to provide care to a group of Medicare recipients (Ansel & Miller, 2010).
Strong incentives to reduce cost, share information across networks, and improve
quality are included in the provisions for reimbursement.

An accountable care organization (ACO) consists of a group of healthcare pro-
viders that provide care to a specified group of patients. Various structures can be
used in ACOs, from loosely affiliated groups of providers to integrated delivery sys-
tems. An ACO is more flexible than an HMO because consumers are free to choose
providers from outside the network. Cognizant of the potential for Medicare con-
tracts and, later, reimbursement by other third-party payers, healthcare providers
and organizations are scrambling to establish collaborative arrangements and
networks.

28 Chapter 2

Redesigning Healthcare
Healthcare is a dynamic environment with multiple factors impinging on continuity
and stability. Implementation of ACOs, demands for safe, quality care, Magnet stan-
dards that promote decentralized organizational structures, and an aging population
with multiple chronic conditions are among the factors that make redesigning health-
care a reality today.

A redesign includes strategies to better provide safe, efficient, quality healthcare.
Some examples of redesign strategies include adopting a patient-centered care model,
focusing on specific service lines, applying lean thinking to the system, and establish-
ing a flat, decentralized organizational structure.

A report entitled Crossing the Quality Chasm (Institute of Medicine, 2001) recom-
mended ways to improve healthcare. One of those was to adopt a patient-centered
care model. Success in implementing a patient- and family-centered care model has
been reported in the literature (Zarubi, Reiley, & McCarter, 2008).

Another patient-centered model is the health home or medical home (Berenson
et al., 2008). Centered by a primary care provider (primary care physician or nurse
practitioner), a health home considers the population it serves and designs its ser-
vices to attract patients to a “home” where they are known over time as a co-partner
in maintaining health. The goal is to provide continuous, accessible, and comprehen-
sive care. Challenges for coordinating care in a health home include the lack of train-
ing for health professionals in this model, poor communication between and among
providers and patients (e.g., absence of electronic medical records for all providers),
the multiple demanding needs of patients with chronic health problems, and fair
compensation for primary care services. These challenges are offset by implement-
ing electronic health records, expanding nurse practitioners’ coverage to include
managing patients with chronic conditions, encouraging patients to self-manage
chronic conditions, and persuading providers to use electronic communication with
patients (Berenson et al., 2008).

Within organizations, individual behavior is greatly influenced by how systems
and processes are designed. As integrated systems form, it becomes an imperative to
ensure that systems and processes are designed for the patient and family experience
and for the provider intersection with these work flow designs. Regardless of whether
a health home or a transitional care program is being designed, lean thinking princi-
ples should be employed (Joosten, Bongers, & Janssen, 2009). Lean thinking focuses on
the system rather than on individuals, concentrates on interventions that improve out-
comes, and disregards those that have little or no effect. If it is determined that a flat,
decentralized organizational structure that centers decision making closest to the point
of care is most desirable, lean thinking principles should guide the design. Lean prin-
ciples promote unit-based decision making and empower staff to create and imple-
ment process improvements in a timely manner (Kramer, Schmalenberg, & Maguire,
2010). Furthermore, a decentralized structure encourages communication and collabo-
ration and provides a quality improvement infrastructure.

Nurse leaders at all levels should be key players in health system redesign efforts.
They are expected not only to initiate change while reducing costs, maintaining or
improving quality of care, coaching and mentoring, and team building, but also to do
so in an ever-changing environment full of ambiguities while their own responsibili-
ties are expanded (Bleich, 2011).

Designing Organizations 29

Organizational Environment and Culture
As organizations grow and evolve in responding to and meeting the needs of those for
whom it was created, a working environment and culture emerge. How decisions get
made, how the values live out through individual and group behavior, how the orga-
nization responds to shifts in the marketplace, and how it recognizes and rewards
innovative or ritualized behavior together shape the feel or tone of the setting. Indi-
viduals are well served if their personal style aligns with the community of peers that
match the organization.

The terms organizational environment and organizational culture, then, describe
the internal conditions in the work setting. Organizational environment is the sys-
temwide conditions that contribute positively or counterproductively to fulfilling the
stated mission, purpose, and goals of the organization within the work setting. In 2005,
the American Association of Critical-Care Nurses (AACN) identified the following six
characteristics of a healthy work environment, characteristics that the organization
continues to promote (AACN, 2011):

• Skilled communication

• True collaboration

• Effective decision making

• Appropriate staffing

• Meaningful recognition

• Authentic leadership

Organizations should not be personified. One way to assess the organiza-
tional environment is to evaluate the qualities of those leading the organization.
An organization in which nursing leaders are innovative, creative, and energetic
will tend to move and/or operate in a fast-moving, goal-oriented fashion. If
humanistic, interpersonal skills are sought in candidates for leadership positions,
the organization will focus on human resources, employees, and patient advocacy
(Hersey, 2011).

Organizational culture, on the other hand, comprises the basic assumptions and
values held by members of the organization (Sullivan, 2013). These are often known as
the unstated “rules of the game.” For example, who wears a lab coat? When is report
given? To whom? Is tardiness tolerated? How late is acceptable?

Like environment, organizational culture varies from one institution to the next,
and subcultures and even countercultures—groups whose values and goals differ sig-
nificantly from those of the dominant organization—may exist. A subculture is a group
that has shared experiences or like interests and values. Nurses form a subculture
within healthcare environments. They share a common language, rules, rituals, and
dress, and they have their own unstated rules. Individual units also can become sub-
cultures. Countercultures, if unrecognized and/or tolerated, can distract from organi-
zational success. Subcultures, in and of themselves, may or may not stray from the
organizational mission, purpose, and goals.

Systems involving participatory management and shared governance create
organizational environments that reward decision making, creativity, independence,
and autonomy (Kramer, Schmalenberg, & Maguire, 2010). These organizations retain
and recruit independent, accountable professionals. Organizations that empower

30 Chapter 2

nurses to make decisions have expanded potential to exceed consumer needs. As the
healthcare environment continues to evolve, more and more organizations are adopt-
ing consumer-sensitive cultures that require accountability and decision making
from nurses.

What You Know Now
• The schools of organizational theory can be clus-

tered into reductive, humanistic, and adaptive
schools of thought, all useful in framing organi-
zations as they exist.

• Organizations can be viewed as social systems
consisting of people working in a predetermined
pattern of relationships who strive toward a com-
mon mission, purpose, and goals. The mission of
healthcare organizations is to provide a particular
mix of health services.

• Traditional organizational structures include func-
tional, hybrid, matrix, and parallel structures.

• Service-line structures organize clinical services
around specific patient conditions.

• Shared governance provides the framework for
empowerment and partnership within the health-
care organization.

• Accountable care organizations are expanding as
population health is considered in healthcare
design. They can contract with a payer to provide
care to a specific group of patients.

• The health home is one of the patient-centered
models where all services are provided by a group
of healthcare professionals.

• Organizational environment and culture affect
the internal conditions of the work setting.

Questions to Challenge You
1. Secure a copy of the organizational chart from your

employment or clinical site. Would you describe
the organization the same way the chart depicts
it? If not, redraw a chart to illustrate how you see
the organization.

2. What organizational structure would you prefer?
Think about how you might go about finding an
organization that meets your criteria.

3. Organizational theories explain how organizations
function. Which theory (or theories) describes

your organization’s functioning? Do you think it
is the same theory your organization’s adminis-
trators would use to describe it? Explain.

4. Using the six characteristics of a healthy work envi-
ronment listed in this chapter, evaluate the orga-
nization where you work or have clinicals. How
well does it rate? What changes would improve
the environment?

Designing Organizations 31

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Berenson, R. A., Hammons, T., Gans, D. H.,
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Galbraith, J. R. (2009). Designing matrix organizations
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http://www.hfma.org/Templates/InteriorMaster.aspx?id=1523

Chapter 3

Delivering
Nursing Care

Learning Outcomes

After completing this chapter, you will be able to:

1. Differentiate the models of nursing care delivery systems and the
disadvantages of each.

2. Describe the attributes of integrated models of care.

3. Compare three evolving models of care and explain why care
delivery systems will continue to evolve.

Key Terms
critical pathways

patient-centered care

patient-centered medical home
(PCMH)

practice partnership

synergy model of care

Traditional Models of Care
Total Patient Care

Functional Nursing

Team Nursing

Primary Nursing

Integrated Models of Care
Practice Partnerships

Case Management

Critical Pathways

Evolving Models of Care
Patient-centered Care

Synergy Model of Care

Patient-centered Medical Home

33

34 Chapter 3

Introduction
The core business of a healthcare organization is providing nursing care to patients.
The purpose of a nursing care delivery system is to provide a structure that enables
nurses to deliver nursing care to a specified group of patients. Wherever nursing care
is delivered—whether in a hospital, an outpatient clinic, or a primary care practice—it
must be organized to ensure quality care in an era of cost containment.

Over the years, nursing care delivery systems have undergone continuous and
significant changes (see Box 3-1). Various nursing care delivery systems have been
tried and critiqued. Debates regarding the pros and cons of each method have focused
on identifying the perfect delivery system for providing nursing care to patients with
varying degrees of need.

Box 3-1 Job Description of a Floor Nurse in 1887
Developed in 1887 and published in a magazine of Cleveland
Lutheran Hospital.
In addition to caring for your 50 patients, each nurse will
follow these regulations:

1. Daily sweep and mop the floors of your ward, dust the
patients’ furniture and window sills.

2. Maintain an even temperature in your ward by bringing
in a scuttle of coal for the day’s business.

3. Light is important to observe the patient’s condition.
Therefore, each day fill kerosene lamps, clean chim-
neys, and trim wicks. Wash windows once a week.

4. The nurse’s notes are important to aiding the physi-
cian’s work. Make your pens carefully. You may whittle
nibs to your individual taste.

5. Each nurse on day duty will report every day at 7 a.m.
and leave at 8 p.m., except on the Sabbath, on which
you will be off from 12 noon to 2 p.m.

6. Graduate nurses in good standing with the Director of
Nurses will be given an evening off each week for
courting purposes, or two evenings a week if you go
regularly to church.

7. Each nurse should lay aside from each pay a goodly
sum of her earnings for her benefits during her declin-
ing years, so that she will not become a burden. For
example, if you earn $30 a month you should set aside
$15.

8. Any nurse who smokes, uses liquor in any form, gets
her hair done at a beauty shop, or frequents dance
halls will give the Director of Nurses good reason to
suspect her worth, intentions, and integrity.

9. The nurse who performs her labor, serves her patients
and doctors faithfully and without fault for a period of
five years will be given an increase by the hospital
administration of five cents a day providing there are
no hospital debts that are outstanding.

In addition, a delivery system must utilize specific nurses and groups of nurses,
optimizing their knowledge and skills and at the same time ensuring that patients
receive appropriate care. It is no small challenge. In fact, researchers have found
that a better hospital environment for nurses is associated with lower mortality
rates (Aiken, Clarke, Sloane, Lake, & Cheney, 2008) and nurse satisfaction (Spence-
Laschinger, 2008).

Traditional Models of Care
Various models of care have been designed both to meet the needs of patients and to
use nurses effectively. Unfortunately, no one model has been shown to fit every patient
population and every care facility. Total patient care, functional nursing, team nursing,
and primary nursing all offer advantages and disadvantages.

Delivering Nursing Care 35

Total Patient Care
The original model of nursing care delivery was total patient care, in which an RN was
responsible for all aspects of the care of one or more patients. During the 1920s, total
patient care was the typical nursing care delivery system. Student nurses often staffed
hospitals, whereas RNs provided total care to the patient at home. In total patient care,
an RN works directly with the patient, family, physician, and other healthcare staff in
implementing a plan of care. Continuity of care is assured, and communication with
the patient, family, physician, and staff from other departments is fostered.

The disadvantage of this system is that RNs spend some time doing tasks that
could be done more cost-effectively by less skilled persons. This inefficiency adds to
the expense of using a total patient care delivery system.

Functional Nursing
In functional nursing, the needs of a group of patients are separated into tasks that are
assigned to registered nurses (RNs), licensed practical nurses (LPNs), or unlicensed
assistive personnel (UAPs) so that the skill and licensure of each caregiver is used to
his or her best advantage. Under this model an RN assesses patients, whereas others
give baths, make beds, take vital signs, administer treatments, and so forth. As a
result, the staff become very efficient and effective at performing their regularly
assigned tasks.

Because of problems with continuity, difficulties with follow-up, and the lack of
an understanding of the total patient, functional nursing care is used infrequently in
acute care facilities and only occasionally in long-term care facilities.

Team Nursing
In team nursing, a team of nursing personnel provides total patient care to a group of
patients. The team is led by an RN, and other RNs, LPNs, and UAPs provide patient
care to all patients under the direction of the team leader. The team, acting as a unified
whole, has a holistic perspective of the needs of each patient.

A key aspect of team nursing is the nursing care conference, where the team leader
reviews each patient’s plan of care and progress with all team members. Skills in del-
egating, communicating, and problem solving are essential for a team leader to be
effective. Open communication between team leaders and the nurse manager is also
important to avoid duplication of effort, overriding of delegated assignments, or com-
petition for control or power.

Primary Nursing
Conceptualized by Marie Manthey and implemented during the late 1960s after two
decades of team nursing, primary nursing was designed to place the RN back at the
patient’s bedside (Manthey, 1980). Decentralized decision making by staff nurses is the
core principle of primary nursing, with responsibility and authority for nursing care
allocated to staff nurses at the bedside. Primary nursing recognized that nursing was a
knowledge-based professional practice, not just a task-focused activity.

In primary nursing, the RN maintains a patient load of primary patients. A pri-
mary nurse designs, implements, and is accountable for the nursing care of patients in
the patient load for the duration of the patient’s stay on the unit. Actual care is given
by the primary nurse and/or associate nurses (other RNs).

36 Chapter 3

When primary nursing was first implemented, many organizations perceived that
it required an all-RN staff. This practice was viewed as not only expensive but also
ineffective because many tasks could be done by less skilled persons. As a result, many
hospitals discontinued the use of primary nursing. Other hospitals successfully imple-
mented primary nursing by identifying one nurse who was assigned to coordinate
care and with whom the family and physician could communicate, and other nurses
or UAPs assisted this nurse in providing care. (See Leading at the Bedside: Do Care
Delivery Systems Matter?)

Leading at the Bedside: Do Care Delivery Systems Matter?
You may think it doesn’t matter what care delivery system is
in place where you work. You have a job description and
assigned duties. Your focus is on the patient.

What if you have questions? Do you know whom to
ask? How about when others don’t do their jobs? Or supplies

or equipment don’t show up? Or meds fail to appear when
needed? Answers to these and other questions can be
found in the structure of the delivery system at your work-
place. Don’t be caught without knowing it!

Integrated Models of Care
In an attempt to better integrate disparate care, new models of care were designed.
As with the earlier designs, these models—practice partnerships, case management,
and critical pathways—had both positive and negative aspects.

Practice Partnerships
The practice partnership (see Figure 3-1) was introduced by Marie Manthey in 1989
(Manthey, 1989). In the practice partnership model, an RN and an assistant—UAP,
LPN, or less experienced RN—agree to be practice partners. The partners work
together with the same schedule and the same group of patients. The senior RN part-
ner directs the work of the junior partner within the limits of each partner’s abilities
and within the limits of the state’s nurse practice act.

The relationship between the senior and junior partner is designed to create syner-
gistic energy as the two work in concert with patients. The senior partner performs selec-
ted patient care activities but delegates less specialized activities to the junior partner.

When compared to team nursing, practice partnerships offer more continuity of
care and accountability for patient care. When compared to total patient care or pri-
mary nursing, partnerships are less expensive for the organization and more satisfying
professionally for the partners.

Practice partnerships can be applied to primary nursing and used in other nursing
care delivery systems, such as team nursing, modular nursing, and total patient care.
As organizations restructured in the 1990s, practice partnerships offered an efficient
way of using the skills of a mix of professional and nonprofessional staff with differing
levels of expertise.

Case Management
Case management emerged after payment for care changed from cost-based reim-
bursement to a prospective payment model (Scott, 2014). Case management (see

RN

Patients

Partner

Figure 3-1 Practice
partnerships.

Delivering Nursing Care 37

Figure 3-2) is a model for identifying, coordinating, and monitoring the implemen-
tation of services needed to achieve desired patient care outcomes within a speci-
fied period of time. Nursing case management organizes patient care by major
diagnoses or diagnosis-related groups (categories used by Medicare for reimburse-
ment) and focuses on attaining predetermined patient outcomes within specific
time frames and resources.

To initiate case management, specific patient diagnoses that represent high-
volume, high-cost, and high-risk cases are selected. High-volume cases are those that
occur frequently, such as total hip replacements on an orthopedic floor. High-risk cases
include patients or case types who have complications, stay in a critical care unit lon-
ger than two days, or require ventilatory support, for example. Whatever patient pop-
ulation is selected, baseline data must be collected, including length of stay, cost of
care, and potential complications. These data are analyzed and provide the informa-
tion necessary to measure the effectiveness of case management.

Once a patient population is selected, a collaborative practice team is established,
which includes clinical experts from appropriate disciplines (e.g., nursing, medicine,
physical therapy). Each member of the team helps determine appropriate interven-
tions and decides on specific, measurable outcomes within a specified time frame. All
professionals are equal members of the team; thus, one group does not determine
interventions for other disciplines.

All members of the collaborative practice team agree on the final draft of the criti-
cal pathways, take ownership of patient outcomes, and accept responsibility and
accountability for the interventions and patient outcomes associated with their disci-
pline. The emphasis is on managing interdisciplinary outcomes and building consen-
sus with physicians. In an acute care setting, the case manager has a caseload of 10 to
15 patients and follows patients’ progress through the system from admission to dis-
charge, accounting for variances from expected progress.

Critical Pathways
The term critical pathways—also known as critical paths, care pathways, milestone
maps, and progression of care—refers to the expected outcomes and care strategies
developed by the collaborative practice team (Schrijvers, van Hoorn, & Huiskes, 2012).
Again, interdisciplinary consensus must be reached and specific, measurable out-
comes determined.

Critical paths provide direction for managing the care of an individual patient
during a stipulated time period. Critical paths are useful because they accommo-
date the unique characteristics of the patient and the patient’s condition. Critical

Case manager

Patient caseload

Caregivers CaregiversCaregivers

Figure 3-2 Case management.

38 Chapter 3

paths use resources appropriate to the care needed and thus reduce cost and length
of stay.

A critical path quickly orients the staff to the outcomes that should be achieved for
the patient for that day. Nursing diagnoses identify the outcomes needed. If patient
outcomes are not achieved, the case manager is notified and the situation analyzed to
determine how to modify the critical path.

Altering time frames or interventions is categorized as a variance, and the case
manager tracks all variances. After a time, the appropriate collaborative practice
teams analyze the variances, note trends, and decide how to manage them. The criti-
cal pathway may need to be revised, or additional data may be needed before changes
are made.

Some features are included on all critical paths, such as specific medical diagnosis,
the expected length of stay, patient identification data, appropriate time frames (in
days, hours, minutes, or visits) for interventions, and patient outcomes. Interventions
are presented in modality groups (medications, nursing activity, and so on). The criti-
cal path must include a means to determine whether the outcome has been met and to
easily identify variances.

Evolving Models of Care
Recognizing the need for improving patient care, the Robert Wood Johnson Founda-
tion and the Institute for Healthcare Improvement established a program titled Trans-
forming Care at the Bedside (Lavizzo-Mourey & Berwick, 2009). The goal was, and
continues to be, to help hospitals achieve affordable and lasting improvements to care.
One of its premises is the use of a patient-centered care model.

Patient-centered Care
Patient-centered care is a model of nursing care delivery in which the role of the
nurse is broadened to coordinate a team of multifunctional unit-based caregivers. In
patient-centered care, all patient care services are unit based, including admission
and discharge, diagnostic and treatment services, and support services such as
environmental and nutrition services and medical records. The focus of patient-
centered care is decentralization, the promotion of efficiency and quality, and cost
control.

Using this model of care, the number of caregivers at the bedside is reduced, but
their responsibilities are increased so that service time and waiting time are decreased.
A typical team in a unit providing patient-centered care consists of the following:

• Patient care coordinators (RNs)

• Patient care associates or technicians who are able to perform delegated patient
care tasks

• Unit support assistants who provide environmental services and can assist with
hygiene and ambulation needs

• Administrative support personnel who maintain patient records, transcribe
orders, coordinate admission and discharge, and assist with general office duties

Success using a patient-centered care model continues to be reported in the litera-
ture (Miles & Vallish, 2010; Schneider & Fake, 2010). Furthermore, lower mortality in

Delivering Nursing Care 39

patients with acute myocardial infarctions has been found (Meterko, Wright, Lin,
Lowy, & Cleary, 2010). Patients with chronic conditions are appropriate candidates for
patient-centered care approaches, including the use of complementary and alternative
medicine therapies (Maizes, Rakel, & Niemiec, 2009).

The nurse manager’s role in patient-centered care requires considerable time. No
longer is the manager doing rounds and assisting with patient care. Instead, being
responsible for a staff that is more diverse with fewer professional RN staff demands a
strong leader proficient to interview, hire, train, and motivate staff. Some organiza-
tions share assistive staff between units, also increasing the need for coordination and
cooperation with other managers.

Synergy Model of Care
Developed by the American Association of Critical Nurses (AACN), the synergy
model of care conceptualizes nursing practice based on the needs and characteristics
of patients (American Association of Critical Care Nurses, 2011). These characteristics
drive nurse competencies. Patient characteristics include the following:

• Resiliency

• Vulnerability

• Stability

• Complexity

• Resource availability

• Participation in care

• Participation in decision making

• Predictability

These characteristics are then matched with nurse competencies, including the
following:

• Clinical judgment

• Advocacy and moral agency

• Caring practices

• Collaboration

• Systems thinking

• Response to diversity

• Facilitation of learning

• Clinical inquiry (AACN, 2011)

When patients’ characteristics and nurses’ competencies match, synergy is the
outcome. The model is useful to nurses by delineating job descriptions, evaluation
formats, and advancement criteria. Furthermore, a synergy model helps meet the stan-
dards for Magnet certification (Kaplow & Reed, 2008).

Patient-centered Medical Home
The newest addition to a care delivery system is the patient-centered medical home
(PCMH), a model for delivering primary care to ensure that adequate and appro-
priate care is provided to a population of patients. The concept of a medical home,

40 Chapter 3

or health home, however, is not new. The American Academy of Pediatrics first
proposed the medical home concept in the late 1960s, and by the mid 2000s, the
concept had been adopted by the American Academy of Family Physicians and the
American College of Physicians.

The goal of a PCMH is as follows:

• Coordinates care across settings and providers

• Supervises transitions between providers and hospitals

• Monitors care given by a variety of providers

• Develops personal relationships with individual patients

• Adapts care to unique patient needs

• Follows up each encounter of care and revises or refers as necessary (Henderson,
Princell, & Martin, 2012)

Unlike previous reimbursement policies, the Affordable Care Act of 2010 supports
integrating and coordinating primary care services (Henderson et al., 2012). This
change prompted reorganization of healthcare systems. Accountable care organiza-
tions (ACO) emerged to encompass a wide range of providers and care services,
including, for example, hospitals, physician practices, and ambulatory clinics (Hart,
2012). PCMH may be one component of an ACO, such as a primary care practice, or it
may be an organizational entity itself—that is, the primary care practice is its own
“medical home.”

Coordinating care for today’s population of chronically ill patients is essential to
ensure patients’ safety across a multitude of providers and settings, care that often is
duplicated or left undone (Henderson et al., 2012). The PCMH model includes the
following:

• Provides comprehensive care

• Is patient centered

• Delivers coordinated care

• Ensures accessible services

• Includes quality and safety measures (Agency for Healthcare Research & Qual-
ity, 2015)

Advanced practice nurses are especially suited to lead a PCMH team. In fact, the
definition of primary care in the Affordable Care Act specifically refers to primary care
providers, who, depending on the state’s scope of practice, may be nurse practitioners.
In addition, the Centers for Medicare & Medicaid Services (2014) included nurse prac-
titioners and clinical nurse specialists as primary care providers, thus making them
eligible for direct reimbursement (Amara et al., 2013; Centers for Medicare & Medicaid
Services, 2014). What effect this will have on the healthcare system, in general, and
primary care practice, in particular, remains to be seen.

No delivery system is perfect—or permanent. As healthcare adapts to changes in
reimbursement, demands for quality, and technological advances, models for deliver-
ing care will continue to evolve.

What You Know Now
• Nursing care delivery systems provide a struc­

ture for nursing care.

• Traditional care models include functional nurs­
ing, team nursing, total patient care, and primary
nursing.

• Integrated models of care include practice part­
nerships, case management, and critical pathways.

• Evolving models of care include patient­centered
care, a synergy model of care, and the patient­
centered medical home.

• In patient­centered care, the nurse coordinates a
team of multifunctional unit­based caregivers.

• The synergy model matches patients’ characteris­
tics with nurses’ competencies.

• The patient­centered medical home is a model of
delivering primary care to ensure that adequate
and appropriate care is provided to a population
of patients.

• As healthcare adapts to changes in reimburse­
ment, demands for quality, and technological
advances, models for delivering care will con­
tinue to evolve.

Questions to Challenge You
1. Describe the patient care delivery system(s) at

your place of work or clinical placement site. How
well does it work? Can you suggest a better system?

2. Pretend that you are designing a new nursing care
delivery system. Select the system or combination
of systems you would use. Explain your rationale.

3. Why have different systems been used in earlier
times? Would any of them be useful today? Explain

what characteristics of the healthcare system today
would make them appropriate or inappropriate
to use.

4. As a manager, which system would you prefer?
Why?

5. If you were a patient, which system do you think
would provide you with the best care?

References
Agency for Healthcare Research & Quality. (2015).

Defining the PCMH. Retrieved April 28, 2015, from
http://pcmh.ahrq.gov/page/defining­pcmh

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Delivering Nursing Care 41

http://pcmh.ahrq.gov/page/defining-pcmh

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http://www.beckershospitalreview.com/hospital-management-administration/progression-of-care-case-management-solvesquality-los-measures.html

Chapter 4

Leading, Managing,
Following

Learning Outcomes

After completing this chapter, you will be able to:

1. Differentiate between leaders and managers.

2. Evaluate different theories that explain leadership.

3. Explore how followership is essential to leadership.

4. Explain why nurses need to learn management skills.

5. Describe the management roles that nurses fill in practice.

Key Terms
charge nurse

clinical nurse leader (CNL)

controlling

directing

emotional intelligence

first-level manager

followership

formal leadership

Leaders and Managers
Leadership

Leadership Theories
Traditional Leadership Theories

Contemporary Leadership Theories

Followership: An Essential Component
of Leadership

Traditional Management Functions
Planning

Organizing

Directing

Controlling

Nurse Managers in Practice
Nurse Manager Competencies

Staff Nurse

First-level Management

Charge Nurse

Clinical Nurse Leader

43

44 Chapter 4

informal leadership

leader

manager

organizing

planning

quantum leadership

servant leadership

shared leadership

transactional leadership

transformational leadership

staff nurse

Introduction
Managers are essential to any organization. A manager’s functions are vital, complex,
and frequently difficult. They must be directed toward balancing the needs of patients,
the healthcare organization, employees, physicians, and self. Nurse managers need a
body of knowledge and skills distinctly different from those needed for nursing prac-
tice, yet few nurses have the education or training necessary to be managers. Fre-
quently, managers depend on experiences with former supervisors, who also learned
supervisory techniques on the job. Often a gap exists between what managers know
and what they need to know.

Today, all nurses are managers, not in the formal organizational sense but in prac-
tice. They direct the work of nonprofessionals and professionals in order to achieve
desired outcomes in patient care. Acquiring the skills to be both a leader and a man-
ager will help the nurse become more effective and successful in any position.

Leaders and Managers
The terms manager, leader, supervisor, and administrator are often used interchangeably,
yet they are not the same. A leader is anyone who uses interpersonal skills to influence
others to accomplish a specific goal. The leader exerts influence by using a flexible
repertoire of personal behaviors and strategies. The leader is important in creating
connections and forging links among an organization’s members to promote high lev-
els of performance and quality outcomes.

The functions of a leader are to achieve a consensus within the group about its
goals, maintain a structure that facilitates accomplishing the goals, supply necessary
information that helps provide direction and clarification, and maintain group satis-
faction, cohesion, and performance.

A manager, in contrast, is an individual employed by an organization who is
responsible and accountable for efficiently accomplishing the goals of the organiza-
tion. Managers focus on coordinating and integrating resources, using the functions of
planning, organizing, supervising, staffing, evaluating, negotiating, and representing.
Interpersonal skill is important, but a manager also has authority, responsibility,
accountability, and power defined by the organization. The manager’s job includes the
following:

• Clarify the organizational structure.

• Choose the means by which to achieve goals.

• Assign and coordinate tasks, developing and motivating as needed.

• Evaluate outcomes and provide feedback.

Leading, Managing, Following 45

All good managers are also good leaders—the two go hand in hand. However,
one may be a good manager of resources and not be much of a leader of people. Like-
wise, a person who is a good leader may not manage well. Both roles can be learned;
skills gained can enhance either role.

Leadership
Leadership may be formal or informal. For example, formal leadership is practiced by
a nurse with legitimate authority conferred by the organization and described in a job
description (e.g., nurse manager, supervisor, coordinator, case manager). Formal lead-
ership also depends on personal skills, but it may be reinforced by organizational
authority and position. Insightful formal leaders recognize the importance of their
own informal leadership activities and the informal leadership of others who affect the
work in their areas of responsibility.

Informal leadership is exercised, for example, by a staff member who does not
have a specified management role. A nurse whose thoughtful and convincing ideas
substantially influence the efficiency of work flow is exercising leadership skills. Infor-
mal leadership depends primarily on one’s knowledge, status (e.g., advanced practice
nurse, quality improvement coordinator, education specialist, medical director), and
personal skills in persuading and guiding others.

Leadership Theories
Research on leadership has a long history, but the focus has shifted over time from
personal traits to behavior and style, to the leadership situation, to change agency (the
capacity to transform), and to other aspects of leadership. Each phase and focus of
research has contributed to managers’ insights and understandings about leadership
and its development.

The most effective leadership style for a nurse manager is the one that best com-
plements the organizational environment, the tasks to be accomplished, and the per-
sonal characteristics of the people involved in each situation.

Traditional Leadership Theories
Traditional leadership theories include trait theories, behavioral theories, and con-
tingency theories. In the earliest studies, researchers sought to identify inborn
traits of successful leaders. Although inconclusive, these early attempts to specify
unique leadership traits provided benchmarks by which most leaders continue to
be judged.

Research on leadership in the early 1930s focused on what leaders do. In the
behavioral view of leadership, personal traits provide only a foundation for leader-
ship; real leaders are made through education, training, and life experiences.

Contingency approaches suggest that managers adapt their leadership styles in
relation to changing situations. According to contingency theory, leadership behav-
iors range from authoritarian to permissive and vary in relation to current needs
and future probabilities. A nurse manager may use an authoritarian style when
responding to an emergency situation such as a cardiac arrest but use a participa-
tive style to encourage development of a team strategy to care for patients with
multiple system failure.

46 Chapter 4

Contemporary Leadership Theories
Leaders in today’s healthcare environment place increasing value on collaboration
and teamwork in all aspects of the organization. They recognize that as health systems
become more complex and require integration, personnel who perform the managerial
and clinical work must cooperate, coordinate their efforts, and produce joint results.
Leaders must use additional skills, especially group and political leadership skills, to
create collegial work environments.

QuaNtum LeadershIp Quantum leadership is based on the concepts of chaos
theory. Chaos theory posits that reality is constantly shifting, and levels of complexity
are constantly changing. Movement in one part of the system reverberates throughout
the system. Roles are fluid and outcome oriented. It matters little what you did; it only
matters what outcome you produced. Within this framework, employees become
directly involved in decision making as equitable and accountable partners, and man-
agers assume more of an influential facilitative role, rather than one of control (Porter-
O’Grady & Malloch, 2015).

Quantum leadership demands a different way of thinking about work and leader-
ship. Change is expected. Informational power, previously the purview of the leader,
is now available to all. Patients and staff alike can access untold amounts of informa-
tion. The challenge, however, is to assist patients uneducated about healthcare in
learning how to evaluate and use the information they have. Because staff members
have access to information that only the leader had in the past, leadership becomes a
shared activity, requiring the leader to possess excellent interpersonal skills.

traNsaCtIoNaL LeadershIp transactional leadership is based on the princi-
ples of social exchange theory (Yukl, 2013). The primary premise of social exchange
theory is that individuals engage in social interactions expecting to give and receive
social, political, and psychological benefits or rewards. The exchange process between
leaders and followers is viewed as essentially economic. Once initiated, a sequence of
exchange behavior continues until one or both parties finds that the exchange of per-
formance and rewards is no longer valuable.

The nature of these transactions is determined by the participating parties’ assess-
ments of what is in their best interests—for example, a staff member responds affirma-
tively to a nurse manager’s request to work overtime in exchange for granting special
requests for time off. Leaders are successful to the extent that they understand and
meet the needs of followers and use incentives to enhance employee loyalty and per-
formance. Transactional leadership is aimed at maintaining equilibrium, or the status
quo, by performing work according to policy and procedures, maximizing self-
interests and personal rewards, emphasizing interpersonal dependence, and routiniz-
ing performance (Matson, 2014).

traNsformatIoNaL LeadershIp transformational leadership goes beyond
transactional leadership to inspire and motivate followers (Marshall, 2010). Transfor-
mational leadership emphasizes the importance of interpersonal relationships. Trans-
formational leadership is not concerned with the status quo but, rather, with effecting
revolutionary change in organizations and human service. Whereas traditional views
of leadership emphasize the differences between employees and managers, transfor-
mational leadership focuses on merging the motives, desires, values, and goals of
leaders and followers into a common cause. The goal of the transformational leader is
to generate employees’ commitment to the vision or ideal rather than to themselves.

Leading, Managing, Following 47

Transformational leaders appeal to individuals’ better selves rather than these
individuals’ self-interests. They foster followers’ inborn desires to pursue higher val-
ues, humanitarian ideals, moral missions, and causes. Transformational leaders also
encourage others to exercise leadership. The transformational leader inspires follow-
ers and uses power to instill a belief that followers also have the ability to do excep-
tional things.

Transformational leadership may be a natural model for nursing managers
because nursing has traditionally been driven by its social mandate and its ethic of
human service. In fact, Weberg (2010) found that transformational leadership reduced
burnout among employees, and Grant, Colello, Riehle, and Dende (2010) reported
that transformational leadership positively affected the practice environment in one
medical center. Transformational leadership can be used effectively by nurses with
patients or coworkers at the bedside, in the home, in the community health center, and
in the healthcare organization.

shared LeadershIp Reorganization, decentralization, and the increasing com-
plexity of problem solving in healthcare have forced administrators to recognize the
value of shared leadership, which is based on the empowerment principles of partici-
pative and transformational leadership (Everett & Sitterding, 2011). Essential elements
of shared leadership are relationships, dialogues, partnerships, and an understanding
of boundaries. The application of shared leadership assumes that a well-educated,
highly professional, dedicated workforce is comprised of many leaders. It also assumes
that the notion of a single nurse as the wise and heroic leader is unrealistic and that
many individuals at various levels in the organization must be responsible for the
organization’s fate and performance.

Different issues call for different leaders, or experts, to guide the problem-solving
process. A single leader is not expected always to have knowledge and ability beyond
that of other members of the work group. Appropriate leadership emerges in relation
to the current challenges of the work unit or the organization. Individuals in formal
leadership positions and their colleagues are expected to participate in a pattern of
reciprocal influence processes. Kramer, Schmalenberg, and Maguire (2010) and Wat-
ters (2009) found shared leadership common in Magnet-certified hospitals.

Examples of shared leadership in nursing include the following:

• Self-directed work teams. Work groups manage their own planning, organizing,
scheduling, and day-to-day work activities.

• Shared governance. The nursing staff are formally organized at the service area
and organizational levels to make key decisions about clinical practice standards,
quality assurance and improvement, staff development, professional develop-
ment, aspects of unit operations, and research.

• Co-leadership. Two people work together to execute a leadership role. This kind
of leadership has become more common in service-line management, where the
skills of both a clinical and an administrative leader are needed to successfully
direct the operations of a multidisciplinary service. Co-leadership also occurs in a
matrix organizational structure. For example, a nurse manager provides adminis-
trative leadership in collaboration with a clinical nurse specialist, who provides
clinical leadership. The development of co-leadership roles depends on the flexi-
bility and maturity of both individuals, and such arrangements usually require a
third party to provide ongoing consultation and guidance to the pair.

48 Chapter 4

servaNt LeadershIp Founded by Robert Greenleaf (Greenleaf, 1991), servant
leadership is based on the premise that leadership originates from a desire to serve
and that, in the course of serving, one may be called to lead (The Greenleaf Center for
Servant Leadership, 2015). Servant leaders embody three characteristics:

• Empathy

• Awareness

• Persuasion

Servant leadership appeals to nurses for two reasons. First, our profession is
founded on principles of caring, service, and the growth and health of others (Ander-
son, Manno, O’Connor, & Gallagher, 2010). Second, nurses serve many constituencies,
often quite selflessly, and consequently bring about change in individuals, systems,
and organizations.

emotIoNaL LeadershIp emotional intelligence (Goleman, Boyatzis, & McKee,
2013) has gained acceptance in the business world and in healthcare (Veronsesi, 2009).
Emotional intelligence involves personal competence, which includes self-awareness
and self-management, and social competence, which includes social awareness and
relationship management that begins with authenticity. (See Table 4-1.)

Goleman et al. (2013) assert that attachment to others is an innate trait of human
beings. Thus, emotions are “catching.” Consider a person having a pleasant day. Then
an otherwise innocuous event turns into a negative experience that spills over into

Table 4-1 Emotional Intelligence Domains and Associated Competencies

PERSONAL COMPETENCE: These capabilities determine how we manage ourselves.

Self-Awareness • Emotional self-awareness: Reading one’s own emotions and recognizing
their impact; using “gut sense” to guide decisions

• Accurate self-assessment: Knowing one’s strengths and limits
• Self-confidence: A sound sense of one’s self-worth and capabilities

Self-Management • Emotional self-control: Keeping disruptive emotions and impulses under
control

• Transparency: Displaying honesty and integrity; trustworthiness
• Adaptability: Flexibility in adapting to changing situations or overcoming

obstacles
• Achievement: The drive to improve performance to meet inner standards

of excellence
• Initiative: Readiness to act and seize opportunities
• Optimism: Seeing the upside in events

SOCIAL COMPETENCE: These capabilities determine how we manage relationships.

Social Awareness • Empathy: Sensing others’ emotions, understanding their perspective, and
taking active interest in their concerns

• Organizational awareness: Reading the currents, decision networks, and
politics at the organizational level

• Service: Recognizing and meeting follower, patient, or customer needs

Relationship Management • Inspirational leadership: Guiding and motivating with a compelling vision
• Influence: Wielding a range of tactics for persuasion
• Developing others: Bolstering others’ abilities through feedback and

guidance
• Change catalyst: Initiating, managing, and leading in a new direction
• Conflict management: Resolving disagreements
• Building bonds: Cultivating and maintaining a web of relationships
• Teamwork and collaboration: Cooperation and team building

Source: Goleman, Boyatzis, & McKee. (2013).

Leading, Managing, Following 49

future interactions. Or the reverse: A positive experience lightens the mood and affects
the next encounter. When people feel good, they work more effectively.

Emotional intelligence has been linked with leadership (Antonakis, Ashkanasy, &
Dasborough, 2009; Cote, Lopes, Salovey, & Miners, 2010). One study, however, found
no relationship between emotional intelligence and transformational leadership
(Lindebaum & Cartwright, 2010).

Nurses, with their well-honed skills as compassionate caregivers, are aptly suited
to this direction in leadership that emphasizes emotions and relationships with others
as a primary attribute for success. These skills fit better with the more contemporary
relationship-oriented theories as well. Thus, the workplace is a more complex and
intricate environment than previously suggested.

Healthcare environments require innovations in care delivery and therefore inno-
vative leadership approaches. Quantum, transactional, transformational, shared, ser-
vant, and emotional leadership make up a new generation of leadership styles that
have emerged in response to the need to humanize working environments and
improve organizational performance. In practice, leaders tap a variety of styles culled
from diverse leadership theories.

Followership: An Essential Component
of Leadership
Leaders cannot lead without followers in much the same way that instructors need
students in order to teach. Nor is anyone a leader all the time; everyone is a follower as
well. Even the hospital CEO follows instructions from the board of directors.

followership is interactive and complementary to leadership, and the follower is
an active participant in the relationship with the leader (Crawford & Daniels, 2014). A
skilled, self-directed, energetic staff member is an invaluable complement to the leader
and to the group. Most leaders welcome active followers; they help leaders accomplish
their goals and the team succeed.

Followers are powerful contributors to the relationship with their leaders. Follow-
ers can influence leaders in negative ways, as in government cover-ups, Medicare
fraud, and corporate law-breaking attest. The reverse is also true. Poor managers can
undermine good followers in direct and indirect ways, such as criticizing, belittling, or
ignoring positive contributions to the team (Arnold & Pulich, 2008). In fact, Crawford
and Daniels (2014) found that poor interactions between leaders and followers led to
an increase in nurse burnout, resulting in a decrease in the quality of care and, in some
cases, causing nurses to leave the profession.

Followership is fluid as well. The nurse may be a leader at one moment and
become a follower soon afterward. In fact, the ability to move along the contin-
uum of degrees of followership is a must for successful teamwork. The nurse is
a leader with subordinate staff and a follower of the nurse manager, possibly at
the same time.

An effective follower must maintain credibility and trust with the leader. Further-
more, the follower can improve the relationship with the leader, point out flaws in
proposed plans, and help leaders be more successful (Yukl, 2013). Box 4-1 offers guide-
lines for effective followership.

50 Chapter 4

Source: Yukl, G. (2013). Leadership in organizations. Upper Saddle River, NJ: Pearson, p. 239.

Box 4-1 Guidelines for Followers
• Find out what you are expected to do.
• Take the initiative to deal with problems.
• Keep the boss informed about your decisions.
• Verify the accuracy of information you give the

boss.
• Encourage the boss to provide honest feedback to

you.
• Support efforts to make necessary changes.

• Show appreciation and provide recognition when
appropriate.

• Challenge flawed plans and proposals made by
bosses.

• Resist inappropriate influence attempts by the boss.
• Provide upward coaching and counseling when

appropriate.
• Learn to use self-management strategies.

Traditional Management Functions
In 1916, French industrialist Henri Fayol first described the functions of management
as planning, organizing, directing, and controlling.

Planning
planning is a four-stage process to achieve the following:

• Establish objectives (goals).

• Evaluate the present situation and predict future trends and events.

• Formulate a planning statement (means).

• Convert the plan into an action statement.

Planning is important on both an organizational and a personal level and may
be an individual or group process that addresses the questions of what, why, where,
when, how, and by whom. Decision making and problem solving are inherent in
planning, and computer software programs and databases are available to help
facilitate it.

Organization-level plans, such as determining organizational structure and staff-
ing or operational budgets, evolve from the mission, philosophy, and goals of the
organization. The nurse manager plans and develops specific goals and objectives for
her or his area of responsibility.

Antonio, the nurse manager of a home care agency, plans to establish an in-home pho-
totherapy program, knowing that part of the agency’s mission is to meet the healthcare
needs of the child-rearing family. To effectively implement this program, he would need
to address the following:

• How the program supports the organization’s mission
• Why the service would benefit the community and the organization
• Who would be candidates for the program
• Who would provide the service
• How staffing would be accomplished
• How charges would be generated
• What those charges should be

Leading, Managing, Following 51

Planning can be contingent or strategic. Using contingency planning, the manager
identifies and manages the many problems that interfere with getting work done.
Contingency planning may be reactive in response to a crisis or proactive in anticipa-
tion of problems or in response to opportunities.

What would you do if two registered nurses called in sick for the 12-hour night
shift? What if you were a manager for a specialty unit and received a call for an admis-
sion but had no more beds? What if you were a pediatric oncology clinic manager and
a patient’s sibling exposed a number of immunocompromised patients to chickenpox?
Planning for crises such as these are examples of contingency planning.

Strategic planning refers to the process of continual assessment, planning, and
evaluation to guide the future (Fairholm & Card, 2009). Its purpose is to create an
image of the desired future and design ways to make those plans a reality. A nurse
manager might be charged, for example, with developing a business plan to add a
time-saving device to commonly used equipment, presenting the plan persuasively,
and developing operational plans for implementation, such as acquiring devices and
training staff.

Organizing
organizing is the process of coordinating the work to be done. Formally, it involves
identifying the work of the organization, dividing the labor, developing the chain of
command, and assigning authority. It is an ongoing process that systematically reviews
the use of human and material resources. In healthcare, the mission, formal organiza-
tional structure, delivery systems, job descriptions, skill mix, and staffing patterns
form the basis for the organization.

In organizing the home phototherapy project, Antonio develops job descriptions and
protocols, determines how many positions are required, selects a vendor, and orders
supplies.

Directing
directing is the process of getting the organization’s work done. Power, authority, and
leadership style are intimately related to a manager’s ability to direct. Communication
abilities, motivational techniques, and delegation skills also are important. In today’s
healthcare organization, professional staff are autonomous, requiring guidance rather
than direction. The manager is more likely to sell the idea, proposal, or new project to
staff rather than tell them what to do. The manager coaches and counsels to achieve
the organization’s objectives. In fact, it may be the nurse who assumes the traditional
directing role when working with unlicensed personnel.

In directing the home phototherapy project, Antonio assembles the team of nurses
to provide the service, explains the purpose and constraints of the program, and
allows the team to decide how to staff the project, giving guidance and direction when
needed.

Controlling
Controlling involves comparing actual results with projected results. This includes
establishing standards of performance, determining the means to be used in measur-
ing performance, evaluating performance, and providing feedback. The efficient

52 Chapter 4

manager constantly attempts to improve productivity by incorporating techniques of
quality management, evaluating outcomes and performance, and instituting change
as necessary.

When Antonio introduces the home phototherapy program, the team of nurses involved
in the program identifies standards regarding phototherapy and individual performances.
A subgroup of the team routinely reviews monitors designed for the program and identi-
fies ways to improve the program.

Planning, organizing, directing, and controlling reflect a systematic, proactive
approach to management. This approach is used widely in all types of organizations,
healthcare included, but today’s rapidly changing healthcare environment makes it
more difficult to control events and predict outcomes.

Nurse Managers in Practice
Putting nursing management into practice in the dynamic healthcare system of today
is a challenge. Organizations are in flux, structures are changing, and roles and func-
tions of nurse managers become moving targets.

Managers are essential to any organization. A manager’s functions are vital, com-
plex, and frequently difficult. They must be directed toward balancing the needs of
patients, the healthcare organization, employees, physicians, and self. Nurse manag-
ers need a body of knowledge and skills distinctly different from those needed for
nursing practice, yet few nurses have the education or training necessary to be manag-
ers. Frequently, managers depend on experiences with former supervisors, who also
learned supervisory techniques on the job. Often, a gap exists between what managers
know and what they need to know.

Titles for nurse managers vary as widely as do their responsibilities. The first-level
manager may be titled first-line manager or unit manager. A middle manager might be
deemed a department manager. The top-level nursing administrator could be named
executive manager, chief nursing officer, or vice president of patient care. In addition,
clinical titles might include professional practice leaders who are clinical nurse spe-
cialists or nurse practitioners. Regardless of their titles, all nurse managers must hold
certain competencies.

Nurse Manager Competencies
The American Organization of Nurse Executives (AONE), an organization for the top
nursing administrators in healthcare, identified five areas of competency necessary
for nurses at all levels of management (American Organization of Nurse Executives,
2011). Nurse managers must be skilled communicators and relationship builders, have
a knowledge of the healthcare environment, exhibit leadership skills, display profes-
sionalism, and demonstrate business skills (see Box 4-2). These characteristics intersect
to provide a common core of leadership competencies (see Figure 4-1).

Staff Nurse
Although not formally a manager, the staff nurse supervises LPNs, other profes-
sionals, and assistive personnel and thus is also a manager who needs management

Leading, Managing, Following 53

Professionalism
Communication
and relationship

management

Business skills
and principles

Knowledge of
health care
environment

Leadership

Figure 4-1 Core of leadership competencies.

Source: Copyright © 2005 by the American Organization of Nurse Executives. Address reprint permission requests
to aone@aha.org.

Box 4-2 AONE Five Areas of Competency
AONE believes that managers at all levels must be compe-
tent in the following:

Communication and Relationships-Building Competen-
cies Include:

• Effective communication
• Relationship management
• Influence of behaviors
• Ability to work with diversity
• Shared decision making
• Community involvement
• Medical staff relationships
• Academic relationships

Knowledge of the Health Care Environment Includes:
• Clinical practice knowledge
• Patient care delivery models and work design

knowledge
• Health care economics knowledge
• Health care policy knowledge
• Understanding of governance
• Understanding of evidence-based practice
• Outcome measurement
• Knowledge of and dedication to patient safety
• Understanding of utilization/case management

• Knowledge of quality improvement and metrics
• Knowledge of risk management

Leadership Skills Include:
• Foundational thinking skills
• Personal journey disciplines
• The ability to use systems thinking
• Succession planning
• Change management

Professionalism Includes:
• Personal and professional accountability
• Career planning
• Ethics
• Evidence-based clinical and management practice
• Advocacy for the clinical enterprise and for nursing

practice
• Active membership in professional organizations

Business Skills Include:
• Understanding of health care financing
• Human resource management and development
• Strategic management
• Marketing
• Information management and technology

Source: Copyright © 2011 by the American Organization of Nurse Executives, http://www.aone.org/resources/nec . Address reprint permission requests to aone@aha.org.

http://www.aone.org/resources/nec

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54 Chapter 4

and leadership skills. Communication, delegation, and motivation skills are
indispensable.

In some organizations, shared governance, which gives staff nurses more control
over their practice, has been implemented, and traditional management responsibili-
ties are allocated to the work team. In this case, staff nurses have considerable involve-
ment in managing the unit.

Many staff nurses, however, find delegating and supervising other staff challeng-
ing, often insisting the unit needs more nurses and/or support staff. By reviewing
exactly what tasks the staff nurse is doing, the manager may find the nurse doing
baths, vital signs, and toileting despite having aides who could help. The manager
must teach the nurse how to delegate so all roles are adequately utilized. (See Leading
at the Bedside: Practicing Leadership.)

Leading at the Bedside: Practicing Leadership
This chapter offers the direct caregiver the most advice for
leading and managing in any job designation. Specifically,
the staff nurse role explanation, along with descriptions of
various managers’ duties, can help you understand how
your work fits into the larger organization. In addition,
descriptions of leadership theories (theory is not a dirty
word!) help to explain why and how other people do what

they do. Or why they don’t do what you expect. In fact, you
can find explanations of your own choices and behavior in
these theories.

Leadership is a learned skill. Like any other skill, it
takes practice. Fortunately, working at the bedside gives
you many opportunities to practice.

First-level Management
The first-level manager is responsible for supervising the work of nonmanagerial per-
sonnel and the day-to-day activities of a specific work unit or units. With primary
responsibility for motivating the staff to achieve the organization’s goals, the first-level
manager represents staff to upper administration, and vice versa. Nurse managers
have 24-hour accountability for the management of a unit(s) or area(s) within a health-
care organization. In the hospital setting, the first-level manager is usually the head
nurse, nurse manager, or an assistant manager. In other settings, such as an ambula-
tory care clinic or a home healthcare agency, a first-level manager may be referred to as
a coordinator.

As healthcare becomes more complex, the responsibilities and tasks that fall to
this role continue to grow. Hours are longer, the role is stressful at times, and time
management skills, as well as training charge nurses and others to be extensions of the
manager, are more important than ever before. Box 4-3 describes one first-level man-
ager’s day.

Charge Nurse
Another role that does not fit the traditional levels of management is the charge nurse.
The charge nurse position is an expanded staff nurse role with increased responsibility.
The charge nurse functions as a liaison to the nurse manager, assisting in shift-by-shift
coordination and promotion of quality patient care as well as efficient use of resources.

Leading, Managing, Following 55

The charge nurse often troubleshoots problems and assists other staff members in
decision making. Role modeling, mentoring, and educating are additional roles that
the charge nurse often assumes. Therefore, the charge nurse usually has extensive
experience, skills, and knowledge in clinical practice and is familiar with the organiza-
tion’s standards and practices.

The charge nurse’s job differs, though, from that of the first-level manager. The
charge nurse’s responsibilities are confined to a specific shift or task, whereas the
first-level manager has 24-hour responsibility and accountability for all unit activi-
ties. Also the charge nurse has limited authority; the charge nurse functions as an

Box 4-3 A Day in the Life of a First-level Manager
As the manager for a surgical intensive care unit (SICU),
Jamal Johnson is routinely responsible for supervising
patient care, troubleshooting, maintaining compliance with
standards, and giving guidance and direction as needed.
In addition, he has fiscal and committee responsibilities
and is accountable to the organization for maintaining its
philosophies and objectives. The following exemplifies a
typical day.

As Jamal came on duty, he learned that there had
been a multiple vehicle accident and that three of the vic-
tims were currently in the operating room and destined
for the unit. The assistant manager for nights had secured
more staff for days: two part-time SICU nurses and a
staff nurse from the surgical floor. However, she had not
had time to arrange for two more patients to be moved
out of the unit. From their assigned nurses, Jamal
obtained an update on the patients who were candidates
for transfer from the SICU to another floor and, in consul-
tation with his assistant, made the appropriate arrange-
ments for the transfers.

Other staffing problems were at hand: In addition to
the nurse who had been pulled from the surgical floor, there
were two orientees, and the staff needed to attend a safety
in-service. As soon as the charge nurse came in, Jamal
apprised her of the situation. Together, they reviewed the
operating room schedule and identified staffing arrange-
ments. Fortunately, Jamal had only one meeting that day
and would be available for backup staffing. In the mean-
time, he would work on evaluations.

After his discussions with the charge nurse, Jamal
met with each of the night nurses to get an update on the
status of the other patients. Then he went to his office to
review his messages and plan his day. Tamera, an RN, had
just learned she was pregnant, but stated that she planned
to work until delivery. Jamal learned that his budget hear-
ing had been scheduled for the following Monday at
10:00 a.m. A pharmaceutical representative wanted to

provide an in-service for the unit. Fortunately, there were
no immediate crises.

Jamal called his supervisor to inform her of the status
of affairs on the unit and learned that two other individuals
in the accident had been transported to another hospital;
one had since died. They discussed the ethical and legal
ramifications. Jamal would need to review the policies on
relations with the press and law enforcement and update
his staff.

As the first patient returned from surgery, Jamal went
to help admit the patient and receive a report. Learning
that the patient was stable, he informed Lucinda, the
charge nurse, that the patient they had just received was
likely to be charged with manslaughter and reviewed
media and legal policies with her. They also discussed
how the staff were doing. There were some equipment
problems in room 2110; Lucinda had temporarily placed
the patient in that room on a transport monitor and was
waiting for a biomedical technology staff member to
check the monitor. Could Jamal follow up? Jamal agreed
and commended Lucinda for her problem solving. She
reminded Jamal that they would need backup for lunch
and in-services.

As Jamal returned to his office, he noted that the
alarms were turned off on one of the patients. He pulled
aside the nurse assigned to the patient and reminded her of
the necessity to keep the alarms on at all times. Finally,
back in his office, he called biomedical technology to ascer-
tain the plans to check the monitor and made notes regard-
ing the charge nurse’s problem-solving abilities and the
staff nurse’s negligence.

He reviewed staffing for the next 24 hours and noted
that an extra nurse was needed for both the evening and
night shifts because of the increased workload. After find-
ing staff, he was able to finish one evaluation before cover-
ing for the in-services and lunch and then attending the
policy and procedure team meeting.

56 Chapter 4

agent of the manager and is accountable to the manager for any actions taken or
decisions made.

Although often involved in planning and organizing the work to be done, the
charge nurse has a limited scope of responsibility, usually restricted to the unit for a
specific time period. In the past, the charge nurse had limited involvement in the for-
mal evaluation of performance, but in today’s climate of efficiency, the charge nurse
may be involved in evaluations as well. With the trend toward participative manage-
ment, charge nurses are assuming more of the roles and functions traditionally
reserved for the first-level manager.

The charge nurse has considerable power to build or break the culture of the
unit. Thus, many organizations have shifted away from the charge nurse being a
rotated responsibility or many random staff members taking their turn being in
charge. Today, a set group of nurses who demonstrate leadership, are good role
models, and have shown they can build a positive work environment may be
selected. They are trained to the charge nurse role and compensated appropriately
(Normand, Black, Baldwin, & Crenshaw, 2014). In addition, charge nurses can be
groomed for future leadership roles in the organization (Patrician, Oliver, Miltner,
Dawson, & Ladner, 2012).

Clinical Nurse Leader
The clinical nurse leader (CNL) is not a manager, per se, but instead is a lateral inte-
grator of care responsible for a specified group of patients within a unit of the health-
care setting (Schilling-Broderick, 2013). Questions about the differences between a
clinical nurse specialist (CNS) and the CNL are often raised. While the CNS is assigned
hospital-wide, the CNL is unit based.

The CNL role is designed to respond more effectively to challenges in today’s rap-
idly changing, complex technological environment that can result in dangerously frag-
mented care (Harris & Roussel, 2009; Schilling-Broderick, 2013). Prepared at the
master’s level, the CNL coordinates care at the bedside and supervises the healthcare
team, among other duties (Sherman, 2010).

Use of the CNL positions in healthcare organizations has improved patient out-
comes and reduced costs and is expected to expand as the demand for quality contin-
ues (Hix, McKeon, & Walters, 2009; Ignatious, 2010; Stanley et al., 2008).

Problems have emerged, however, as CNLs transition into organizations. These
include being drawn into direct patient care, explaining the role to other nurses and
healthcare providers, and acceptance by the staff (Sherman, 2010).

Today, all nurses are managers, not in the formal organizational sense but in prac-
tice. They direct the work of nonprofessionals and professionals in order to achieve
desired outcomes in patient care. Leaders are skilled in empowering others, creating
meaning and facilitating learning, developing knowledge, thinking reflectively, com-
municating, solving problems, making decisions, and working with others. Leaders
generate excitement; they clearly define their purpose and mission. Leaders under-
stand people and their needs; they recognize and appreciate differences in people,
individualizing their approach as needed. Acquiring the skills to be both a leader and
a manager will help the nurse become more effective and successful in any position.
See how one nurse described her work in Box 4-4.

Leading, Managing, Following 57

Box 4-4 A Leader Describes Her Work
I believe that the most important role of a nurse leader is to
live the life and exemplify at all times the qualities that every
professional nurse leader should. I also believe the nurse
leader/manager must be the person to set the bar high and
perform at the highest levels in order to inspire staff to
achieve the same.

As a nurse manager, I at all times work to be compas-
sionate, caring, an excellent communicator, vested in my
job, willing to go above and beyond and assist people with
any task or issue they just need a little extra support on. I
feel that by doing this, there is never a question what I
expect from them and those around me. I verbally set
expectations, then live them as a role model.

For example, at shift change two nights ago, a physi-
cian wanted to do a bedside procedure. I was actually
planning on leaving soon after a long day. I knew it was shift
change, and didn’t want the staff to be interrupted, so I
volunteered to stay and do the procedure so they could
continue with report, and the physician and patient were

not kept waiting. The staff were very appreciative, but more
important, I think it set the right example of teamwork,
being flexible, being patient focused.

I think it is important for the nurse leader to provide
feedback at times other than evaluations. The nurse leader
should schedule time into the workweek to have informal
conversations with staff on the floor about comments a
patient or coworker has shared or to send an email to a
staff member about feedback the leader has received. I
think constructive feedback needs to be timely and sup-
portive and the need for improvement discussed long
before an evaluation.

I like starting conversations with questions such as
“What are your goals?” or “What can I help you explore or
do that you’ve been dreaming about to enhance your nurs-
ing career?” People need to feel comfortable having these
conversations with their trusted nurse leader. Building rela-
tionships with those you lead is important.

What You Know Now
• A leader employs specific behaviors and strate-

gies to influence individuals and groups to attain
goals.

• Managers are responsible for efficiently accom-
plishing the goals of the organization.

• Contemporary leadership theories emphasize
cooperation and collaboration.

• Quantum, transactional, transformational, ser-
vant, emotional, and shared leadership are exam-
ples of contemporary leadership theories.

• Both leaders and followers contribute to the effec-
tiveness of their relationship.

• Traditional management functions include plan-
ning, organizing, directing, and controlling.

• Successful leaders inspire and empower others,
generate excitement, and individualize their
approach to differences in people.

Tools for Leading, Managing, and Following
1. In any interaction, pay attention to the context:

Are you leading, managing, or following in this
situation?

2. Notice others whose leadership style you
admire and try to incorporate their behaviors

in your own leadership if the situation is
appropriate.

3. Evaluate yourself at regular opportunities in
order to find ways to improve your abilities to
lead, manage, and follow.

58 Chapter 4

Questions to Challenge You
1. Think about people you know in management

positions. Are any of them leaders as well?
Describe the characteristics that make them leaders.

2. Consider people you know who are not in man-
agement positions but are leaders nonetheless.
What characteristics do they have that make them
leaders?

3. Describe the manager to whom you report. (If
you are not employed, use the first-level manager
on a clinical placement site.) Evaluate this person
using the management functions described in
this chapter.

4. Imagine yourself as a manager whether you are
in a management position or not. What skills do
you possess that help you? What skills would
you like to improve?

5. Evaluate yourself as a follower. Find at least one
characteristic listed in this chapter that you
would like to develop or improve. During the
next week, try to find opportunities to practice
that skill.

6. Assess yourself as a leader. How would you like
to improve?

References
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Home

Home

Chapter 5

Initiating and
Managing Change

Learning Outcomes

After completing this chapter, you will be able to:

1. Explain why nurses have the opportunity to be change agents.

2. Describe how different theorists explain change.

3. Delineate steps in the change process.

4. Differentiate among change strategies.

5. Evaluate ways to handle resistance to change.

6. Describe the nurse’s role in planned and unplanned change.

The Nurse as Change Agent

Change Theories

The Change Process
Step 1: Identify the Problem or Opportunity

Step 2: Collect Necessary Data and Information

Step 3: Select and Analyze Data

Step 4: Develop A Plan for Change, Including Time
Frame and Resource

Step 5: Identify Supporters and Opposers

Step 6: Implement Interventions to Achieve
Desired Change

Step 7: Evaluate Effectiveness of the Change and,
if Successful, Stabilize the Change

Change Strategies
Power–Coercive Strategies

Empirical–Rational Model Strategies

Normative–Reeducative Strategies

Resistance to Change

The Nurse’s Role
Initiating Change

Implementing Change

Unplanned Change

Handling Constant Change

60

Initiating and Managing Change 61

Key Terms
change

change agent

driving forces

empirical–rational model

normative–reeducative strategies

power–coercive strategies

restraining forces

transitions

Introduction
Change is inevitable, if not always welcome. Organizational change is essential for
adaptation; creative change is mandatory for growth (Heath & Heath, 2010). Change,
though, is a continually unfolding process rather than an either/or event. The process
begins when the present state is disrupted, moves through a transition period, and
ultimately comes to a desired state. Once the desired state has been reached, however,
the process begins again.

Leading change was never needed more than in today’s rapidly evolving system of
healthcare. Those who initiate and manage change often encounter resistance. Even
when planned, change can be threatening and a source of conflict because it is the pro-
cess of making something different from what it was. There is a sense of loss of the famil-
iar, the status quo. This is particularly true when change is unplanned or beyond human
control. Even when change is expected and valued, a grief reaction still may occur.

Although nurses should understand and anticipate these reactions to change, they
need to develop and exude a different approach. They can view change as a challenge
and encourage their colleagues to participate. They can become uncomfortable with
the status quo and be willing to take risks.

The present is a particular fortuitous time for the nursing profession (Nickitas,
2010). The report published by the Institute of Medicine (IOM) on the future of nursing
proposes radical change for the profession (Institute of Medicine, 2010). The key mes-
sages of the report appear in Box 5-1.

Source: IOM (Institute of Medicine). 2011. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press.

Box 5-1 Key Messages from The Future of Nursing:
Leading Change, Advancing Health
• Nurses should practice to the full extent of their edu-

cation and training.

• Nurses should achieve higher levels of education and
training through an improved education system that
promotes seamless academic progression.

• Nurses should be full partners with physicians and
other healthcare professionals in redesigning health-
care in the United States.

• Effective workforce planning and policymaking require
better data collection and an improved information
infrastructure.

Furthermore, the IOM makes eight recommendations:

• Remove scope-of-practice barriers.
• Expand opportunities for nurses to lead and diffuse

collaborative improvement efforts.
• Implement nurse residency programs.
• Increase the proportion of nurses with baccalaureate

degrees to 80% by 2020.
• Ensure nurses engage in lifelong learning.
• Prepare and enable nurses to lead change to advance

health.
• Build an infrastructure for the collection and analysis of

interprofessional healthcare workforce data.

62 Chapter 5

The Nurse as Change Agent
A change agent is one who works to bring about a change. Being a change agent is not
easy. Although the end result of change may benefit nurses and patients alike, initially
it requires time, effort, and energy, all of which are in short supply in the high-stress
environment of healthcare.

Several recent reports document nurses’ roles in facilitating change. MacDavitt,
Cieplincki, and Walker (2011) report that when nurses made small changes in com-
munication on a pediatric inpatient unit, improved patient satisfaction resulted.
McMurray, Chaboyer, Wallis, and Fetherston (2010) found that nurse managers played
a key role in implementing successful change in bedside handover in two hospitals.

Changes will continue at a rapid pace with or without nursing’s expert guidance.
Nonetheless, nurses, like organizations, cannot afford merely to survive changes. If
they are to exist as a distinct profession that has expertise in helping individuals
respond to actual or potential health problems, they must be proactive in shaping the
future. Opportunities exist now for nurses, especially those in management positions,
to change the system about which they so often complain.

Change Theories
Because change occurs within the context of human behavior, understanding how
change does (or does not) occur is helpful in learning how to initiate or manage change.
Five theories explain the change process. See Table 5-1 for a comparison.

Lewin (1951) proposes a force-field model, much like a football field (see Figure 5-1).
He sees behavior as a dynamic balance of forces working in opposing directions within
a field (such as an organization). Driving forces facilitate change because they push
participants in the desired direction. Restraining forces impede change because they
push participants in the opposite direction.

To plan change, one must analyze these forces and shift the balance in the direc-
tion of change through a three-step process: unfreezing, moving, and refreezing.
Change occurs by adding a new force, changing the direction of a force, or changing
the magnitude of any one force. Basically, strategies for change are aimed at increasing
driving forces, decreasing restraining forces, or both. The image of people’s attitudes
thawing and then refreezing is conceptually useful. This symbolism helps to keep the-
ory and reality in mind simultaneously.

Table 5-1 Comparison of Change Models

Lewin Lippitt Havelock Rogers Kotter

1. Unfreezing
2. Moving
3. Refreezing

1. Diagnose problem
2. Assess motivation
3. Assess change agent’s

motivations and
resources

4. Select progressive
change objects

5. Choose change agent
role

6. Maintain change
7. Terminate helping

relationships

1. Building a relationship
2. Diagnosing the problem
3. Acquiring resources
4. Choosing the solution
5. Gaining acceptance
6. Stabilization and

self-renewal

1. Knowledge
2. Persuasion
3. Decision
4. Implementation
5. Confirmation

1. Create urgency
2. Form a powerful

coalition
3. Create a vision for

change
4. Communicate the vision
5. Empower others to act
6. Generate short-term

wins
7. Consolidate changes
8. Institutionalize new

approach

Initiating and Managing Change 63

Lippitt, Watson, and Wesley (1958) extended Lewin’s theory to a seven-step pro-
cess and focused more on what the change agent must do than on the evolution of
change itself. (See Table 5-1.) They emphasized participation of key members of the
target system throughout the change process, particularly during planning. Commu-
nication skills, rapport building, and problem-solving strategies underlie their phases.

Havelock (1973) described a six-step process, also a modification of Lewin’s
model. Similar to Lippitt et al., Havelock describes an active change agent as one who
uses a participative approach.

Rogers (2003) takes a broader approach than Lewin, Lippitt et al., or Havelock (see
Table 5-1). His five-step innovation–decision process details how an individual or
decision-making unit passes from first knowledge of an innovation to confirmation of
the decision to adopt or reject a new idea. His framework emphasizes the reversible
nature of change: Participants may initially adopt a proposal but later discontinue it,
or the reverse—they may initially reject it but adopt it at a later time. This is a useful
distinction. If the change agent is unsuccessful in achieving full implementation of a
proposal, it should not be assumed the issue is dead. It can be resurrected, perhaps in
an altered form or at a more opportune time.

Rogers stresses two important aspects of successful planned change: Key people
and policy makers must be interested in the innovation and committed to making it
happen. Erwin (2009) found that organizational change in hospitals could only be suc-
cessful and sustained if senior administrators were fully committed to the change.

More recently, Kotter (2012) identifies lessons from organizations that succeeded
with change and critical mistakes by those organizations that failed. Successful

Restraining forces

Driving forces

Example:

Fear of
job loss

Nurse manager
lacks change
agent skills

Entrenched
director of

nurses

Present
(status quo)

Force will
be toward
change

Budget in red
(financial incentive

to change)

Administration
mandates the

change

Interested
vice-president

Need new solution
(old one doesn’t work)

Some long-term
employees

resist change

Almost complete
turnover of staff

(many new nurses)

Restraining forces

Driving forces

(unfreezing)
(refreezing)

New
equilibrium

MovingPresent equilibrium
(status quo)

Restraining forces

Driving forces

Figure 5-1 Lewin’s force-field model of change.

Adapted from Resolving Social Conflicts and Field Theory in Social Science by K. Lewin. Copyright © 1997, by the
American Psychological Association. Adapted with permission.

64 Chapter 5

organizations created a sense of urgency for the change, formed a powerful coalition to
guide the change, created a vision of the desired change, communicated that vision to all,
empowered employees to act on the vision, planned for and created short-term wins, con-
solidated improvements, and institutionalized the new approach. Failed organizations, on
the other hand, did not create a sense of urgency, a guiding coalition, or a vision. They did
not plan for short-term wins, declared victory too soon, and did not anchor the changes in
the organization’s culture. Success in using Kotter’s eight-step process has been reported in
a variety of healthcare organizations (Berger, Conway, & Beaton, 2012; Shirey, 2011).

The Change Process
The steps in the change process are the same whether the change is major (e.g.,
merging several organizations) or minor (e.g., trying hourly 4P rounding on a unit).
(See Box 5-2.)

Box 5-2 Steps in the Change Process
1. Identify the problem or opportunity.
2. Collect necessary data and information.
3. Select and analyze data.
4. Develop a plan for change, including time frame and

resources.

5. Identify supporters and opposers.
6. Implement interventions to achieve desired change.
7. Evaluate effectiveness of the change and, if success-

ful, stabilize the change.

Step 1: Identify the Problem or Opportunity
Because change is often planned to close a discrepancy between the actual and desired
state of affairs, the first step is to identify the problem. Discrepancies may arise because
of problems in reaching performance goals or because new goals have been created.

Opportunities demand change as much as (or more than) problems do, but they
are often overlooked. Be it a problem or an opportunity, it must be identified clearly. If
the issue is perceived differently by key individuals, the search for solutions becomes
confused.

Start by asking the right questions, such as these:

• Where are we now?

• What is unique about us?

• What should our business be?

• What can we do that is different from and better than what our competitors do?

• What is the driving stimulus in our organization?

• What determines how we make our final decisions?

• What prevents us from moving in the direction we wish to go?

• What kind of change is required?

This last question generates integrative thinking on the potential effect of change
on the system. Organizational change involves modifications in the system’s interact-
ing components: technology, structure, and people.

Initiating and Managing Change 65

Introducing new technology changes the structure of the organization. The physi-
cal plant may be altered if new services are added and then relationships among the
people who work in the system change when the structure is changed. Surveillance
cameras, cell phones, magnetic entry cards, bar codes, and communication technology,
including social media, have altered the care environment as much as they’ve changed
our personal world. The Affordable Care Act introduced new rules and regulations,
suggested new authority structures, and forced new budgeting methods to emerge.
These changes, in turn, altered staffing needs, requiring people with different skills,
knowledge bases, attitudes, and motivations.

Step 2: Collect Necessary Data and Information
Once the problem or opportunity has been clearly defined, the change agent collects
data external and internal to the system. This step is crucial to the eventual success of
the planned change. All driving and restraining forces are identified so the driving
forces can be emphasized and the restraining forces reduced.

The costs and benefits of the proposed change are obvious focal points as is the
need to assess resources—especially those the manager can control. A manager who
has the respect and support of an excellent nursing staff has access to a powerful
resource in today’s climate.

Step 3: Select and Analyze Data
The kinds, amounts, and sources of data collected are important, but they are useless
unless they are analyzed. The change agent should focus more energy on analyzing
and summarizing the data than on just collecting it. The point is to flush out resistance,
identify potential solutions and strategies, begin to identify areas of consensus, and
build a case for whichever option is selected.

At a not-for-profit hospital in the process of seeking Magnet status, each service line is
looking for opportunities to improve standards of care, efficiency, and patient safety. In
the ambulatory surgery center, the process of providing preoperative services was often
slow and inefficient. The surgery center nurses were charged with finding ways to
improve efficiency.

Step 4: Develop a Plan for Change, Including Time
Frame and Resource
Planning the who, how, and when of the change is a key step. What will be the target sys-
tem for the change? Members from this system should be active participants in the plan-
ning stage. The more involved they are at this point, the less resistance there will be later.
Lewin’s unfreezing imagery is relevant here. Present attitudes, habits, and ways of think-
ing have to soften so members of the target system will be ready for new ways of thinking
and behaving. Boundaries must melt before the system can shift and restructure.

This is the time to make people uncomfortable with the status quo and establish a
sense of urgency (Kotter, 2012). Introduce information that may make people feel dis-
satisfied with the present and interested in something new. This information comes
from the data collected (e.g., research findings, quantitative data, and patient satisfac-
tion questionnaires or staff surveys). Couch the proposed change in comfortable terms
as far as possible, and minimize anxiety about the new change.

66 Chapter 5

Managers need to plan the resources required to make the change and establish
feedback mechanisms to evaluate its progress and success. Establish control points
with people who will provide the feedback, and work with these people to set specific
goals with time frames. Develop operational indicators that signal success or failure in
terms of performance and satisfaction.

Three surgery center nurses designed a flow chart of how the process could be improved.
They took it to their administration and were put in charge of its implementation.

Step 5: Identify Supporters and Opposers
Who will gain from this change? Who will lose? Who has more power and why? Can
those power bases be altered? How? Who in control may be benefiting now? Egos,
commitment of the involved people, and personal likes and dislikes are as important
to assess as the formal organizational structures and processes.

Selecting and placing personnel or terminating key people often is used to alter
the forces for or against change. When key supporters of the planned change are
given the authority and accountability to make the change, their enthusiasm and
legitimacy can be effective in leading others to support the change. Conversely, if
those opposed to the change are transferred or leave the organization, the change is
more likely to succeed.

Step 6: Implement Interventions to Achieve
Desired Change
The plans are put into motion (Lewin’s moving stage). Interventions are designed to
gain the necessary compliance. The change agent creates a supportive climate, acts as
an energizer, obtains and provides feedback, and overcomes resistance.

The surgery center nurses worked with physician offices, insurance companies, and
other hospital departments to implement the new process for preoperative services.

Step 7: Evaluate Effectiveness of the Change
and, if Successful, Stabilize the Change
The change agent determines whether presumed benefits were achieved from a finan-
cial as well as a qualitative perspective, explaining the extent of success or failure.
Unintended consequences, positive or negative, may have occurred.

The change is extended past the pilot stage, and the target system is refrozen. For
example, a nursing unit starts an hourly rounding program. Each hour the nurses or
aides check pain, potty, position, and possessions (4P rounding). The goal is to improve
patient satisfaction. After trying the rounding for 6 months, fall rates improve and call
light usage goes down. The decision is made to continue the rounding (Mitchell,
Lavenberg, Trotta, & Umscheid, 2014).

The change agent terminates the relationship by delegating responsibilities to tar-
get system members. The energizer role is still needed to reinforce new behaviors
through positive feedback.

Over the next 3 months, the preoperative services department was able to show a 90%
decrease in duplicate test orders, a 50% decrease in patient waiting time, and an 80%
increase in physician satisfaction with the process.

Initiating and Managing Change 67

Change Strategies
Regardless of the setting or proposed change, the change process should be followed.
Specific strategies can be used, however, depending on the amount of resistance antici-
pated and the degree of power the change agent possesses.

Power–Coercive Strategies
Power–coercive strategies are based on the application of power by legitimate author-
ity, economic sanctions, or political clout. Changes are made through law, policy, or
financial appropriations. Those in control enforce changes by restricting budgets or cre-
ating policies. Those who are not in power may not even be aware of what is happen-
ing. Even if they are aware, they have little power to stop it. The Affordable Care Act
legislation is an example of power–coercive strategy by the federal government.

Power–coercive strategies are useful when a consensus is unlikely despite efforts
to stimulate participation by those involved. When much resistance is anticipated,
time is short, and the change is critical for organizational survival, power–coercive
strategies may be necessary.

Empirical–Rational Model Strategies
In the empirical–rational model of change strategies, the power ingredient is knowl-
edge. The assumption is that people are rational and will follow their rational self-
interest if that self-interest is made clear to them. It is also assumed that the change
agent who has knowledge has the expert power to persuade people to accept a ratio-
nally justified change that will benefit them.

The flow of influence moves from those who know to those who do not know.
New ideas are invented and communicated or diffused to all participants. Once
enlightened, rational people will either accept or reject the idea based on its merits and
consequences. Empirical–rational strategies are often effective when little resistance to
the proposed change is expected and the change is perceived as reasonable.

The change agent can direct the change. There is little need for staff participation
in the early steps of the change process, although input is useful for the evaluation and
stabilization stages. The benefits of change for the staff and research documenting
improved patient outcomes are the major driving forces.

Normative–Reeducative Strategies
In contrast to the empirical–rational model, normative–reeducative strategies of
change rest on the assumption that people act in accordance with social norms and
values. Information and rational arguments are insufficient strategies to change peo-
ple’s patterns of actions; the change agent must focus on noncognitive determinants of
behavior as well. People’s roles and relationships, perceptual orientations, attitudes,
and feelings will influence their acceptance of change.

In this mode, the power ingredient is skill in interpersonal relationships, not
authority or knowledge. The change agent uses collaboration, not coercion or nonre-
ciprocal influence. Members of the target system are involved throughout the change
process. Value conflicts from all parts of the system are brought into the open and
worked through so change can progress.

Normative–reeducative strategies are well suited to the creative problem solving
needed in nursing and healthcare today. This approach can be effective in reducing

68 Chapter 5

resistance and stimulating personal and organizational creativity. The obvious draw-
back is the time required for group participation and conflict resolution throughout
the change process. With their firm grasp of the behavioral sciences and communica-
tion skills, nurses are especially well suited to use this model.

Resistance to Change
Resistance to change is to be expected for a number of reasons: lack of trust, vested inter-
est in the status quo, fear of failure, loss of status or income, misunderstanding, and
belief that change is unnecessary or that it will not improve the situation (Yukl, 2013). In
fact, if resistance does not surface, the change may not be significant enough.

Employees may resist change because they dislike or disapprove of the person
responsible for implementing the change or because they may distrust the change pro-
cess. Regardless, managers continually deal with change—both the change that they
themselves initiate and change initiated by the larger organization.

The change agent should anticipate and look for resistance to change. It will be
lurking somewhere, perhaps where least expected. It can be recognized in statements
such as the following:

• We tried that before.

• It won’t work.

• No one else does it like that.

• We’ve always done it this way.

• We can’t afford it.

• We don’t have the time.

• It will cause too much commotion.

• You’ll never get it past the board.

• Let’s wait awhile.

• Every new boss wants to do something different.

• Let’s start a task force to look at it; put it on the agenda.

Expect resistance and listen carefully to who says what, when, and in what cir-
cumstances. Open resisters are easier to deal with than closet resisters. Look for non-
verbal signs of resistance, such as poor work habits and lack of interest in the change.

Resistance prevents the unexpected. It forces the change agent to clarify informa-
tion, keep interest level high, and establish why change is necessary. It draws attention
to potential problems and encourages ideas to solve them. Resistance is a stimulant as
much as it is a force to be overcome. It may even motivate the group to do better what
it is doing now, so that it does not have to change.

On the other hand, resistance is not always beneficial, especially if it persists
beyond the planning stage and well into the implementation phase. It can wear down
supporters and redirect system energy from implementing the change to dealing with
resisters. Morale can suffer.

To manage resistance, use the following guidelines:

1. Talk to those who oppose the change. Get to the root of their reasons for opposition.

2. Clarify information, and provide accurate feedback.

Initiating and Managing Change 69

3. Be open to revisions but clear about what must remain.

4. Present the negative consequences of resistance (e.g., threats to organizational sur-
vival, compromised patient care).

5. Emphasize the positive consequences of the change and how the individual or
group will benefit. However, do not spend too much energy on rational analysis
of why the change is good and why the arguments against it do not hold up. Peo-
ple’s resistance frequently flows from feelings that are not rational.

6. Keep resisters involved in face-to-face contact with supporters. Encourage propo-
nents to empathize with opponents, recognize valid objections, and relieve unnec-
essary fears.

7. Maintain a climate of trust, support, and confidence.

8. Divert attention by creating a different disturbance. Energy can shift to a more
important problem inside the system, thereby redirecting resistance. Alternatively,
attention can be brought to an external threat to create a bully phenomenon. When
members perceive a greater environmental threat (such as competition or restric-
tive governmental policies), they tend to unify internally.

The Nurse’s Role
Contrary to popular opinion, change often is not initiated by top-level management
(Yukl, 2013) but rather emerges as new initiatives or problems are identified. Further-
more, Weiner, Amick, and Lee (2008) posit that organizational readiness is the key to
initiating change.

Initiating Change
Staff nurses often think that they are unable to initiate and create change, but that is
not so.

Home health nurses were often frustrated by not having appropriate supplies with them
when seeing a patient for the first time. A team of nurses completed a chart audit to
identify commonly used supplies and equipment that nurses were using on their home
visits. Each nurse was then supplied with a small plastic container to keep in his or her car
with these items. Frustration decreased, and efficient use of nursing time was improved.

The manager, as well, may resist leading change. Fearful of “rocking the boat” or
that no one will join the effort, recalling that past attempts at change had failed, or
even reluctance to become involved—all may prevent the nurse from initiating change.

Making change is not easy, but it is a mandatory skill for managers. Successful
change agents demonstrate certain characteristics that can be cultivated and mastered
with practice. (See Leading at the Bedside: Leading Change.) These characteristics
include the following:

• The ability to combine ideas from unconnected sources

• The ability to energize others by keeping the interest level up and demonstrating
a high personal energy level

• Skill in human relations: well-developed interpersonal communication, group
management, and problem-solving skills

• Integrative thinking: the ability to retain a big picture focus while dealing with
each part of the system

70 Chapter 5

• Sufficient flexibility to modify ideas when modifications will improve the change,
but enough persistence to resist nonproductive tampering with the planned
change

• Confidence and the tendency not to be easily discouraged

• Realistic thinking

• Trustworthiness: a track record of integrity and success with other changes

• The ability to articulate a vision through insights and versatile thinking

• The ability to handle resistance

Leading at the Bedside: Leading Change
Do you think that change always occurs because adminis-
trators order it? That may be the case but not always.
Change often emerges as new issues or problems are identi-
fied. Recall the example of the home health nurses who were
frustrated because they didn’t have supplies available when
they needed them. They followed up to determine a solution.

Such initiatives are not uncommon, but they require nurses
to pay attention to problems, consider possible solutions,
and share the issue with appropriate decision makers.

Don’t abdicate your responsibility to improve your
workplace to benefit both staff and patients. It’s part of your
duty as a professional nurse.

Energy is needed to change a system. Power is the main source of that energy. Infor-
mational power, expertise, and possibly positional power can be used to persuade others.

To access optimum power, use the following strategies:

1. Analyze the organizational chart. Know the formal lines of authority. Identify
informal lines as well.

2. Identify key persons who will be affected by the change. Pay attention to those
immediately above and below the point of change.

3. Find out as much as possible about these key people. What are their “tickle
points”? What interests them, gets them excited, turns them off? What is on their
personal and organizational agendas? Who typically aligns with whom on impor-
tant decisions?

4. Begin to build a coalition of support before you start the change process. Identify
the key people who will be affected by the change. Talk informally with them to
flush out possible objections to your idea and potential opponents. What will the
costs and benefits be to them, especially in political terms? Can your idea be
modified in ways that retain your objectives but appeal to more key people?

5. Follow the organizational chain of command in communicating with administra-
tors. Do not bypass anyone to avoid having an excellent proposal undermined.

This information helps you develop the most sellable idea or at least pinpoint
probable resistance. It is a broad beginning to the data-collection step of the change
process and has to be fine-tuned once the idea is better defined. The astute manager
keeps alert at all times to monitor power struggles.

Although a cardinal rule of change is “Don’t try to change too much too fast,” the
savvy manager develops a sense of exquisite timing by pacing the change process ac –
cording to the political pulse. For example, the manager unfreezes the system during a
period of coalition building and high interest, while resistance is low or at least unorganized.

Initiating and Managing Change 71

You may decide to stall the project beyond a pilot stage if resistance solidifies or
gains a powerful ally. In this case, do whatever you can to reduce resistance. If resis-
tance continues, two options should be considered:

• The change is not workable and should be modified to meet the strongest objec-
tions (compromise).

• The change is fine-tuned sufficiently, but change must proceed now and resistance
must be overcome.

Implementing Change
In addition to initiating change, nurses and nurse managers are called on to assist with
change in other ways. They may be involved in the planning stage, charged with sharing
information with coworkers, or asked to help manage the transition to planned change.

Transitions are those periods of time between the current situation and the time
when change is implemented (Bridges, 2009). They are the times ripe for a change
agent to act. Just as initiating change is not easy, neither is transitioning to changed
circumstances.

Letting go of long-term, comfortable activities is difficult. The tendency is to do
the following instead:

• Add new work to the old

• Make individual decisions about what to add and what to let go

• Toss out everything done before (Bridges, 2009)

Accepting loss and honoring the past with respect is essential. Passion for the
work is based on results, not activities, regardless of their necessity or effectiveness.

A large national for-profit healthcare system purchased a new hospital clinical
information system. Because all paper charting would be eliminated, nurses would be
directly affected. Their participation could spell success or failure for the new system. To
help the transition occur smoothly, nurses from each department met together for a
demonstration of the new clinical information system and provided feedback to the IT
department about nursing process and integrating patient care with the new system.
Then a few nurses on each unit were selected to be trained as experts in the new
technology, and they in turn trained other staff members, communicating with the IT
department when concerns arose.

A nurse manager in a home healthcare agency used change management strate-
gies to overcome resistance, as shown in Case Study 5-1.

Unplanned Change
So far we have been discussing planned change—change that the organization desires.
Unplanned change, by contrast, occurs without warning and challenges the organiza-
tion to respond. Two recent events are examples: the impact of the Boston Marathon
bombing on Massachusetts General Hospital (Erickson, 2014) and what the Texas
Health Presbyterian Hospital Dallas learned as a result of treating the first non-
healthcare worker for the Ebola virus (Edmonson, 2015).

In the first example, expert preparation and frequent drills enabled the staff of
Massachusetts General Hospital, a Magnet-certified hospital, to remain calm and

72 Chapter 5

focused during this mass casualty event (Erickson, 2014). In addition to injured patients
and their families, the staff also concentrated on the entire hospital community. Some
staff had run the race, others had family members or friends in it, and still others
watched it. All were affected by this tragedy.

Texas Health Presbyterian Hospital Dallas, also a Magnet-certified institution,
was prepared to deal with infectious diseases, but the Ebola virus was unique
(Edmondson, 2015). It defied the usual protections, and two nurses became infected.
As a result of this hospital’s experiences, all hospitals are better prepared today
should they need exceptional precautions and protections when facing unanticipated
contagions in the future.

The nurse’s role in leading unplanned change is to ensure that your team is well-
prepared for emergencies, that coordination and collaboration are assured, and that
the focus is on patients and their families. During the event and its aftermath, the
leader’s ability to remain calm and focused will help ensure that the best quality of
care is provided (Erickson, 2014). Furthermore, the staff’s functioning and emotional
health depend on the leader’s calm composure.

Handling Constant Change
Change has always occurred; what is different today is both the pace of change and
that an initial change causes a chain reaction of more and more change (Bridges, 2009).
Rather than being an occasional event, change has become the norm.

Case study 5-1 | encouraging Change
Peter Beasley is the nurse manager of pediatric home care
for a private home healthcare agency. Last year, the agency
completed a pilot of wireless devices for use in document­
ing home visits. With the new devices, charges for supplies
and medical equipment are automatically generated as
nurses complete the documentation. The agency director
informed the nurse managers that all nurses would be req­
uired to use the wireless devices within the next 3 months.

Charlene Ramirez has been a pediatric nurse for
18 years, working for the home healthcare agency for the
past 5 years. Charlene was active in updating the pediatric
documentation and training staff when new paper­based
documentation was implemented in the past. Although she
was part of the pilot last year, Charlene is very opposed to
using the new wireless devices. She complains that she
can barely see the text. At a recent staff meeting, Charlene
stated that she would rather quit than learn to use the new
wireless devices.

Peter empathizes with Charlene’s reluctance to use
the new technology. He also recognizes how much Char­
lene contributes in expertise and leadership to the depart­
ment. However, he knows that the new performance

standards require all employees to use the wireless devices.
After three mandatory training sessions, Charlene repeat­
edly tells coworkers, “We’ve tried things like this before,
and it never works. We’ll be back on paper within six
months, so why waste my time learning this stuff?” The
program trainer reports that Charlene was disruptive during
the class and failed her competency exam.

Peter meets privately with Charlene to discuss her
resistance to the new technology. Charlene again states
that she fails to see the need for wireless devices in deliver­
ing quality patient care. Peter reviews the new performance
standards with Charlene, emphasizing the technology
requirements. He asks Charlene if she has difficulty under­
standing the application or just in using the device. Char­
lene admits that she cannot read the text on the screen and
therefore cannot determine what exactly she is document­
ing. Peter informs Charlene that the agency’s health bene­
fits include vision exams and partial payment for corrective
lenses. He suggests that she talk with an optometrist to
see if special glasses would help her see the screen. Peter
also makes a note to speak with the technology specialist
to see if there are aids to help staff view data on the device.

Initiating and Managing Change 73

Regardless of their position in an organization, nurses find themselves constantly
dealing with change. Whether they thrive in such an atmosphere is a function of both
their own personal resources and the environment in which change occurs.

If you do not like the current situation, you may look forward to change. As Mid-
westerners are fond of saying when asked about the weather, “If you don’t like it
today, just wait until tomorrow. It will change.”

What You Know Now
• In today’s healthcare system, change is inevitable,

necessary, and constant.

• With changes proposed for the nursing profes-
sion, nurses are in a pivotal position to initiate
and participate in change.

• For change to be positive for nurses, they must
develop change agent skills.

• Critical evaluation of change theories provides
guidance and direction for initiating and manag-
ing change.

• The change process follows the same steps
whether the change is major or minor.

• Resistance to change is to be expected, and it can
be a stimulant as well as a force to be overcome.

• The nurse may be involved in change by initiat-
ing it or participating in implementing change.

• Handling constant change is a challenge in
today’s healthcare environment.

Tools for Initiating and Managing Change
1. Communicate openly and honestly with employ-

ees who oppose change.
2. Maintain support and confidence in staff even if

they are resistive to change.

3. Emphasize the positive outcomes from the change.
4. Find solutions to problems that are obstacles to

change.
5. Accept the constancy of change.

Questions to Challenge You
1. Identify a needed change in the organization where

you practice. Using the change process, outline the
steps you would take to initiate that change.

2. Consider your school or college. What change do
you think is needed? Explain how you would
implement change to make it a better place for
learning.

3. Have you had an experience with change occur-
ring in your organization? What was your initial
reaction? Did that change? How well did the
change process work? Was the change successful?

4. Do you have a behavior you would like to change?
Using the steps in the change process, describe
how you might effect that change.

5. How do you normally react to change? Choose
from the following:
a. I love new ideas, and I’m ready to try new things.
b. I like to know that something will work out

before I try it.
c. I try to avoid change as much as possible.

6. Did your response to the previous question alter
how you would like to view change? Think about
this the next time change is presented to you.

74 Chapter 5

References
Berger, J. T., Conway, S., Beaton, K. J. (2012).

Developing and implementing a nursing
professional practice model in a large health
system. Journal of Nursing Administration, 42(3),
170–175.

Bridges, W. (2009). Managing transitions: Making the
most of change. Cambridge, MA: Da Capo Press.

Edmondson, C. (2015). Lessons from unplanned
change. Journal of Nursing Administration, 45(2),
61–62.

Erickson, J. I. (2014). Leading unplanned change.
Journal of Nursing Administration, 44(3), 125–126.

Erwin, D. (2009). Changing organizational
performance: Examining the change process.
Hospital Topics: Research and Perspectives on
Healthcare, 87(3), 28–40.

Havelock, R. (1973). The change agent’s guide to
innovation in education. Englewood Cliffs, NJ:
Educational Technology Publications.

Heath, C., & Heath, D. (2010). Switch: How to change
things when change is hard. New York,
NY: Crown.

Institute of Medicine. (2010). The future of nursing:
Leading change, advancing health. Retrieved
May 25, 2015, from http://www.iom.edu/
Reports/2010/The-Future-of-Nursing-Leading-
Change-Advancing-Health.aspx

Kotter, J. P. (2012). Leading change. Boston, MA:
Harvard Business Review Press.

Lewin, K. (1951). Field theory in social science. New
York NY: Harper & Row.

Lippitt, R., Watson, J., & Westley, B. (1958). The
dynamics of planned change. New York, NY:
Harcourt & Brace.

MacDavitt, K., Cieplinski, J. A., & Walker, V.
(2011). Implementing small tests of change to
improve patient satisfaction. Journal of Nursing
Administration, 41(1), 5–9.

McMurray, A., Chaboyer, W., Wallis, M., &
Fetherston, C. (2010). Implementing bedside
handover: Strategies for change management.
Journal of Clinical Nursing, 19(17–18), 2580–2589.

Mitchell, M. D., Lavenberg, J. G., Trotta, R. L., &
Umscheid, C. A. (2014). Hourly rounding to
improve nursing responsiveness. Journal of
Nursing Administration, 44(9), 462–472.

Nickitas, D. M. (2010). A vision for future health care:
Where nurses lead the change. Nursing Economics,
28(6), 361, 385.

Rogers, E. (2003). Diffusion of innovations (5th ed.).
New York, NY: Free Press.

Shirey, M. R. (2011). Addressing strategy execution
challenges to lead sustainable change. Journal of
Nursing Administration, 41(1), 1–4.

Weiner, B. J., Amick, H., & Lee, S. D. (2008).
Conceptualization and measurement of
organizational readiness for change: A review of
the literature in health services research and other
fields. Medical Care Research and Review, 65(4),
379–436.

Yukl, G. A. (2013). Leadership in organizations (8th ed.).
Upper Saddle River, NJ: Pearson.

7. Think back to your first time on a clinical unit.
How did you feel? Overwhelmed? Afraid of fail-
ing? Those are feelings that people have when

facing change. When you encounter resistance
to change, try to remember how you have felt in
the past.

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

Chapter 6

Managing and
Improving Quality

Learning Outcomes

After completing this chapter, you will be able to:

1. Describe how total quality management, continuous quality
management, Six Sigma, Lean Six Sigma, and DMAIC
address quality.

2. Delineate efforts to improve the quality of healthcare.

3. Explain how nurses are involved in reducing risks.

Key Terms
continuous quality improvement

(CQI)

DMAIC

Hospital Consumer Assessment of
Healthcare Providers and Systems
(HCAHPS)

Quality Management
Total Quality Management

Continuous Quality Improvement

Components of Quality Management

Six Sigma

Lean Six Sigma

DMAIC Method

Improving the Quality of Care
National Initiatives

Evidence-based Practice

Electronic Health Records

Dashboards

Rounding

Reducing Medication Errors

Risk Management
Nursing’s Role in Risk Management

Incident Reports

Examples of Risk

Root-cause Analysis

Peer Review

Role of the Nurse Manager

Creating a Blame-free Environment

75

76 Chapter 6

incident reports

indicator

just culture

Lean Six Sigma

outcome standards

pay for performance (P4P)

process standards

quality management

reportable incident

risk management

root-cause analysis

Six Sigma

spaghetti diagram

structure standards

total quality management (TQM)

value-based purchasing (VBP)

Introduction
In today’s highly competitive healthcare environment, each member of the healthcare
organization must be accountable for the quality, safety, and cost of healthcare. Both
quality and cost containment are part of the concept of total quality management
(TQM), which has evolved into a model of continuous quality improvement designed
to improve system and process performance. Risk management is integrated within a
quality management program.

Quality Management
The concept of quality management is one in which problems are prevented and
improvement of care and quality is sought. The implementation of quality manage­
ment has moved healthcare from a mode of identifying failed standards, problems,
and problem people to a proactive organization. This paradigm shift involves all in the
organization and promotes problem solving and experimentation.

A quality management program is based on an integrated system of information
and accountability. Clinical information systems can provide the data needed to enable
organizations to track activities and outcomes. For example, data from clinical informa­
tion systems can be used to track patient wait times from admitting to outpatient test­
ing to admission in an inpatient care unit. Delays in the process can be identified so that
in the future, appropriate staff and resources are available at the right time to decrease
delays and increase efficiency and patient satisfaction. Methods can be devised to dis­
cover problems in the system without blaming the “sharp end,” the last individual in
the chain to act (e.g., the nurse who gives a wrong medication). The system must be
accepted and used by the entire staff.

Total Quality Management
Total quality management (TQM) is a management philosophy that emphasizes
a  commitment to excellence throughout the organization. The creation of Dr. W.
Edwards Deming, TQM was adopted by the Japanese after World War II and helped
transform their industrial development. Dr. Deming based his system on principles
of quality management that were originally applied to improve quality and per­
formance in the manufacturing industry. The principles are now widely used to
improve quality and customer satisfaction in a number of service industries, includ­
ing healthcare.

Managing and Improving Quality 77

The following are the four core characteristics of total quality management:

• Focus on customer/patient.

• Involve the total organization.

• Use quality tools and statistics for measurement.

• Identify key processes for improvement.

A common management adage is “You can’t manage what you can’t (or don’t)
measure.” There are many tools, formats, and designs that can be used to build knowl­
edge, make decisions, and improve quality. Tools for data analysis and display can be
used to identify areas for process and quality improvement, and then to benchmark
the progress of improvements. Deming applied the scientific method to the concept of
TQM to develop a model he called the PDCA (Plan, Do, Check, Act) cycle, which is
depicted in Figure 6­1.

PlanPlan

DoAct

Check

Figure 6-1 PDCA cycle.

Continuous Quality Improvement
TQM is the overall philosophy, whereas continuous quality improvement (CQI) is
used to improve quality and performance. TQM and CQI often are used synonymously.
In healthcare organizations, CQI is the process used to systematically investigate ways
to improve patient care. As the name implies, continuous quality improvement is a
never­ending endeavor.

CQI means more than just meeting standards and thresholds or solving prob­
lems. It involves evaluation, actions, and a mind­set focused on striving constantly
for excellence. This concept is sometimes difficult to grasp because patient care
involves the synchronization of activities in multiple departments. Therefore, devel­
oping and implementing a well­thought­out process is key to a successful CQI
implementation.

Components of Quality Management
A comprehensive quality management plan is a systematic method to design, mea­
sure, assess, and improve organizational performance. Using a multidisciplinary
approach, this plan identifies processes and systems that represent the goals and mis­
sion of the organization, identifies customers, and specifies opportunities for improve­
ment. Critical pathways are an example of a quality management plan in that they
identify expected outcomes within a specific time frame. Then variances are tracked
and accounted for.

78 Chapter 6

The quality management plan includes written statements that define a level
of performance or a set of conditions. Standards relate to three major dimensions of
quality care:

• Structure standards relate to the physical environment, organization, and man-
agement of an organization.

• Process standards are those connected with the actual delivery of care.

• Outcome standards involve the end results of care that has been given.

An indicator is a tool used to measure the performance of structure, process, and
outcome standards. It is measurable, objective, and based on current knowledge.
Once indicators are identified, benchmarking—comparing performance using iden-
tified quality indicators across institutions or disciplines—is the key to quality
improvement.

In nursing, both generic and specific standards are available from the American
Nurses Association (ANA) and specialty organizations; however, each organization
and each patient care area must designate standards specific to the patient population
being served. These standards are the foundation on which all other measures of qual-
ity are based. An example of a standard is “Every patient will have a written care plan
within 12 hours of admission.”

Six Sigma
Six Sigma is another quality management program that uses, primarily, quantitative
data to monitor progress. Six Sigma is a measure, a goal, and a system of management.

• As a measure. Sigma is the Greek letter (Σ) for standard, meaning how much per-
formance varies from a standard. This is similar to how CQI monitors results
against an outcome measure.

• As a goal. One goal might be accuracy. How many times, for example, is the right
medication given in the right amount, to the right patient, at the right time, by the
right route?

• As a management system. Compared to other quality management systems, Six
Sigma involves management to a greater extent in monitoring performance and
ensuring favorable results.

The system has six themes:

• Customer (patient) focus

• Data driven

• Process emphasis

• Proactive management

• Boundaryless collaboration

• Aim for perfection, but tolerate failure

The first three themes are similar to other quality management programs. The
focus is on the object of the service; in nursing’s case, this is the patient. Data provide
the evidence of results, and the processes used in the system are emphasized.

The latter three themes, however, differ from other programs. Management is
actively involved, and boundaries are breached (e.g., the disconnect between

Managing and Improving Quality 79

departments). More radically, Six Sigma tolerates failure (a necessary condition for
creativity) while striving for perfection.

Lean Six Sigma
Lean Six Sigma focuses on improving process flow and eliminating waste. Waste
occurs when the organization provides more resources than are required. Data driven,
Lean Six Sigma focuses on identifying steps that have little or no value to patient care
and cause unnecessary delays. Furthermore, the method strives to eliminate variations
in care and to improve efficiencies and effectiveness. Because the goal of Lean Six
Sigma is to identify and reduce waste, it provides tools that can be used with a Six
Sigma management system.

Studies have shown Lean Six Sigma to be effective in reducing inappropriate hos­
pital stays, improving the quality of care, and reducing costs at the same time (Yama­
moto, Malatestinic, Lehman, & Juneja, 2010). One emergency department reduced
nurses’ wasted time using Lean methodology (Richardson et al., 2014), and a post­
anesthesia unit reported improvement in nurses’ working conditions in another study
(Haenke & Stichler, 2015). In addition, using the method improved the care of inpa­
tient diabetic patients (Niemeijer, Trip, Ahaus, Does, & Wendt, 2010).

DMAIC Method
DMAIC—an acronym for define, measure, analyze, improve, and control—is a Six Sigma
process improvement method (as shown in Figure 6­2). The following are the steps in
the method:

• Define what measures will indicate success.

• Measure baseline performance.

• Analyze results.

• Improve performance.

• Control and sustain performance (DMAICTools.com, n.d.).

Define

MeasureControl

Improve Analyze

Figure 6-2 DMAIC: The Six Sigma Method.

Adapted from DMAIC tools: Six Sigma training tools. Retrieved October 21, 2011, from www.dmaictools.com

An example of an inexpensive way to monitor efficiency and work flow is a spa­
ghetti diagram (Six Sigma Material, 2015). A spaghetti diagram (see Figure 6­3) is a draw­
ing of the actual work flow in a specified area at a point in time. Because nothing moves
in a straight line, cooked spaghetti is imagined when visualizing such movements.

DMAIC: Define, Measure, Analyze, Improve, Control

80 Chapter 6

The spaghetti diagram in Figure 6­3 identifies the movements of a nurse aide try­
ing to room four patients. Current practice for rooming is for the aide to escort the
patient from the waiting room to the clinic area, weigh the patient on the scale, and
take the patient to an exam room. Then the aide walks from the clinic area to the hall­
way to fetch the blood pressure machine from its station there and moves it to the
patient’s room, takes the patient’s blood pressure, and returns the machine to the hall­
way. The aide walks to the nurse station to notify the nurse that the patient is ready to
see, then goes to get the next patient and repeats the process.

Blood pressure is done in the room so the patient can be seated and relax. The
blood pressure machine is returned to its stationed place in the hallway between
patients so it can be readily grabbed if an emergent situation arises. There is a hypoth­
esis that the aide spends excess time walking to get the blood pressure machine for
each patient. The spaghetti diagram helps to determine if other options should be
evaluated. The following are suggested options:

• Get a blood pressure machine installed in each exam room.

• Place a chair by the blood pressure machine in the hallway, and after weighing the
patient on the scale, seat the patient, take the blood pressure, then escort the patient
to the room.

• Leave the work flow the way it is.

By tracing the exact movements of a staff member, managers can identify wasted
time and energy and put processes in place to reduce this waste.

Improving the Quality of Care
Over many years, numerous efforts have been made to improve the quality of health­
care. The National Quality Forum, the Joint Commission (the organization that accred­
its hospitals), and more recently changes enacted by passage of the Affordable Care
Act (ACA) have moved these efforts into the mainstream of healthcare. Even if legis­
lation changes ACA’s provisions, demands for quality care are expected to continue.

Exam
2

Exam
1

Nurse Aid Pattern
to Room 4 Patients in Clinic

Exam
3

Exam
4

Enter

Exit

F
ront D

esk
C

heck In

Waiting
Area

BP
Machine

N
urses’

W
ork S

tation

Scale

Figure 6-3 Spaghetti diagram.

Managing and Improving Quality 81

National Initiatives
The National Quality Forum is a nonprofit organization that strives to improve the
quality of healthcare by building consensus on performance goals and standards for
measuring and reporting them (National Quality Forum, 2016). In addition, the Insti­
tute for Healthcare Improvement (IHI) offers programs to assist organizations in
improving the quality of care they provide (IHI, 2015). The following are their goals:

• No needless deaths

• No needless pain or suffering

• No helplessness in those served or serving

• No unwanted waiting

• No waste

• No one left out

The Joint Commission has adopted mandatory national patient safety goals (Joint
Commission, 2016). Hospitals are charged to do the following:

• Identify patients correctly

• Improve staff communication

• Use medicines safely

• Prevent infection

• Check patient medicines

• Identify patient safety risks

• Prevent mistakes in surgery

The Joint Commission recommends that quality measures be based on the follow­
ing four criteria:

• The measure must be based on research that shows improved outcomes. More
than one research study is required for documentation.

• Reports document that evidence­based practice has been given. Aspirin following
an acute myocardial infarction is an example.

• The process documents desired outcome. Appropriately administering medica­
tions is an example.

• The process has minimal or no unintended adverse effects. (Chassin, Loeb,
Schmaltz, & Wachter, 2010)

The ACA has changed the way that healthcare organizations are paid for health­
care. Previously, healthcare organizations were paid for the volume of care they
provided—that is, the more they did for patients, the more they were paid, regardless
of the outcome. The ACA, however, specifies that healthcare organizations be paid for
the value of their care. One way to assess the value is to measure patient satisfaction.
While in the past most healthcare organizations assessed their patients’ satisfaction
with care, no common instrument existed that could compare those results with other
similar organizations. Thus, three federal agencies—the Centers for Medicare and
Medicaid (CMS), the Agency for Healthcare Research and Quality (AHRQ), and the
Department of Health and Human Services (DHHS)—developed an instrument to
measure patient satisfaction across institutions (Hospital Consumer Assessment of
Healthcare Providers and Systems, 2015).

82 Chapter 6

The result of their efforts is the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS), a 32-item instrument that identifies patients’ per-
ceptions of their care after discharge (HCAHPS, 2015). Hospital scores are publicly
reported (Medicare.gov, 2015), and Medicare reimbursement is now linked to hospi-
tals’ scores on HCAHPS and is known as pay for performance (P4P) or value-based
purchasing (VBP) (Wolosin, Ayala, & Fulton, 2012). Hospitals are challenged to keep
their satisfaction scores high while keeping their costs under control (Dempsey, Reilly,
& Buhlman, 2014).

Evidence-based Practice
Evidence-based practice (EBP) stems from the concept that using research to decide
on clinical treatments would improve quality of care, and that might be the case.
Barriers, however, prevent EBP from being widely used by nurses. Such barri-
ers, consistent across settings, include lack of time, autonomy over their practice,
ability to find and assess evidence, and support from administration (Houser &
Oman, 2010).

Furthermore, EBP is most reliable when the research study includes a rigorous
design (Hader, 2010) and when more than one study has confirmed the results (Chas-
sin et al., 2010). These are not easily surmountable hurdles, due to the fast-paced clini-
cal environment and the barriers previously mentioned.

Electronic Health Records
Also mandated in the ACA is the use of electronic health records (EHRs) that can be
shared across providers. Instant access to identical records improves accuracy, reduces
redundancies, decreases errors, and speeds communication among care providers.
Kutney-Lee and Kelly (2011) found that EHRs improved patient safety, nursing effi-
ciency, and coordination of care. As EHR use expands, more data will be available for
comparison with quality (Amer, 2013).

Dashboards
Dashboards are electronic tools that can provide real-time data or retrospective data,
known as a scorecard. Both data types are useful in assessing quality. Ease of access
and the visual appearance of the dashboard make its use more likely. Dashboards
may report on hospital census or patient satisfaction results, for example. Dash-
boards are also useful to guide staffing and match staffing with patient outcomes
(Frith, Anderson, & Sewell, 2010), and to provide accurate financial data on nurse
staffing and quality (Anderson, Frith, & Caspers, 2011). As technology advances,
widespread use of dashboards to aggregate data and guide decision making is
expected.

Rounding
Another quality method to improve patient satisfaction is rounding, a proactive strat-
egy that has been shown to reduce falls and call light occurrences (Petras, Dudjak, &
Bender, 2013). Known as 4P rounding, this practice requires the nurse or aide to check
pain, potty, position, and possessions every hour (Mitchell, Lavenberg, Trotta, & Ums-
cheid, 2014).

Managing and Improving Quality 83

Reducing Medication Errors
Ever since Medicare discontinued payment for hospital­based errors, pressure has
increased for hospitals to prevent costly errors. In 2009, the federal government passed
the Health Information Technology for Economic and Clinical Health Act (HITECH).
The purpose of HITECH is to stimulate technology use in healthcare, including
improving technology for medication administration.

Studies have shown that when nurses are interrupted during medication prepara­
tion, a 25% rate of injury­causing errors occurs (Westbrook, Woods, Rob, Dunsmuir, &
Day, 2010). One strategy to alert others that a nurse should not be interrupted is the
use of a sash or vest that the nurse dons to prepare medications (Heath & Heath, 2010).

Other strategies to reduce medication errors include computerized prescriber
order entry (CPOE), electronic medication administration record (eMAR), remote
order review by pharmacists, automated dispensing at the bedside, bar code adminis­
tration, smart pumps, and unit doses ready to be administered (Federico, 2010).
Despite increased use of these methods, medication errors still occur far too often
(Leapfrog Group, 2015).

Quality and safety are challenging and ongoing concerns for everyone who works
in healthcare today. Our patients depend on us to continually strive to improve these
processes.

Risk Management
Risk management is a component of quality management. Its purpose is to identify,
analyze, and evaluate risks and then to develop a plan for reducing the frequency and
severity of accidents and injuries. Risk management is a continuous daily program of
detection, education, and intervention (Barger, 2014).

A risk management program involves all departments of the organization. It must
be an organization­wide program, with the board of directors’ approval and input
from all departments. The program must have high­level commitment, including that
of the chief executive officer and the chief nurse.

A risk management program has these responsibilities:

• Identifies potential risks for accident, injury, or financial loss. Formal and informal
communication with all organizational departments and inspection of facilities
are essential to identifying problem areas.

• Reviews current organization­wide monitoring systems (incident reports, audits,
committee minutes, oral complaints, patient questionnaires), evaluates complete­
ness, and determines additional systems needed to provide the factual data essen­
tial for risk management control.

• Analyzes the frequency, severity, and causes of general categories and specific
types of incidents causing injury or adverse outcomes to patients. To plan risk
intervention strategies, it is necessary to estimate the outcomes associated with
the various types of incidents.

• Reviews and appraises safety and risk aspects of patient care procedures and new
programs.

• Monitors laws and codes related to patient safety, consent, and care.

• Eliminates or reduces risks as much as possible.

84 Chapter 6

• Reviews the work of other committees to determine potential liability and recom-
mend prevention or corrective action. Examples of such committees are infection,
medical audit, safety/security, pharmacy, nursing audit, and productivity.

• Identifies needs for patient, family, and personnel education suggested by all of
the foregoing and implements the appropriate educational program.

• Evaluates the results of a risk management program.

• Provides periodic reports to administration, medical staff, and the board of
directors.

Nursing’s Role in Risk Management
In the organizational setting, nursing is the one department involved in patient care
24 hours a day; nursing personnel are therefore critical to the success of a risk manage-
ment program. (See Leading at the Bedside: You and Quality Care.) The chief nursing
administrator must be committed to the program. Her or his attitude will influence the
staff and their participation. After all, it is the staff, with their daily patient contact, who
actually implement a risk management program.

High-risk areas in healthcare fall into five general categories:

• Medication errors

• Complications from diagnostic or treatment procedures

• Falls

• Patient or family dissatisfaction with care

• Refusal of treatment or refusal to sign consent for treatment

Nursing is involved in all of these areas, but the medical staff may be primarily
responsible in cases involving refusal of treatment or consent to treatment.

Incident Reports
Incident reports are used to analyze the severity, frequency, and causes of occurrences
within the five risk categories. Along with medical records, they serve to document
organizational, nurse, and physician accountability. For every reported occurrence,
however, many more are unreported. If records are faulty, inadequate, or omitted, the
organization is more likely to be sued and more likely to lose. Such analysis serves as
a basis for intervention.

Accurate and comprehensive reporting on both the patient’s chart and in the
incident report is essential to protect the organization and caregivers from litiga-
tion. Incident reporting is often the nurse’s responsibility. Reluctance to report inci-
dents is usually due to fear of the consequences. This fear can be alleviated in the
following ways:

• Holding staff education programs that emphasize objective reporting

• Omitting inflammatory words and judgmental statements

• Having a clear understanding that the purposes of the incident reporting process
are documentation and follow-up

• Never using the report, under any circumstances, for disciplinary action

Nursing colleagues and nurse managers should not berate an employee for an inci-
dent, and never in front of other staff members, patients, or patients’ family members.

Managing and Improving Quality 85

A reportable incident should include any unexpected or unplanned occurrence
that affects or could potentially affect a patient, family member, or staff. The report is
only as effective as the form on which it is reported, so attention should be paid to the
adequacy of the form as well as to the data required.

Reporting incidents involves the following steps:

1. Discovery. Nurses, physicians, patients, families, or any employee or volunteer
may report actual or potential risk.

2. Notification. The risk manager receives the completed incident form within
24 hours after the incident. A telephone call may be made earlier to hasten follow-
up in the event of a major incident.

3. Investigation. The risk manager or representative investigates the incident imme-
diately.

4. Consultation. The risk manager consults with the referring physician, risk
management committee member, or both to obtain additional information and
guidance.

5. Action. The risk manager should clarify any misinformation with the patient or
family, explaining exactly what happened. The patient should be referred to the
appropriate source for help and, if needed, be assured that care for any necessary
service will be provided free of charge.

6. Recording. The risk manager should be sure that all records, including incident
reports, follow-up, and actions taken, if any, are filed in a central depository.

Examples of Risk
The following are some examples of actual events in the various risk categories.

Medication errors A reportable incident occurs when a medication or fluid is
omitted, the wrong medication or fluid is administered, or a medication is given to the
wrong patient, at the wrong time, in the wrong dosage, or by the wrong route. Here
are some examples:

Patient A. Weight was transcribed incorrectly from emergency department sheet.
Medication dose was calculated on incorrect weight; therefore, patient was
given double the dose required. Error was discovered after first dose and cor-
rected. Second dose omitted per physician’s order.

Patient B. Tegretol dosage was written in Medex as “Tegretol 100 mg chewable
tab—50 mg po BID.” Tegretol 100 mg given po at 1400. Meds checked at 1430 and

Leading at the Bedside: You and Quality Care
Quality care requires the efforts of every nurse, regardless
of whether that care is in a hospital, a storefront clinic, a
free-standing surgical center, or the patient’s home. No
matter what care the patient receives from other providers,
the nurse is the one constant in the patient’s world. You are
the face of the organization, the staff member called at any

time of the day or night, the person charged with maintain-
ing a safe and healthy environment for your patients.

When mistakes are made (and they will be), you must
learn how to handle and report such adverse events. This
chapter tells you how to do so with dignity for both the
patient and the staff.

86 Chapter 6

error noted. Fifty mg Tegretol should have been given two times per day to
total 100 mg in 24 hours. Doctor notified. Second dose held.

Patient C. During rounds at 1530 found .9% sodium chloride at 75 mLs per hour
hanging. Order was written for D5W to run at 75 mLs per hour. Fluids last
checked at 1400. Changed to correct fluid. Doctor notified.

Diagnostic ProceDure Any incident occurring before, during, or after such
procedures as blood sample stick, biopsy, x-ray examination, lumbar puncture, or
other invasive procedure is categorized as a diagnostic procedure incident.

Patient A. When I checked the IV site, I saw that it was red and swollen. For this
reason, I discontinued the IV. When removing the tape, I noted a small area of
skin breakdown where the tape had been. There was also a small knot on the
medial aspect of the left antecubital above the IV insertion site. Doctor notified.
Wound dressed.

Patient B. Patient found on the floor after lumbar puncture. Right side rail down.
Examined by a physician, BP 120/80, T 98.6, P 72, R 18. No injury noted on
exam. Patient returned to bed, side rail placed up. Will continue to monitor
patient condition.

MeDical–legal inciDent If a patient or family refuses treatment as ordered
and prescribed or refuses to sign consent forms, the situation is categorized as a
medical–legal incident.

Patient A. After a visit from a member of the clergy, patient indicated he was no
longer in need of medical attention and asked to be discharged. Physician
called. Doctor explained to patient potential side effects if treatment were dis-
continued. Patient continued to ask for discharge. Doctor explained “against
medical advice” (AMA) form. Patient signed AMA form and left at 1300 with-
out medications.

Patient B. Patient refused to sign consent for bone marrow biopsy. States side
effects not understood. Doctor reviewed reasons for test and side effects three
different times. Doctor informed the patient that without consent he could not
perform the test. Offered to call in another physician for second opinion. Patient
agreed. After doctor left, patient signed consent form.

Patient or FaMily DissatisFaction with care When a patient or family
indicates general dissatisfaction with care and the situation cannot be or has not been
resolved, an incident report is filed.

Patient A. Mother complained that she had found child saturated with urine
every morning (she arrived around 0800). Explained to mother that diapers
and linen are changed at 0600 when 0600 feedings and meds are given. Patient’s
back, buttocks, and perineal areas are free of skin breakdown. Parents continue
to be distressed. Discussed with primary nurse.

Patient B. Mr. Smith appeared very angry. Greeted me at the door complaining
that his wife had not been treated properly in our emergency department the
night before. Wanted to speak to someone from administration. Was unable to
reach the administrator on call. Suggested Mr. Smith call the administrator in
the morning. Mr. Smith thanked me for my time and assured me that he would
call the administrator the next day.

Managing and Improving Quality 87

Root­cause Analysis
Root-cause analysis is a method to work backward through an event to examine every
action that led to the error or event that occurred; it is a complicated process. A simpli­
fied method to conduct a root­cause analysis follows:

• Patient—What patient factors contributed to the event?

• Personnel—What personnel actions contributed to the event?

• Policies—Are there policies for this type of event?

• Procedures—Are there standard procedures for this type of event?

• Place—Did the workplace environment contribute to the event?

• Politics—Did institutional or outside politics play a role in the event? (Weiss, 2009)

Peer Review
Used to improve care, the peer review process is not intended to serve as a perfor­
mance appraisal nor to be punitive (Spiva, Jarrell, & Baio, 2014). The purpose is to
review an incident, determine if clinical standards were met or not, and propose an
action plan to prevent a future occurrence.

The peer review process is appropriate in the following situations:

• An adverse patient outcome has occurred.

• A serious risk or injury to a patient occurred.

• A failure to rescue incident occurred (Fujita, Harris, Johnson, Irvine, & Latimer,
2009).

A shared governance structure facilitates the peer review process, fostering peer­
to­peer accountability (Fujita et al., 2009). Furthermore, the process can help determine
if a breach in practice is an isolated incident or a trend occurring across a unit or
throughout the organization. In a shared governance environment, unit councils or the
nursing council can address unit­wide or system problems. To aggregate trends, peer
review cases can be categorized as one of the following:

• Appropriate care with no adverse outcomes

• Appropriate care with adverse/unexpected outcomes

• Inappropriate care with no adverse outcomes

• Inappropriate care with adverse/unexpected outcomes

Role of the Nurse Manager
The nurse manager plays a key role in the success of any risk management program.
Nurse managers can reduce risk by helping their staff to view health and illness from
the patient’s perspective. Usually, a staff’s understanding of quality differs from the
patient’s expectations and perceptions. By understanding the meaning to the patient
and the family of the course of illness, the nurse will manage risk better, because that
understanding can enable the nurse to individualize patient care. This individualized
attention produces respect and, in turn, reduces risk.

A patient incident or an expression of dissatisfaction by the patient or the patient’s
family regarding care indicates not only some slippage in quality of care but also
potential liability. A distraught, dissatisfied, complaining patient is a high risk; a

88 Chapter 6

satisfied patient or family is a low risk. A risk management or liability control program
should therefore emphasize a personal approach. Many claims are filed because of a
breakdown in communication between the healthcare provider and the patient. In
many instances after an incident or bad outcome, a quick visit or call from an orga­
nization’s representative to the patient or family can soothe tempers and clarify
misinformation.

In the examples given throughout this chapter, prompt attention and care by the
nurse manager protected the patients involved and may have averted a potential lia­
bility claim. Once an incident has occurred, the following are the important factors in
successful risk management:

• Recognition of the incident

• Quick follow­up and action

• Personal contact

• Immediate restitution (where appropriate)

The concerns of most patients and their families can and should be handled
at the unit level. When that first line of communication breaks down, however,
the nurse manager needs a resource—usually the risk manager or nursing service
administrator.

HAnDLIng COMPLAInTS Handling a patient or family member’s complaints
stemming from an incident can be very difficult. These confrontations are often highly
emotional; the patient or family member must be calmed down, yet have their con­
cerns satisfied. Sometimes just an opportunity to release the anger or emotion is all
that is needed.

The first step is to listen to the person, to identify concerns, and to help defuse the
situation. Arguing or interrupting only increases the person’s anger or emotion. After
the patient or family member has had his or her say, the nurse manager can then
attempt to solve the problem by asking what is expected in the form of a solution. The
nurse manager should ensure that immediate patient care and safety needs are met,
collect all facts relevant to the incident, and, if possible, comply with the patient or
family member’s suggested resolution.

Sometimes, a simple apology from a staff member or moving a patient to a differ­
ent room on the unit can resolve a difficult situation. If the patient and/or family mem­
ber’s requested resolution exceeds the nurse manager’s authority, the nurse manager
should seek the assistance of a nurse administrator or hospital legal counsel. Offering
vague solutions (e.g., “Everything will be taken care of”) may only lead to more prob­
lems later if expectations as to solution and timing differ.

All incidents must be properly documented. Information on the incident form
should be detailed and include all the factors relating to the incident, as demonstrated
in the previous examples. The documentation in the chart, however, should be only a
statement of the facts and of the patient’s physical response; no reference to the inci­
dent report should be made, nor should words such as error or inappropriate be used.

When a patient receives 100 mg of Demerol instead of 50 mg as ordered, the
proper documentation in the chart is “100 mg of Demerol administered. Physician
notified.” The remainder of the documentation should include any reaction the
patient has to the dosage, such as “Patient’s vital signs unchanged.” If there is an
adverse reaction, a follow­up note should be written in the chart, giving an update of
the patient’s status. A note related to the patient’s reaction should be written as

Managing and Improving Quality 89

frequently as the status changes and should continue until the patient returns to his
or her previous status.

The chart must never be used as a tool for disciplinary comments, actions, or
expressions of anger. Notes such as “Incident would never have occurred if Doctor X
had written the correct order in the first place” or “This carelessness is inexcusable” or
“Paged the doctor eight times, as usual, no reply” are wholly inappropriate and serve
no meaningful purpose. Carelessness and incorrect orders do indeed cause errors and
incidents, but the place to address and resolve these issues is in the risk management
committee or in the nurse manager’s office, not on the patient chart.

Handling a complaint without punishing a staff member is a delicate situation.
The manager must determine what happened in order to prevent another occur-
rence, but using an incident report for discipline might result in fewer or erroneous
incident reports in the future. Learn how one manager handled a situation of this
kind in Case Study 6-1.

A CAring Attitude With employees, the nurse manager sets the tone that contrib-
utes to a safe and low-risk environment. One of the most important ways to reduce risk
is to instill a sense of confidence in both patients and families by emphasizing and recog-
nizing that they will receive personalized attention and that their needs will be attended
to with competence. This confidence is created environmentally and professionally.

Examples of environmental factors include cleanliness, attention to patients’ pri-
vacy, promptly responding to patients and family members’ requests, a unit that is
orderly in appearance, and engaging in minimal social conversations in front of

Case study 6-1 | Risk Management
Yasmine Dubois is the nurse manager for the cardiac
catheterization lab and special procedures unit in a subur-
ban hospital. The hospital has an excellent reputation for
its cardiac care program, including the use of cutting-
edge technology. The cath lab utilizes a specialized com-
puter application that records the case for the nursing
staff, requiring little handwritten documentation at the end
of a procedure.

Last month, a 56-year-old woman was brought from
the ER to the cath lab at approximately 1900 for placement
of a stent in her left anterior descending coronary artery.
During the procedure, the heart wall was perforated. The
patient coded and was taken in critical condition to the OR,
where she died during surgery.

Two days following the incident, the patient’s hus-
band requested a review of his wife’s medical records.
During his review, he pointed out to the medical records
clerk that the documentation from the cath lab stated that
his wife “tolerated the procedure well and was taken in sat-
isfactory condition to the recovery area.” The documenta-
tion was signed, dated, and timed by Elizabeth Clark, RN.
The medical records director notified the hospital’s risk

manager of the error. The risk manager investigated the
incident and determined that Elizabeth Clark’s charting
was in error.

Following her meeting with the risk manager, Yasmine
met with Elizabeth to discuss the incident. She showed
Elizabeth a copy of the cath lab report. Elizabeth asked
Yasmine if she could have the chart from medical records
so she could correct her mistake. Yasmine informed Eliza-
beth that she couldn’t correct her charting at this time. But,
she could, however, write an addendum to the chart, with
today’s date and time, to clarify the documentation. Yas-
mine also told Elizabeth that the addendum would be
reviewed by the risk manager and the hospital’s attorney
prior to inclusion in the chart.

To ensure compliance with the hospital’s documenta-
tion standards and to determine whether Elizabeth or any
other cath lab nurse had committed any similar charting
errors, Yasmine requested charts for all patients who had
been sent to surgery from the cath lab during the past
12 months due to complications during a procedure. She
conducted a retrospective audit and determined that this
had been an isolated incident.

90 Chapter 6

patients. One example of portraying professional confidence is to provide patients and
families with the name of the person in charge. A sincere visit by that person is reassur­
ing. In addition, a thorough orientation creates independence for the patient and con­
fidence in an efficient unit.

To encourage staff to be open and honest and to contribute to improving care, the
manager should be certain to thank staff for reporting adverse incidents. Such reports
are opportunities to improve a system or a process rather than to punish an individual.
If the nurse manager has developed a patient­focused atmosphere in which patients
believe their best interests are a priority, the potential for risk will be reduced.

Creating a Blame­free Environment
The healthcare environment is known to be a blame culture that “is a major source of
medical errors and poor quality of patient care” (Khatri, Brown, & Hicks, 2009, p. 320).
Such a culture inhibits reporting of inadequate practice, underreporting of adverse
events, and inattention to possible safety problems.

A just culture, in contrast, allows for reporting of errors without fear of undue
retribution. Khatri et al. (2009) suggest that transitioning to a just culture does more
than improve reporting mechanisms or initiate training programs. A just culture pro­
vides an environment in which employees can question policies and practices, express
concerns, and admit mistakes without fear of retribution. A just culture requires
organizational commitment, managerial involvement, employee empowerment, an
accountability system, and a reporting system (Fanus, Huddleston, Wisotzkey, &
Hempling, 2014).

Accountability for errors, however, must be maintained. Errors can be categorized
as follows:

• Human errors, such as unintentional behaviors that may cause an adverse conse­
quence

• At­risk behaviors, such as unsafe habits, negligence, carelessness

• Reckless behaviors, such as conscious disregard for standards

A just culture is prepared to handle incidents involving human error. At­risk or
reckless behaviors, however, are not tolerated.

Managing and improving quality requires ongoing attention to system­wide pro­
cesses and individual actions. The nurse manager is in a key position to identify prob­
lems and encourage a culture of safety and quality.

What You Know Now
• Total quality management is a philosophy commit­

ted to excellence throughout the organization.

• Continuous quality improvement is a process to
improve quality and performance.

• Six Sigma is another quality management pro­
gram that uses measures, has goals, and is a man­
agement system.

• Lean Six Sigma provides tools to improve flow
and eliminate waste.

Managing and Improving Quality 91

• DMAIC is a Six Sigma process improvement
method to define, measure, analyze, improve,
and control performance.

• Changes mandated by the Affordable Care Act
reimburse healthcare providers for the value of
their care rather than paying for the volume
of care. These changes are expected to continue
even if legislation alters the ACA’s provisions.

• Electronic health records, dashboards, and round­
ing can be used to improve and monitor quality.

• Reducing medication errors is a priority for health­
care organizations and policy makers.

• A risk management program focuses on reducing
accidents and injuries and intervening if either
occurs.

• A caring attitude and prompt attention to com­
plaints help to reduce risk.

• A just culture is more likely to encourage report­
ing of adverse events, including near misses, as
well as to point out unsafe practices.

Tools for Managing and Improving Quality
1. Remember: Quality management is a system.

When something goes wrong, it is usually due to
a flaw in the system.

2. Become familiar with standards and outcome
measures and use them to guide and improve
your practice.

3. Strive for perfection, but be prepared to tolerate
failure in order to encourage innovation.

4. Be sure that performance appraisals and incident
reports are not used for discipline but rather are
the bases for improvements to the system and/or
development of individuals.

5. Remind yourself and your colleagues that a car­
ing attitude is the best prevention of problems.

Following an incident:
1. Meet with the risk manager and hospital attorney

to review documentation and determine which
staff will be interviewed regarding the incident.

2. Provide any requested information to adminis­
tration in a timely manner.

3. Audit documentation and processes to determine
if an incident is part of a pattern or an isolated
incident.

4. Provide the results of any audits or discussions
with staff to appropriate administrators.

5. Educate staff as appropriate.
6. Determine if disciplinary action is required.
7. Follow up with risk management, nursing admin­

istration, and human resources as appropriate.
8. Continue to cooperate with the hospital attorney

if the incident results in litigation.

Questions to Challenge You
1. Imagine that an organization is debating several

quality management programs. What would you
recommend? Why?

2. Do you know what standards and outcome mea­
sures are used in your clinical setting? How are
data handled? Are they shared with employees?

3. What comparable groups, both internal and ex­
ternal, are used for benchmarking performance
in your organization?

4. Universities also use benchmarking. What insti­
tutions does your college or university use to
benchmark its performance? Find out.

5. Have you, a family member, or a friend ever
had a serious problem in a healthcare organiza­
tion that resulted in injury? What was the out­
come? Is this how you would have handled it
today? What will you do in the future in a simi­
lar situation?

6. Have you or anyone you know ever made a mis­
take in a clinical setting? What happened? Would
you assess the organization as a blame­free envi­
ronment?

92 Chapter 6

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Managing and Improving Quality 93

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94 Chapter 7

Chapter 7

Understanding Legal
and Ethical Issues

Learning Outcomes

After completing this chapter, you will be able to:

1. Differentiate between law and ethics.

2. Analyze the ethical principles of autonomy, beneficence,
nonmaleficence, and distributive justice.

3. Examine the sources of law, types of law, and liability in the legal
system.

4. Explore legal issues in nursing involving licensure, patient care,
management, and employment matters.

Key Terms
administrative law

advance directive

allocation

autonomy

beneficence

common law

confidentiality

corporate liability

distributive justice

durable power of attorney

Law and Ethics

Ethical Decision Making
Autonomy

Beneficence and Nonmaleficence

Distributive Justice

The Legal System
Sources of Law

Types of Law

Liability

Legal Issues in Nursing
Nursing Licensure

Patient Care Rights

Management Issues

Employment Issues

94

Understanding Legal and Ethical Issues 95

ethics

informed consent

intentional torts

invasion of privacy

job reassignment

laws

licensure

living will

malpractice

negligence

nonmaleficence

nurse practice acts

personal liability

private law

public law

rationing

respondeat superior

statutory law

tort law

vicarious liability

Introduction
The complexities of today’s healthcare system present many ethical and legal issues
for nurses. Advanced technology, patient autonomy and privacy, and end-of-life deci-
sions are just a few of the factors posing ethical dilemmas. As the role of the profes-
sional nurse expands to include increased expertise, specialization, autonomy, and
accountability, so does the number of legal issues involving nurses. Legal protections
for patients as well as employees and management liability present additional chal-
lenges in healthcare.

Law and Ethics
Laws are rules of conduct, established and enforced by authority, that prohibit
extremes in behavior so that one can live without fear for oneself or one’s property.
Ethics is a science that deals with principles of right and wrong, good and bad; it gov-
erns our relationship with others. Ethics are based on personal beliefs and values that
guide decision making.

Although the definitions of law and ethics may seem clear, there is a fine line
between them, and the two may overlap in some healthcare encounters. In some
cases, the overlap may be congruent; in others, it may be conflictual. For example,
what is ethical may not be legal, and what is legal may not be ethical. Making this
distinction between ethics and law is important because the outcomes are very dif-
ferent: When you violate legal principles, you may be held liable for your actions;
when you violate ethical principles, you may suffer emotionally due to the results
of your actions.

The Code of Ethics of the American Nurses Association (2015), found in
Box 7-1, makes explicit the profession’s values and standards of conduct. Originally
adopted in 1950, this document is revised periodically to reflect changes in the pro-
fession and in society. It serves to inform the nurse and the public of the profes-
sion’s expectations in ethical matters. It also provides a decision-making framework
for solving ethical problems. Although the code of ethics is not legally enforceable,
violation of these standards often is a violation of laws that have been enacted to
ensure protection of the public. For example, breaching a patient’s confidentiality
also violates the law.

96 Chapter 7

Ethical Decision Making
Several key principles play a role in solving ethical dilemmas. The principles most
directly related to nursing are the principles of autonomy, beneficence, nonmalefi-
cence, and distributive justice.

Autonomy
Autonomy is the right of individuals to take action for themselves. It includes respect
for individuals and the right of individuals to make decisions for and about them-
selves, even if those decisions are not congruent with others’ goals. To respect auton-
omy is to respect others. It requires recognizing the uniqueness of others and listening
to and understanding another person in a way that allows you to put yourself in that
other person’s position. Respecting a terminally ill patient’s decision to discontinue
treatment is an example.

People engaged in autonomous and self-determining actions must have the capabil-
ity of self-governance, operate from a stable and internalized set of principles, and view
themselves as capable of implementing autonomous decisions. Inherent in this principle
is the understanding that a person acts with intention, with knowledge, and without
external control or influence. Like most rights, autonomy is not an absolute right: Under
certain circumstances, the individual’s right does not prevail over the rights of others.
Individual autonomy does not prevail when it interferes with the rights, health, or well-
being of another. For example, a nurse has the right to refuse to render care to a patient
because of personal beliefs. However, if the safety of the patient is jeopardized because
of that lack of care, the nurse may suffer legal consequences. Regardless of personal
beliefs, the nurse has an ethical obligation to be sure the patient has adequate care.

Box 7-1 Code of Ethics for Nurses
1. The nurse, in all professional relationships, practices

with compassion and respect for the inherent dignity,
worth, and uniqueness of every individual, unrestricted
by considerations of social or economic status, per­
sonal attributes, or the nature of health problems.

2. The nurse’s primary commitment is to the patient,
whether an individual, family, group, or community.

3. The nurse promotes, advocates for, and strives to pro­
tect the health, safety, and rights of the patient.

4. The nurse is responsible and accountable for individ­
ual nursing practice and determines the appropriate
delegation of tasks consistent with the nurse’s obliga­
tion to provide optimum patient care.

5. The nurse owes the same duties to self as to others,
including the responsibility to preserve integrity and
safety, to maintain competence, and to continue per­
sonal and professional growth.

6. The nurse participates in establishing, maintaining,
and improving healthcare environments and condi­
tions of employment conducive to the provision of qua­
lity healthcare and consistent with the values of the
profession through individual and collective action.

7. The nurse participates in the advancement of the pro­
fession through contributions to practice, education,
administration, and knowledge development.

8. The nurse collaborates with other health professionals
and the public in promoting community, national, and
international efforts to meet health needs.

9. The profession of nursing, as represented by asso­
ciations and their members, is responsible for articu­
lating nursing values, for maintaining the integrity of
the profession and its practice, and for shaping
social policy.

Source: From Code of Ethics for Nurses with Interpretive Statements 2015. Reprinted with permission from American Nurses Association. Washington, DC: American
Nurses Association.

Understanding Legal and Ethical Issues 97

Beneficence and Nonmaleficence
Beneficence is the duty to help others by doing what is best for them. This belief also
implies the principle of nonmaleficence, or to “do no harm.” One has the duty not
only to do good but also not to inflict harm or to risk harm to others. A beneficent
nurse acts with empathy for the patient without resentment or malice. A nurse who
acts in bad faith or out of ill will or who makes false accusations concerning a patient
or employee violates the principle of beneficence.

In many instances, the demands of beneficence and the functions required in a
healthcare setting come into conflict. Sometimes, for example, treatment decisions are
viewed as harmful from the patient’s perspective. When an individual does not desire
what others determine to be in that person’s best interest—such as when a patient
refuses treatment—the principles of beneficence and autonomy conflict. Generally
speaking, in conflict situations involving patient care decisions, the principle of auton-
omy overrides the principle of beneficence.

Distributive Justice
Distributive justice is giving a person that which he or she deserves. It implies that
benefits and burdens ought to be distributed equally and fairly, regardless of race,
gender (including gender orientation and gender identity), religion, or socioeco-
nomic status so that no one person bears a disproportionate share of benefits or
burdens. As healthcare technology advances and healthcare costs continue to climb,
nurses may find themselves entrenched in conflicts between cost containment and
the equal distribution of finite healthcare resources regardless of the patient’s abil-
ity to pay.

Allocation (macroallocation) and rationing (microallocation) of scarce resources
continue to be concerns in healthcare today. Allocation is the decision society makes
regarding how many of its resources will be devoted to a particular effort—for exam-
ple, organ transplants. Rationing is a decision regarding who gets the service or sup-
ply and who does not—again using the example of organ transplants. Allocation and
rationing decisions require that some societal values take precedence over some indi-
vidual values. For example, decisions about recipients for heart transplants require
consideration of the availability of hearts, the likelihood of the patient to survive, and
the patient’s age. The societal goal is to implant hearts in people most likely to survive
and thrive in the future.

The Legal System
Law comes from a variety of sources. Understanding the sources of law and the vari-
ous types of laws helps determine their impact on nursing practice. Nurses must
understand the changing legal climate and their responsibilities as viewed by the pub-
lic and the legal system.

Sources of Law
Three branches of government—legislative, judicial, and executive—contribute to
the creation of law. They, in conjunction with the Constitution, form the basis of
the judicial system of the United States. The Constitution is the supreme law of

98 Chapter 7

the land. It defines the structure, power, and limits of the government and guar-
antees people certain fundamental rights as individuals. Influences of the three
branches of government are reflected in statutory law, common law, and adminis-
trative law.

StAtutory LAw Statutory law is enacted by the legislative branch of government.
This type of law is designed to declare, command, or prohibit something. Licensing
laws for healthcare providers, including nurses, are examples of statutory laws that
protect the public from incompetent practitioners. Other statutory laws affecting nurs-
ing practice are guardianship codes, statutes of limitation, informed consent, living
will legislation, and protective and reporting laws.

Common LAw Common law is judge-made law. This type of law is derived
from earlier decisions made by courts. Common law establishes a custom or tradi-
tion by which other similar cases are judged; this custom is referred to as legal prec-
edent. Common law is not absolute. Earlier decisions can be and frequently are
overruled. As time and circumstances change, court decisions become obsolete and
may require a different opinion. Each state has its own body of common law related
to the delivery of healthcare within that state. These laws should be reviewed by
health professionals as a basis for accountability, quality, and risk management
within their professional practice. Awareness of these laws assists nurses in func-
tioning within the boundaries of their role and advocating for nursing practice
when necessary.

ADminiStrAtivE LAw Administrative law is made by administrative agencies.
According to certain statutes, administrative agencies are granted authority to enact
rules and regulations that will carry out specific intentions of the statute. This allows
the legislature to delegate to an administrative agency of experts in the field the
authority to create rules and regulations governing a specific area of practice. For
example, state boards of nursing are authorized by nurse practice acts (statutory law)
to write rules and regulations governing the practice of nursing. These rules and regu-
lations are incorporated into the nurse practice act and are as binding as the statutory
law itself. Another example of administrative law is the attorney general’s opinion
regarding the interpretation of a law, which also is binding.

Types of Law
Law also can be categorized according to specific types. The two basic types of law are
public law and private law (civil law). Public law consists of constitutional law, admin-
istrative law, and criminal law. Private law is further classified into tort law, contract
law, and protecting and reporting law. All these have an impact on nursing practice,
but the most common law affecting nursing practice is tort law.

tort LAw tort law is divided into two categories—unintentional and intentional.
Negligence and malpractice (professional negligence) fall under the category of unin-
tentional torts.

negligence is defined as the failure of an individual not to perform an act (omis-
sion) or to perform an act (commission) that a reasonable, prudent person would or
would not perform in a similar set of circumstances. malpractice is professional negli-
gence. It evolves from negligence law and the premise that all individuals are respon-
sible for the consequences of their actions or inactions. It refers to any misconduct or

Understanding Legal and Ethical Issues 99

lack of skill in carrying out professional responsibilities. For malpractice to exist, four
elements must be present:

• Duty

• Breach of duty

• Causation

• Injury

If there is no preponderance of evidence that demonstrates negligence, then the
malpractice claim may be dismissed.

In intentional torts, the intent to harm is present. Assault (including sexual
assault), battery, false imprisonment, invasion of privacy, inappropriate disclosure of
private information, libel, slander, and defamation of character are examples of inten-
tional torts.

Liability
To understand malpractice, one must understand the various types of liability. As indi-
viduals, nurses are responsible and accountable for their own actions or inactions. This
is referred to as personal liability. In addition, the law ascribes negligence to certain
parties who may not be negligent themselves but whose negligence is assumed
because of association with the negligent person. This is called vicarious liability. It is
based on the legal principle of respondeat superior, which means “let the master
speak.” This doctrine allows the courts to hold the employer responsible for the actions
of the employee when the employee is performing services for the organization.

All too frequently, nurses have a false sense of security concerning the doctrines of
respondeat superior and vicarious liability. Employees sometimes believe that the
organization’s responsibility protects them from being sued as individuals, but this is
not the case. Patients have the right to sue both the employee and the organization
when they have suffered an injury as a result of substandard care. Also, the organiza-
tion has the right to sue the employee for damages incurred as a result of the nurse’s
substandard care. For these reasons, it is important for nurses to carry their own per-
sonal liability insurance.

Nurse mangers are not responsible for the actions of others but are responsible for
their own acts of delegation and supervision of others. Failure to delegate and super-
vise properly can result in liability for the nurse manager. This is not a result of vicari-
ous liability but, rather, an issue of personal liability.

Corporate liability holds that the organization is responsible for its own wrongful
conduct. The healthcare organization has the responsibility to maintain an environ-
ment conducive to quality healthcare for its consumers. Corporate liability includes
the following:

• The duty to hire, supervise, and maintain qualified, competent, and adequate
staff

• The duty to provide, inspect, repair, and maintain reasonably adequate equipment

• The duty to maintain safety in the physical environment.

Responsibility to achieve these goals is delegated to managers even though the
organization is ultimately responsible. For example, the organization has a responsi-
bility to have a mechanism in place to report incompetent, unethical, and illegal

100 Chapter 7

practice. If the nurse manager is aware of such practice but does not report it, the nurse
manager also is liable. Many states have statutory laws regarding mandatory report-
ing of legal violations.

Legal Issues in Nursing
Legal issues in nursing involve licensure, patients’ rights, and management and
employment matters. Each of these topics poses challenges for nurses and managers.

Nursing Licensure
Licensure is a credential provided for by state statutes that authorizes qualified indi-
viduals to perform designated skills and services. In nursing, these statutes are referred
to as nurse practice acts. Each state establishes its own board of nursing whose mem-
bers are granted the authority to set and enforce rules and regulations pertaining to the
practice of nursing, including the requirements for licensure in that state. Licensure
protects the use of the titles—registered nurse, practical nurse, or advanced practice
nurse—and establishes standards for education, examination, and behavior to protect
the health, safety, and welfare of the public.

Because each state controls and maintains its own database of licensees, mobility
for nurses is hampered. To practice in a state other than the one in which the nurse is
already licensed, an RN must apply for a reciprocal license from that state. Although
all RNs take the same licensure exam, not all states’ policies regarding nursing practice
are alike, such as requirements to complete continuing education.

uniform LiCEnSurE rEquirEmEnt One remedy proposed by the National
Council of State Boards of Nursing (NCSBN) is to develop uniform licensure require-
ments among the states that would not only facilitate nurse mobility, but also
ensure public access to qualified practitioners (National Council of State Boards of
Nursing, 2011).

muLtiStAtE LiCEnSurE Another initiative by the NCSBN is multistate licensure.
Multistate licensure is a process similar to obtaining a driver’s license, allowing prac-
tice in more than one state. As of May 2015, twenty-five states have entered an inter-
state compact to allow multistate licensure privilege (National Council of State Boards
of Nursing, 2015). The state of residence is considered the home state. All other states
in the contract are remote states. The nurse is still responsible for meeting the stan-
dards set forth by the nurse practice acts in which he or she practices. Disciplinary
actions may be taken by both the home and remote states.

moDEL nurSE PrACtiCE ACt The NCSBN also has developed a model nursing
practice act (National Council of State Boards of Nursing, 2012). The model act defines
nursing, its scope of practice, titles, advanced practice nursing standards, educational
requirements, and violations and penalties. Improved uniformity among states would
result if states adopt the model act.

Patient Care Rights
When individuals enter the healthcare system, they retain the basic fundamental rights
ascribed to them by the Constitution and courts of law. Additional rights are designed

Understanding Legal and Ethical Issues 101

to protect the rights of individuals at the times when they are most vulnerable. These
include the right to privacy and confidentiality, the opportunity to make informed
consent, the right to refuse treatment, and the right to be free from restraint.

PrivACy rightS invasion of privacy is the violation of a person’s right to be left
alone without being subjected to unwarranted or uninvited publicity and to make per-
sonal choices without interference. Information disclosed by the patient is confidential
and as such is available to authorized personnel only. Patients can sue for invasion of
privacy when confidential information is revealed to any unauthorized person. Simi-
larly, a patient can sue for invasion of privacy when unauthorized personnel, directly
or indirectly, observe the patient without permission. Authorized personnel are those
involved in the diagnosis, treatment, and related care of the patient. Generally speak-
ing, these are members of the healthcare team.

Nurses, as well as others, may not use photos, videos, or research data without the
explicit permission of the involved patient. Also, the nurse should be discreet about
the release of information over the phone regarding the patient’s status because it is
difficult, if not impossible, to identify the caller accurately over the phone. The nurse
must even obtain the patient’s permission to release information to family members
and close friends.

Other cases regarding invasion of privacy involve the freedom to make choices
without interference. Patients have the right to make informed choices, such as contra-
ception use, abortion, and the right to refuse treatment. Furthermore, they should be
assured that these decisions will be respected and upheld even if they are not the same
decisions or choices the health professional might make. Nurses often serve as advo-
cates to safeguard these rights.

Difficulty arises when the nurses’ personal beliefs interfere with their caregiving.
Some issues that nurses raise include death with dignity versus extraordinary lifesav-
ing measures, use of medical marijuana, and, not surprisingly, abortion of a nonviable
fetus. The manager’s role is to support nurses in their personal beliefs while, at the
same time, ensuring that all patients receive unbiased care.

The Health Insurance Portability and Accountability Act (HIPAA), implemented
in 2003, (U.S. Department of Health & Human Services, 2015a) requires healthcare
providers, including individuals and organizations, to take far more stringent mea-
sures to ensure their patients’ privacy than were required previously. Communication
between providers requires a release from the patient. Offices and public places in
healthcare agencies must prevent names and identifying information from being over-
heard or seen. Providers must be certain that mail, fax, email, texts, and voice mes-
sages are accessible only by the patient. Complying with the requirement for HIPAA
involved a major overhaul of most healthcare systems, but soon protecting patients’
privacy became standard nursing practice (Wielawski, 2009).

ConfiDEntiALity Confidentiality is the right to privacy of records. Individuals
have the right to believe that information disclosed to health professionals is to be
used strictly for the purpose of diagnosis and treatment and will not be released to
others without permission of the individual. This is considered protected information
by the privilege doctrine. According to this doctrine, people who have protected rela-
tionships cannot be forced to reveal communication unless the other person in the
relationship agrees to it.

Confidentiality assurances were strengthened with the regulation of HIPAA.
Under certain circumstances, the nurse can lawfully disclose confidential information

102 Chapter 7

about the patient, such as when the welfare of a person or a group is at stake or when
a personal injury or workers’ compensation claim is filed.

informED ConSEnt Three basic requirements are necessary for informed con-
sent: capacity, voluntariness, and information. Individual capacity to consent is deter-
mined by age and competence. Generally, one must be an adult in the technical and
legal sense in order to consent to treatment. The legal age for adult status is established
by state statute and varies from state to state. Based on the state statute, minors may
consent to certain types of treatment, such as abortion or substance abuse treatment.
Adults are considered competent when they can make choices and understand the
consequences of their choices.

Individuals act voluntarily when they exercise freedom of choice without force,
fraud, deceit, duress, or any other form of coercion. Consent that is compelled by
threat or provoked by fraud is legally considered to be no consent at all. Because
patients are exceptionally vulnerable when they need medical care, they may believe,
or be led to believe, that they must comply with the recommendations of healthcare
professionals. Often patients believe that if they do not comply, they may get less than
adequate care or no care at all. All too frequently, nurses and other health professionals
take it for granted that because a patient is under their care, the patient will agree to
whatever care is deemed necessary. Nurses have an obligation to create an atmosphere
that avoids any indication of coercion or manipulation. To provide treatment without
the patient’s consent, except in an emergency situation, could result in liability for
unauthorized touching or battery.

The third element of informed consent is information. Information must be sup-
plied to patients in a manner that is understandable to them. Lay terminology is pre-
ferred to professional jargon. The information must include the following:

• An explanation of the treatment to be performed and the expected results

• A description of the anticipated risks and discomforts

• A list of potential benefits

• A disclosure of possible alternatives

• An offer to answer the patient’s questions

• A statement that the patient may withdraw his or her consent at any time

The legal responsibility to provide the necessary information for informed con-
sent rests with the individual who will perform the treatment. When a nurse asks a
patient to sign a consent form, the nurse is merely attesting to the fact that there is
reason to believe that the patient is informed regarding the impending treatment
and is witnessing the signature. If the nurse asks the patient to sign a consent form
knowing that the patient has had no prior explanation of the treatment, the consent
is invalid.

right to rEfuSE trEAtmEnt Just as competent adults have the right to consent
to treatment, they also have the right to refuse treatment. In addition, guardians of
incompetent adults have the right to refuse treatment for them. The right of competent
adults to refuse treatment is guaranteed by the Constitution and has been tested in
court with several landmark cases (Cruzan v. Director, Missouri Department of Health,
1990; Quinlan v. New Jersey, 1976; Schindler v. Schiavo, 2005). Most states have adopted
statutory laws to protect these rights and to protect the healthcare provider who agrees
to not treat even when treatment could be considered medically indicated. The legal

Understanding Legal and Ethical Issues 103

documents that adhere to these laws and protect individuals are referred to as advance
directives, living wills, and durable powers of attorney.

As a direct result of the Cruzan case, Congress enacted the Patient Self-Determination
Act in 1990 (Koch, 1992). This federal law requires every healthcare facility that receives
Medicare or Medicaid funds to provide written information to adult patients concern-
ing their right under state law to make healthcare decisions. These decisions include the
right to accept or refuse treatment and the right to formulate advance directives.

An advance directive is a document that allows a competent patient to make
choices prior to the need for medical treatment. Examples include decisions such as
refusing nourishment, being placed on a ventilator, or stopping treatment. The two
most common advance directives are a living will and a durable power of attorney for
healthcare.

With a living will, the competent adult signs a form indicating what healthcare
the person does and does not want in the event of terminal illness. An individual may
want all lifesaving measures continued no matter how dire the prognosis, or a person
might want only comfort measures should the need arise. These decisions will be
upheld should that adult’s decision-making capacity be lost.

Both Case Study 7-1 and Leading at the Bedside: Respecting Patient Directives
highlight the importance for nurses to respect the patient’s wishes as expressed in these
legal documents.

A durable power of attorney for healthcare decisions permits a competent
adult to appoint a surrogate or proxy to make decisions in the event that the indi-
vidual becomes unable to do so. The healthcare provider must follow the
expressed wishes as stated in these documents. Difficulties arise when the patient
is unconscious and does not have an advance directive or the directive is vague.
In these cases, the health provider often relies on family members to make these
decisions. In most states, however, family members do not have the legal author-
ity to make such decisions unless they are the legally appointed guardians or
parents.

Freedom From restraint Another potential area of liability is the use of
restraints. The Omnibus Budget Reconciliation Act (OBRA) of 1987 provides patients
the right to be free from any physical or chemical restraint imposed for the purpose
of discipline or convenience and not required to treat medical symptoms. These reg-
ulations apply to nursing homes, state and federal agencies, and other healthcare
organizations that receive Medicare and Medicaid funds. According to these rules,
health professionals are required to assess the need for restraints and consider the
use of alternative measures. When restraints are deemed necessary, a physician’s
order specifying duration and circumstances is required. No order for as-needed
(PRN) restraints is permitted. When restraints are used, the patient must be moni-
tored closely and reassessed periodically to evaluate the continued need for
restraints. In addition to federal regulations, most states have laws governing the
use of restrictive devices.

Federal mandates also call for the judicious use of psychotropic drugs, which
are frequently used as chemical restraints. Psychotropic drugs no longer may be
used for the purpose of controlling behavior; they may be prescribed only for
diagnosis-related conditions. The intention is to prevent indiscriminate use of psy-
chotropic drugs that frequently cause patients to become sedated, agitated, or
combative.

104 Chapter 7

Leading at the Bedside: Respecting Patient Directives
As a nurse, you will undoubtedly encounter ethical issues
as you care for patients. You may find that your personal
beliefs conflict with the patient’s decisions or the medical
recommendations. You may even face legal issues at some
point in your career. Only you can decide if your personal
beliefs are such that you cannot care for the patient or that
you can provide compassionate care in spite of your views.

Here is an example: Your patient is terminally ill, but
both he and his family want to “do everything.” You believe

in the patient’s autonomy, but you also know that contin-
ued interventions will cause him pain, reduce his ability to
interact with his family, and prolong his inevitable death.
Plus, you have watched several of your own family mem-
bers suffer long and painful deaths. Although you think that
you would make a different decision if you were the patient,
you continue to care for him and his family with compas-
sion and respect.

Case study 7-1 | death with dignity
For 2 weeks Kristine, an RN on the medical surgical unit,
had been caring for a young woman on her shifts. The
young woman, Enid, was 36 years old and had been diag-
nosed with a rare neurological disease. Married with three
young daughters, Enid had an extended family that visited
her often in the hospital.

During rounds, in which Kristine had participated, the
physicians told Enid they would get her through her imme-
diate crisis and work on getting her on some medications
to help her symptoms with her newly diagnosed disease.
Throughout her hospital stay, Enid learned that her disease
was ultimately fatal and that in the next year or two she
would likely develop complete paralysis and be unable to
communicate or take care of herself, and eventually need a
breathing tube and feeding tube to stay alive.

Kristine had been quiet and contemplative in recent
days. Then, one morning, Kristine walked in to greet Enid
and share that she would be her nurse again that day. Kris-
tine was growing very fond of Enid. Kristine was also a
young woman and a mother. She had been thinking about
how sad she would be if she developed the condition that
Enid had.

That same morning, Enid asked Kristine to sit down
and talk with her. Enid shared that she had been thinking
for many days about her future and the complications of
her disease that would limit her length and quality of life.
Enid shared that she did not want her husband caring for
her or her children to grow up with a mom who was not
taking care of them. Enid told Kristine that one of her
worst nightmares was coming true. Kristine tried to com-
fort Enid. Enid told Kristine she wanted to learn about the
death with dignity movement and was considering

choosing when her life would end as her disease pro-
gressed.

Kristine was devastated and angry. She couldn’t
believe Enid would want to choose to die and not be a
mom to her kids. Kristine did not know what to say to Enid,
so she only said that she would tell the doctor and left
Enid’s room.

Kristine went to find her nurse manager. Kristine cried
as she told her manager what Enid had said. Kristine said
she did not think she could take care of Enid if she wanted
Kristine to help her kill herself.

Kristine’s nurse manager listened thoughtfully. When
Kristine was finished talking for a moment, her nurse
manager helped her sort through her feelings and think
about what the present scenario really presented to
Kristine.

Enid was not asking Kristine to help her end her life.
Enid had only shared her thoughts with Kristine because
she trusted her as her nurse. The manager went on to
remind Kristine that in their state death with dignity was not
offered, and Kristine would need to explore those options
after her discharge from the hospital and decide what was
right for her. Ultimately, Kristine’s role remained to provide
good care to Enid during her admission and help her pro-
gress to a safe discharge from the hospital. As the nurse
manager talked, Kristine began to think about her conver-
sation with Enid differently.

Kristine left her manager’s office feeling better. She still
did not agree with Enid’s thoughts but realized her role was
to take care of Kristine in her current healthcare crisis and
support a safe discharge when the time came so Enid could
move on with her life and decide how she wanted to live.

Understanding Legal and Ethical Issues 105

The use of restraints should be based on the principles of informed consent. If
patients are unable to consent, then reliable proxy consent should be obtained with
full disclosure of risks and benefits. Restraining patients without consent or suffi-
cient justification may be interpreted as false imprisonment. In additional to legal
rights, the use of restraints clearly involves ethical issues such as autonomy and
beneficence.

Management Issues
Management includes delegation and supervision, staffing the area of responsibility,
reassigning staff as needed, following the organization’s policies and procedures, and
ensuring that patient privacy is maintained. In addition, management concerns
involve identifying and addressing incompetent practice, and familiarity with national
records of sanctions against healthcare professionals.

DELEgAtion AnD SuPErviSion Nursing management encompasses supervi-
sion of nursing care and the personnel who provide that care. Nurses are personally
liable for the reasonable exercise of the delegation and supervision activities. They
must be aware of the staff member’s knowledge, skills, and competencies when dele-
gating tasks and should supervise them appropriately. Nurses have a legal duty to
ensure that staff members under their supervision are performing in a manner consis-
tent with the accepted standard of practice. If a nurse makes an assignment to an indi-
vidual who the nurse knows is not competent to perform that assignment, the nurse
will be liable if the patient is injured.

StAffing According to established standards, the organization must provide ade-
quate staffing with qualified personnel (Joint Commission, 2015). The organization
that fails to retain the level of nursing personnel required to provide safe, quality care
may be held liable under the doctrines of respondeat superior and corporate liability if
an injury occurs related to short staffing.

Although retaining appropriate nursing personnel is the responsibility of the
organization, if it can be shown that the staff nurse acted unreasonably under the
circumstances, the individual nurse also can be held liable for acts of omission or
commission. In other words, inadequate staff is no excuse for negligent acts. If the
nurse acts reasonably under the circumstances, however, the individual may not
be found culpable for malpractice. In addition, if the hospital can demonstrate that
it has taken appropriate actions to alleviate the staffing crisis, then it may not be
held liable.

Staffing an organization is not as clear-cut as it may seem. Although the organi-
zation has some guidelines to follow, such as those mandated by federal and state
regulatory bodies, these guidelines are broad and require a certain amount of judg-
ment. Adequate staffing includes not only the number of staff but also their skill
level (e.g., RN, LPN, UAP), their experience, and the unit to which the will be
assigned (e.g., critical care).

JoB rEASSignmEnt The hospital has a legal duty to ensure that all areas of the
hospital are adequately staffed. With fluctuating patient census, this often places the
hospital in a position in which reassigning nurses’ duties is the only way to balance
the needs of the unit and the safety of patients. Job reassignment (floating) is the pro-
cess of pulling nurses from one area of the hospital to another. This practice is

106 Chapter 7

commonplace in today’s healthcare organizations, but concerns are raised about it by
both staff and administration. Floating nurses to unfamiliar areas, especially specialty
areas, increases the chance of error and may increase nurses’ anxiety, which in turn
may affect job satisfaction and morale.

The nurse who refuses to float may face the possibility of discharge on the grou-
nds of insubordination, although nurses have argued that they do not have the requi-
site skills to care for patients in the intended unit (Guido, 2014). Nurses have a
responsibility to serve in the best interest of the patient. Some solutions to the problem
of reassignment are open communication regarding limitations and concerns, creative
problem solving, and cross-training.

PoLiCiES AnD ProCEDurES When the nurse is responsible for performing proce-
dures that require judgments beyond the usual scope of nursing practice, a standard-
ized procedure, or protocol, is necessary. These procedures must be written and
authorized by the organization. Routinely, the standardized protocol must specify the
following:

• Functions the nurse may perform under specific circumstances

• Requirements that must be followed in performing the function

• Education, experience, and training requisites of the nurse performing the
procedures

• Method for evaluating the competence of the nurse performing the practice

Policies and procedures are required for all healthcare organizations. These docu-
ments serve to standardize care, set standards, and guide practices. They should be
well delineated, clearly stated, and based on current and actual practice.

rELEASE of informAtion The same guiding principles regarding release of
information about patients also apply to release of information about employees.
Information about employees is considered confidential and must not be released out-
side the organization without the explicit consent of the employee, except to verify
employment or to comply with a legal investigation. The Privacy Act of 1974 (1974)
outlined the stringent requirements for handling personnel matters related to privacy
issues. The nurse manager needs to be familiar with this law, especially as it relates to
giving references and recommendations.

inComPEtEnt PrACtiCE The “due care” standard requires nurse managers to
confront unsafe practice. It is important for the nurse manager to be familiar with
both the organization’s procedures for addressing safety and professional conduct
and the state board of nursing guidelines. Many states have instituted mandatory
reporting of unsafe practices to safeguard public health. Mandatory reporting is a
complex process involving both legal and ethical parameters. The vast majority of the
complaints and disciplinary actions related to mandatory reporting are for impair-
ment or drug diversion.

nAtionAL PrACtitionEr DAtE BAnk The National Practitioner Date Bank
(NPDB) serves as an information clearinghouse regarding adverse actions, such as
licensure sanctions against healthcare professionals, including physicians and nurses
(U.S. Department of Health and Human Services, 2015b). Federal regulations require
healthcare institutions, licensing boards, professional societies, and malpractice pay-
ers to report any actions taken against professionals.

Understanding Legal and Ethical Issues 107

Employment Issues
Nurses who serve in management roles are also employees, so they need to be familiar
with the growing body of discrimination laws for themselves as well as for those they
supervise. Discrimination statutes have a profound effect on hiring, advancement, and
termination practices. Matters of employee rights have been pronounced since the
passage of the Civil Rights Act of 1964. Today, we continue to see increased activity
related to discrimination of various kinds, and many states have enacted laws govern-
ing civil rights and discrimination.

CiviL rightS ACtS Title VII of the 1964 Civil Rights Act (CRA) bars discrimina-
tion on the basis of race, color, sex, or national origin (1991). Title VII governs all public
and private agencies with 15 or more employees and addresses all aspects of employ-
ment (e.g., hiring, promotion, discipline, supervision, performance appraisal, dis-
missal). The Equal Employment Opportunity Commission (EEOC) is the federal
agency that administers and enforces Title VII.

Two exceptions to the law are the bona fide occupational qualifications (BFOQ)
and bona fide seniority or merit system. The BFOQ states that it is lawful to make
employment decisions on the basis of national origin, religion, and sex (but not race) if
this is necessary for the job. Examples include mandatory retirement ages for airplane
pilots, required beliefs for teachers in religious schools, or proficiency in a second lan-
guage (but not national origin) for some nurses.

SExuAL hArASSmEnt In 1991, the Civil Rights Act was amended to expand the
definition of sexual harassment in the workplace and to delineate the employer’s
responsibilities. Specifically, the employer can be held liable for acts of sexual harass-
ment committed by employees, whether or not the employer had any prior knowledge
of the reported acts. Employers must establish proactive policies to sensitize employ-
ees to the problem and prevent its occurrence.

AgE DiSCriminAtion in EmPLoymEnt ACt Passage of the Age Discrimina-
tion in Employment Act (ADEA) in 1967 made it unlawful for employers to discrimi-
nate against older men and women in decisions regarding all phases of employment.
Discrimination against individuals over the age of 40 and mandatory retirement for
persons at any age are prohibited.

AmEriCAnS with DiSABiLitiES ACt Title I of the Americans with Disabilities
Act (ADA) of 1990 is designed to eliminate discrimination against disabled persons in
employment by enforcing equal access to jobs and accommodations. The ADA defines
disability as follows:

• A physical or mental impairment that substantially limits one or more major life
activities

• A record of such impairment

• Being regarded as having such impairment

These guidelines apply to all phases of the employment process, including hiring,
promotion, compensation, training, and termination. Furthermore, the ADA requires
employers to provide reasonable accommodations for disabled employees, including
those recovering from alcohol or substance abuse. Reasonable accommodations might
include providing a leave of absence with or without pay, job reassignment, or job
restructuring.

108 Chapter 7

fAmiLy AnD mEDiCAL LEAvE ACt The Family and Medical Leave Act (FMLA) of
1993 provides eligible employees with a leave of up to 12 weeks during any 12-month
period for the employee’s own serious illness, the birth or adoption of a child, or the
care of a seriously ill child, spouse, or parent.

oCCuPAtionAL SAfEty AnD hEALth ACt The Occupational Safety and Health
Act of 1970 was established to ensure a safe and healthful work environment for
employees. OSHA standards are sets of rules designed to minimize specific on-the-job
risks to employees. These risks include exposure to toxic chemicals, infectious agents,
hazardous waste, and dangerous equipment.

In 1991, the Occupational Safety and Health Administration (OSHA) published
regulations designed to reduce infection from bloodborne pathogens. It applied to all
occupations and covered exposure to blood and other body fluids. Then, in 2000, Con-
gress passed the Needlestick Safety and Prevention Act, which required employers to
select and use safer medical devices, including needleless systems, to reduce the dan-
ger from bloodborne pathogens.

As the world learned from the Ebola outbreak in 2014, the usual protective gear
and procedures were not always adequate to protect healthcare workers. Also, as
new viruses emerged (e.g., severe acute respiratory syndrome [SARS] in the early
2000s and Middle East respiratory syndrome [MERS] in 2014), healthcare orga-
nizations will continue to be challenged to protect both their patients and their
employees.

Nurse managers are challenged today to provide quality healthcare, manage
employee concerns, and meet legal and ethical standards of the profession. This is no
small task. Careful attention to the law and to ethical guidelines will help managers
meet their obligations.

What You Know Now
• Both ethical and legal principles guide the prac-

tice of nurses and nurse managers.

• Ethics deal with principles of right and wrong,
are based on personal beliefs and values, and
govern our relationships with others.

• The Code of Ethics for Nurses explicitly defines
the profession’s values and standards of conduct.

• Laws are rules of conduct, established and
enforced by authority, that prohibit extremes in
behavior so that one can live without fear for self
or property.

• Negligence is the failure of an individual to per-
form or not perform an act that a reasonably pru-
dent person under the same circumstances would
or would not perform.

• Liability may be personal, vicarious, or corporate.

• Liability issues that directly concern nurse man-
agers are delegation and supervision, staffing,
floating, policies and procedures, unsafe practice,
and employment regulations.

• Nurse managers must be knowledgeable about
federal and state laws governing patient care as
well as employee supervision and responsibility.

Understanding Legal and Ethical Issues 109

References
American Nurses Association. (2015). Code of ethics for

nurses with interpretive statements. Washington, DC:
American Nurses Association.

Cruzan v. Director, Missouri Department of Health
(1990), 23, 137, 141-142, 146t.

Guido, G. W. (2014). Legal and ethical issues
in nursing (6th ed.). Upper Saddle River,
NJ: Pearson.

Joint Commission. (2015). Standards information for
health care staffing services. Retrieved June 23,
2015, from http://www.jointcommission.org/
certification/hcs_standards.aspx

Koch, K. A. (1992). Patient Self-Determination Act.
Journal of the Florida Medical Association, 79(4),
240–241.

National Council of State Boards of Nursing. (2011).
The 2011 Uniform Licensure Requirements. Retrieved
March 6, 2016, from http://www.ncsbn.org/12_
ULR_table_adopted

National Council of State Boards of Nursing. (2012).
NCSBN model act. Retrieved June 18, 2015, from
http://www.ncsbn.org/14_Model_Act_0914

National Council of State Boards of Nursing. (2015).
Nurse licensure compact. Retrieved June 18, 2015,
from http://www.ncsbn.org/nurse-licensure-
compact.htm

Privacy Act of 1974, 5 U.S. Code Section 552a (1974).
Quinlan v. New Jersey, 355 A. 2d 647 (NJ 1976).
Schindler v. Schiavo, 403 F.3d 1289 (11th Cir. 2005).
U.S. Department of Health & Human Services. (2015a).

Summary of the HIPAA privacy rule. Retrieved June
17, 2015, from http://www.hhs.gov/ocr/privacy/
hipaa/understanding/summary/index.html

U.S. Department of Health & Human Services. (2015b).
National Practitioner Data Base (NPDB). Retrieved
June 19, 2015, from http://www.npdb.hrsa.gov

Wielawski, I. M. (2009). HIPAA: Not so bad after all?
American Journal of Nursing, 109(7), 22–24.

Questions to Challenge You
1. Study the Code of Ethics for Nurses. Do you agree

with it? Explain your reasons.
2. Have you been faced with an ethical dilemma?

Are you satisfied with the way you handled your
part? How did it turn out? Would you handle a
similar situation differently now?

3. You are manager of the home care division of a
healthcare organization. What regulations might
apply in the following situations?
a. An employee’s husband has just been diag-

nosed with cancer.

b. An employee who has been on sick leave
returns to announce that she’s been treated for
alcohol dependency.

c. An employee reports a needlestick injury and
you discover the organization is not using the
latest needle safety equipment.

4. How would you handle each of the preceding
situations?

5. Have you been involved in a legal action or threat
of one in healthcare? How was the situation han-
dled and what was the outcome?

http://www.jointcommission.org/certification/hcs_standards.aspx

http://www.ncsbn.org/12_ULR_table_adopted

http://www.ncsbn.org/14_Model_Act_0914

http://www.ncsbn.org/nurse-licensure-compact.htm

http://www.ncsbn.org/nurse-licensure-compact.htm

http://www.ncsbn.org/nurse-licensure-compact.htm

http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

http://www.npdb.hrsa.gov

http://www.jointcommission.org/certification/hcs_standards.aspx

http://www.ncsbn.org/12_ULR_table_adopted

http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

110 Chapter 8

Chapter 8

Understanding
Power and Politics

Learning Outcomes

After completing this chapter, you will be able to:

1. Differentiate between power and leadership.

2. Describe how to use power appropriately.

3. Explain how to use shared visioning as a power tool.

4. Explore the relationships among power, politics, and policy.

5. Summarize ways nurses can influence nursing’s future.

Key Terms
coercive power

connection power

expert power

information power

legitimate power

personal power

policy

politics

position power

power

power plays

referent power

reward power

shared visioning

stakeholders

vision

Power and Leadership
Power: How Managers and Leaders Get Things Done

Using Power
Image as Power

Using Power Appropriately

Shared Visioning as a Power Tool

Power, Politics, and Policy
Nursing’s Political History

Using Political Skills to Influence Policies

Influencing Public Policies

How Nurses Can Influence
the Future

110

Understanding Power and Politics 111

Introduction
Power is the potential ability to influence others (Hersey, 2013). Power is involved in
every human encounter, whether you recognize it or not. Power can be symmetrical
when two parties have equal and reciprocal power, or it may be asymmetrical with one
person or group having more control than another (Mason, Leavitt, & Chafee, 2014).
Power can be exclusive to one party or may be shared among many people or groups. To
acquire power, maintain it effectively, and use it skillfully, nurses must be aware of the
sources and types of power that they will use to influence and transform patient care.

Power and Leadership
Real power—principle-centered power—is based on honor, respect, loyalty, and com-
mitment. Principle-centered power is a model congruent with nursing’s values. Origi-
nally conceived by Stephen Covey (1991), the model is increasingly used by leaders in
many fields (Ikeda, 2015). Power sharing evolves naturally when power is centered on
one’s values and principles. In fact, the notion that power is something to be shared
seems to contradict the usual belief that power is something to be amassed, protected,
and used for one’s own purposes.

Leadership power comes from the ability to sustain proactive influence, because
followers trust and respect the leader to do the right thing for the right reason. As lead-
ers in healthcare, nurses must understand and select behaviors that activate principle-
centered leadership:

• Get to know people. Understanding what other people want is not always simple.

• Be open. Keep others informed. Trust, honor, and respect spread just as equally as
fear, suspicion, and deceit.

• Know your values and visions. The power to define your goals is the power to
choose.

• Sharpen your interpersonal competence. Actively listen to others and learn to
express your ideas well.

• Use your power to enable others. Be attentive to the dynamics of power and pay
attention to ground rules, such as encouraging dissenting voices and respecting
disagreement.

• Enlarge your sphere of influence and connectedness. Power sometimes grows out
of someone else’s need.

Power: How Managers and Leaders Get Things Done
Classically, managers relied on authority to rouse employees to perform tasks and
accomplish goals. In contemporary healthcare organizations, managers use persua-
sion, enticement, and inspiration to mobilize the energy and talent of a work group
and to overcome resistance to change.

A leader’s use of power alters attitudes and behavior by addressing individual
needs and motivations. There are seven generally accepted types of interpersonal
power used in organizations to influence others (Hersey, 2013):

1. Reward power is based on the inducements the manager can offer group mem-
bers in exchange for cooperation and contributions that advance the manager’s

112 Chapter 8

objectives. The degree of compliance depends on how much the follower values
the expected benefits. For example, a nurse manager may grant paid educational
leave as a way of rewarding a staff nurse who agreed to work overtime. Reward
power often is used in relation to a manager’s formal job responsibilities.

2. Coercive power is based on the penalties a manager might impose on an individ-
ual or a group. Motivation to comply is based on fear of punishment (coercive
power) or withholding of rewards. For example, the nurse manager might make
undesirable job assignments, mete out a formal reprimand, or recommend termi-
nation for a nurse who engages in disruptive behavior. Coercion is used in relation
to a manager’s perceived authority to determine employment status.

3. Legitimate power stems from the manager’s right to make a request because of
the authority associated with job and rank in an organizational hierarchy. Follow-
ers comply because they accept a manager’s prerogative to impose requirements,
sanctions, and rewards in keeping with the organization’s mission and aims. For
instance, staff nurses will comply with a nurse manager’s directive to take time off
without pay when the workload has dropped below projected levels because they
know that the manager is charged with maintaining unit expenses within budget
limitations.

4. Expert power is based on possession of unique skills, knowledge, and compe-
tence. Nurse managers, by virtue of experience and advanced education, are often
the best qualified to determine what to do in a given situation. Employees are
motivated to comply because they respect the manager’s expertise. Expert power
relates to the development of personal abilities through education and experience.
Newly graduated nurses might ask the nurse manager for advice in learning
clinical procedures or how to resolve conflicts with coworkers or other health
professionals.

5. Referent power is based on admiration and respect for an individual. Follow-
ers comply because they like and identify with the manager. Referent power
relates to the manager’s likeability and success. For example, a new graduate
might ask the advice of a more experienced and admired nurse about career
planning.

6. Information power is based on access to valued data. Followers comply because
they want the information for their own needs. Information power depends on a
manager’s organizational position, connections, and communication skills. For
example, the nurse manager is frequently privy to information about pending
organizational changes that affect employees’ work situations. A nurse manager
might exercise information power by sharing significant information at staff meet-
ings, thereby improving attendance.

7. Connection power is based on an individual’s formal and informal links to influ-
ential or prestigious persons inside and outside an area or organization. Followers
comply because they want to be linked to influential individuals. Connection
power also relates to the status and visibility of the individual. If, for example, a
nurse manager is a neighbor of an organization’s board member, followers may
believe that connection will protect or advance their work situation.

Managers have both personal and position power. Position power is determined
by the job description, assigned responsibilities, recognition, advancement, authority,

Understanding Power and Politics 113

the ability to withhold money, and decision making. Legitimate, coercive, and reward
power are positional because they relate to the “right” to influence others based on
rank or role. The extent to which managers mete out rewards and punishment is usu-
ally dictated by organizational policy. Information and legitimate power are directly
related to the manager’s role in the organizational structure.

Expert, referent, information, and connection power are based, for the most part,
on personal traits. Personal power refers to one’s credibility, reputation, expertise,
experience, control of resources or information, and ability to build trust. The extent to
which one may exercise expert, referent, information, and connection power relates to
personal skills and positive interpersonal relationships as well as employees’ needs
and motivations. Guidelines for using power are shown in Box 8-1.

Box 8-1 Guidelines for the Use of Power
in Organizations
Guidelines for Using Legitimate
Authority
• Make polite, clear requests.
• Explain the reasons for a request.
• Don’t exceed your scope of authority.
• Verify authority if necessary.
• Follow proper channels.
• Follow up to verify compliance.

Insist on compliance if appropriate.

Guidelines for Using Reward Power
• Offer the type of rewards that people desire.
• Offer rewards that are fair and ethical.
• Don’t promise more than you can deliver.
• Explain the criteria for giving rewards and keep it

simple.
• Provide rewards as promised if requirements are met.
• Use rewards symbolically (not in a manipulative way).

Guidelines for Using Coercive Power
• Explain rules and requirements and ensure that people

understand the serious consequences of violations.
• Respond to infractions promptly and consistently with-

out showing any favoritism to particular individuals.
• Investigate to get the facts before using reprimands or

punishment, and avoid jumping to conclusions or mak-
ing hasty accusations.

• Except for the most serious infractions, provide suffi-
cient oral and written warnings before resorting to
punishment.

• Administer warnings and reprimands in private and
avoid making rash threats.

• Stay calm and avoid the appearance of hostility or per-
sonal rejection.

• Express a sincere desire to help the person comply
with role expectations and thereby avoid punishment.

• Invite the person to suggest ways to correct the prob-
lem and seek agreement on a concrete plan.

• Maintain credibility by administering punishment if
noncompliance continues after threats and warnings
have been made.

Guidelines for Using Expert Power
• Explain the reasons for a request or proposal and why

it is important.
• Provide evidence that a proposal will be successful.
• Don’t make rash, careless, or inconsistent statements.
• Don’t exaggerate or misrepresent the facts.
• Listen seriously to the person’s concerns and suggestions.
• Act confidently and decisively in a crisis.

Ways to Acquire and Maintain
Referent Power
• Show acceptance and positive regard.
• Act in a supportive and helpful way.
• Use sincere forms of ingratiation.
• Defend and back up people when appropriate.
• Do unsolicited favors.
• Make self-sacrifices to show concern.
• Keep promises.

Adapted from Yukl, G. (2012). Leadership in organizations (8th ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.

114 Chapter 8

Using Power
Despite the increase in pride and self-esteem that comes with using power and influ-
ence, some nurses still consider power unattractive. Power grabbing, which has been the
traditionally accepted means of relating to power for one’s own self-interests and use,
is how nurses often think of power. Rather, nurses tend to be more comfortable with
power sharing and empowerment: power “with” rather than power “over” others.

Image as Power
A major source of power for nurses is an image of power. Even if one does not have
actual power from other sources, the perception by others that one is powerful bestows
a degree of power. The same is true for the profession as a whole. If the public sees the
profession of nursing as powerful, the profession’s ability to achieve its goals and
agendas is enhanced.

Images emerge from interactions and communications with others. If nurses pres-
ent themselves as caring and compassionate experts in healthcare through their inter-
actions and communications with the public, then a strong, favorable image develops
for both the individual nurse and the profession. Nurses, as the ambassadors of care,
must understand the importance and benefits of positive therapeutic communications
and image. Developing a positive image of power is important for both the individ-
ual and the profession.

Individual nurses can promote an image of power by a variety of means, such as
the following:

1. Appropriately introducing yourself by saying your name, making eye contact,
and shaking hands can immediately establish you as a powerful person. If nurses
introduce themselves by first name to the physician, Dr. Smith, they have immedi-
ately set forth an unequal power relationship unless the physician also uses his or
her first name. Although women are not socialized to initiate handshakes, it is a
power strategy in male-dominated circles, including healthcare organizations. In
Western cultures, eye contact conveys a sense of confidence and connection to the
individual to whom one is speaking. These seemingly minor behaviors can have a
major impact on how competent and powerful the nurse is perceived.

2. Attire can symbolize power and success (Sullivan, 2013). Although nurses may
believe that they are limited in choice of attire by uniform codes, it is in fact the
presentation of the uniform that can hold the key to power. For example, a nurse
manager needs a powerful image both with unit staff and with administrators and
other professionals who are setting organizational policy. An astute nurse man-
ager might wear a suit rather than a uniform to work on the day of a high-level
interdisciplinary committee meeting. Certainly, attention to details of grooming
and uniform selection can enhance the power of the staff nurse as well.

3. Conveying a positive and energetic attitude sends the message that you are a
“doer” and someone to be sought out for involvement in important issues. Chronic
complaining conveys a sense of powerlessness, whereas solving problems and
being optimistic promote a “can do” attitude that suggests power and instills con-
fidence in others.

4. Pay attention to how you speak and how you act when you speak. Nonverbal signs
and signals say more about you than words. Stand erect and move energetically.

Understanding Power and Politics 115

Speak with an even pace and enunciate words clearly. Make sure your words are
reflected in your body language. Keep your facial expression consistent with your
message.

5. Use facts and figures when you need to demonstrate your point. Policy changes
usually evolve from data presented in a compelling story. Positioning yourself as
a powerful player requires the ability to collect and analyze data. Technology
facilitates data retrieval. Remember that power is a matter of perception; there-
fore, you must use whatever data are available to support your judgment.

6. Knowing when to be at the right place at the right time is crucial for gaining access
to key personnel in the organization. This means being invited to events, meet-
ings, and parties not necessarily intended for nurses. It means demanding to sit at
the policy table when decisions affecting staffing and patient care are made. Influ-
ence is more effective when it is based on personal relationships and when people
see others in person: “If I don’t see you, I can’t ask you for needed information,
analysis, and alternative recommendations.” Become visible. Be available. Offer
assistance. You can be invaluable in providing policy makers with information,
interpreting data, and teaching them about the nursing side of healthcare.

7. In dealing with people outside of nursing, it is important to develop powerful
partnerships. Learn how to share both credit and blame. When working on col-
laborative projects, use we instead of they, and be clear about what is needed. If
something is not working well, say so. Never accept another’s opinion as fact.
Facts can be easily manipulated to fit one’s personal agenda. Learn how to probe
and obtain additional information. Do not assume you have all the information.
Beware of unsolicited commentary. Do not be fearful of giving strong criticism,
but always put criticisms in context. Before giving any criticism, give a compli-
ment, if appropriate. Also, make sure your partners are ready to hear all sides of
the issue. It is never superfluous to ask “Do you want to talk about such and such
right now?” Once an issue is decided—really decided—do not raise it again.

8. Make it a point to get to know the people who matter in your sphere of influence.
Become a part of the power network so that when people are discussing issues or
seeking people for important appointments of leadership, your name comes to
mind. Be sure to deal with senior people. Know who holds the power. Identify the
key power brokers. The more contact you have with the power brokers, the more
support you can generate in the future should the need arise. Develop a strategy
for gaining access to power brokers through joining alliances and coalitions. The
more power you use, the more you get. Learn how to question others and how to
become part of the organizational infrastructure.

9. There is an art to determining when, what, and how much information is ex changed
and communicated at any one time, and to determining who does so. Powerful
people have a keen sense of timing. Be sure to position yourself to be at the right
place at the right time. Any strategy will involve a good deal of energy and effort.
Direct influence and efforts toward issues of highest priority or when greatest
benefits are likely to result.

10. Use power appropriately to promote consensus in organizational goals, develop
common means to achieve these goals, and enhance a common culture to bind
together organizational members. As the healthcare providers closest to the
patient, nurses best understand patients’ needs and wants. In the hospital, nurses

116 Chapter 8

Leading at the Bedside: Power and Influence
Every nurse has power and influence. Each encounter with a
patient or family member—in the hospital, in a clinic, or in the
home—is an opportunity to help someone recover, regain
health, or experience a dignified death. Your words, your
actions, and, most important, your demeanor can help or
hinder your patient’s future. What could be more powerful?

Beyond the bedside or the exam room, you can influ-
ence the unit’s functioning, not only by your work but also

by how you work with others—colleagues, support staff,
and managers. Also, you can use your knowledge to inform
others what nurses do and why we are indispensable in
healthcare. Who else could do it better?

As a member of a profession more than 3 million
strong and continually ranked the most admired profession
in the annual Gallup poll, you and your nursing colleagues
have both individual and collective power. Use it!

are present from the first patient contact and thereafter for 24 hours a day, 7 days a
week. In the clinic, the nurse may be the person the patient sees first and most
frequently. By capitalizing on the special relationship that nurses have with
patients, they can enhance their position and image as professional caregivers.
(See Leading from the Bedside: Power and Influence.)

Nursing as a profession must market its professional expertise and ability to
achieve the objectives of healthcare organizations. From a marketing perspective,
nursing’s goal is to ensure that identified markets (e.g., patients, physicians, other
health professionals, community members) have a clear understanding of what nurs-
ing is, what it does, and what it is going to do. In doing so, nursing is seen as a profes-
sion that gives expert care with a scientific knowledge base.

Nursing care often is seen as an indicator of an organization’s overall quality.
Regardless of the setting, quality nursing care is something that is desired and valued.
Through understanding patients’ needs and preferences for programs that promote
wellness and maintain and restore health, nurses can show how their work fits
the preventive care goals. Marketing an image of expertise linked with quality and
cost can position nursing powerfully and competitively in the new healthcare
marketplace.

Using Power Appropriately
Using power not only affects what happens at the time but also has a lasting effect on
your relationships. Therefore, it is best to use the least amount of power necessary to
accomplish your goals. Also, use power appropriate to the situation (Sullivan, 2013).
Box 8-2 lists rules for using power.

Box 8-2 Rules for Using Power
1. Use the least amount of power you can to be effective

in your interactions with others.
2. Use power appropriate to the situation.
3. Learn when not to use power.
4. Focus on the problem, not the person.
5. Make polite requests, never arrogant demands.

6. Use coercion only when other methods do not work.
7. Keep informed to retain your credibility when using

your expert power.
8. Understand you may owe a return favor when you use

your connection power.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.

Understanding Power and Politics 117

Improper use of power can destroy your effectiveness. Power can be overused or
underused. Overusing power occurs when you use excessive power relative to the
situation. If you fail to use power when it is needed, you are underusing your power.
In addition to the immediate loss of influence, you may lose credibility for the future.

Power plays are another way that power is used inappropriately. Power plays are
attempts by others to diminish or demolish their opponents. Typical power plays
include comments such as these:

“Let’s be fair.”
“Can you prove that?”
“It’s either this or that; which is it? Take your pick.”
“But you said . . . and now you say . . . .”

Such statements engender feelings of insecurity, incompetence, confusion, embar-
rassment, and anger. You do not need to respond directly in these situations; rather,
you can simply restate your initial point in a firm manner. Keep your expression neu-
tral, ignore accusations, and restate your position, if appropriate. If you refuse to
respond to these thinly veiled attacks, your opponent is unable to intimidate and
manipulate you.

Nursing must perceive power for what it really is: the ability to mobilize and focus
energy and resources. What better position can nurses be in than to assume power to
face new problems and responsibilities in reshaping nursing practice to adapt to envi-
ronmental changes? Power is the means, not the end, to seek new ways of doing things
in this uncertain and unsettling time in healthcare.

Shared Visioning as a Power Tool
Shared visioning is a powerful tool for influencing an organization’s future. It is not
the same as shared governance, but it sets the stage for shared governance (Berlinger,
2015). Shared visioning is an interactive process in which both leaders and followers
commit to the organization’s goals (Kantabutra, 2009; Weberg & Weberg, 2014). A
vision is a mental model of a possible future (Kantabutra, 2008). It should inspire and
challenge both leaders and followers to accomplish the organization’s goals set forth
in the vision.

A shared vision of an organization achieves the following:

• Drives the organization’s future

• Determines future goals

• Makes implementing the necessary, and often difficult, changes easier

• Provides a benchmark to evaluate future projects

• Encourages both administrators and staff to accomplish goals

• Inspires and challenges both leaders and followers

If the manager and the staff work together in establishing a shared vision of the
unit’s future (just like the manager and executives do for the larger organization), then
they will work toward the same goals, know what new undertakings to accept or
decline, and share in the unit’s accomplishments.

Nurse managers often do not realize the power and importance they have in their
skill set and knowledge base. To talk to legislators who may not be familiar with

118 Chapter 8

healthcare, for example, the manager should use concise, lay language to convey
important points. By doing so, the manager helps legislators acquire information that
will help them be more knowledgeable in their conversations with others—a win-win
for both the manager and legislators.

The chief nursing officer (CNO) approached Tameka, nurse manager of the telemetry
unit. The CNO had heard generalized complaints about nurses’ dissatisfaction with their
schedules and their inability to get their shifts scheduled. Tameka explained that the new
upgrade on the scheduling software had created disadvantages for staff on the day shift.
The new schedule opens for sign up at 12:00 a.m. rather than the old way at 8:00 a.m. So,
night-shift nurses who work that shift are awake and can sign up for their shifts right
away. The old system opened at 8:00 a.m., and both night shift nurses just getting off
work and day nurses arriving for work had equal opportunity to schedule their shifts,
even though it was still first come, first serve.

The CNO would not know about this problem, nor would it be in the CNO’s job
description. By sharing her quick assessment, Tameka alerted the CNO to a situation
causing stress among the staff, allowing the CNO to address the problem at the sys-
tem level.

Today’s leaders recognize that their power must be shared and that integrated
leadership styles—bottom up and lateral—are essential for success. Consensus
about the organization’s future can motivate leaders and employees alike to envi-
sion their preferred future and do their best to achieve it. In addition, in a shared
vision Kantabutra (2009) posits that the leader is not a passive participant in the
visioning process. The leader should be an active group member, leading the group
toward the desired vision in a participative fashion. The leader helps guide the
group toward consensus.

Power, Politics, and Policy
While power is the potential ability to influence others, politics is the art of influenc-
ing others to achieve a goal (Mason et al., 2014). The Affordable Care Act, passed in
2010, radically changed healthcare in the United States and such changes are expected
to continue regardless of legislative changes. To succeed with this legislation required
significant political skills from numerous organizations, legislators, and the public.

Politics encompasses the following:

• It is an interpersonal endeavor—it uses communication and persuasion.

• It is a collective activity—it requires the support and action of many people.

• It calls for analysis and planning—it requires an assessment of the issue and a plan
to resolve it.

• It involves image—it hinges on the image people have of change makers.

Nursing’s Political History
Nurses’ political activities began with Florence Nightingale, continued with the emer-
gence of nursing schools and women’s suffrage, and improved with the establishment
of nursing organizations and the feminist movement (Sullivan, 2013). Establishing the
National Center for Nursing Research in 1985 (in 1993, the name was changed to

Understanding Power and Politics 119

the National Institute of Nursing Research) within the National Institutes of Health is
an example of nurses’ powerful political action.

In the early 1980s, after the Institute of Medicine report recommended a federal nurs-
ing research entity as part of the mainstream scientific community, nursing leaders in
the United States began promoting the establishment of a nursing institute at the
National Institutes of Health (NIH). This effort involved lobbying Congress, the Reagan
administration, and the other institutes at NIH—a formidable task. A few members of
Congress were interested in the potential that nursing science had for improving health,
but the administration was not in favor of another institute at NIH, and the other insti-
tutes seemed puzzled as to why nursing would need its own institute to do research.
Couldn’t nurse researchers receive funding through existing institutes? Medicine did so
without a separate institute.

Step by step, nursing leaders persuaded (harassed?) institute directors and Congress,
insisting that nursing research would improve human response to illness and assist in
maintaining and enhancing health. A bill was born. Concern about cost and increasing
bureaucracy emerged and was overcome. The bill passed, only to be vetoed by President
Ronald Reagan. Then a funny thing happened. Nursing made an unprecedented move.
The profession came together, united with one goal: to override President Reagan’s veto
(none had been successfully overridden before).

One by one, across the United States, nurses called their senators and congressional
representatives, urging support for a nursing institute, explaining that nurses were rep-
resented only among a few funded researchers at other institutes who did not understand
the impact of nursing interventions on health and recovery. A modest investment, they
explained, would yield exponentially greater results. Thanks to a few persuasive mem-
bers of Congress, a compromise was negotiated, and the National Center for Nursing
Research was established in 1985. Through a statutory revision in 1993, the Center
became an Institute.

Similarly, Georgia nurses successfully changed that state’s practice act to include
prescriptive authority for advanced practice nurses, overcoming fierce opposition
from the medical association. Working in concert with each other and with consumers
and the media, they generated a letter-writing campaign that countered every obstacle
the medical association tried. Georgia became the last state to grant prescribing privi-
leges to nurse practitioners.

Policy, on the other hand, is the decision that determines action. Policies result
from political action.

Using Political Skills to Influence Policies
Political skill, per se, is not included in nursing education (nor is it tested on state
board exams), yet it is a vital skill for nurses to acquire. Being political is not negative;
it’s the way to make a difference for your patients, your profession, and yourself.

Adhere to the following to improve your political skill:

• Learn self-promotion—report your accomplishments appropriately.

• Be honest and tell the truth—say what you mean and mean what you say.

• Use compliments—recognize others’ accomplishments.

• Discourage gossip—silence is the best response.

120 Chapter 8

• Learn and use quid pro quo—do and ask for favors.

• Remember: Appearance matters—attend to grooming and attire.

• Use good manners—be courteous.

Healthcare involves multiple special-interest groups, all competing for their
share of a limited pool of resources. The delivery of nursing services occurs at many
levels in healthcare organizations. The effectiveness of care delivery is linked to the
application of power, politics, and marketing. Nurses belong to a complex organiza-
tion that is continually confronted with limited resources and is in competition for
those resources.

How politically savvy are you? Ask yourself the following questions:

• Do you get credit for your ideas?

• Do you know how to deal with a difficult colleague?

• Do you have a mentor?

• Are you “in the loop”?

• Can you manage and influence others’ perceptions of you and your work?

• Are you able to convert enemies to friends?

• Do your ideas get a fair hearing?

• Do you know when and how to present them? (Reardon, 2011)

To take action, first decide what you want to accomplish. Is it realistic? Will you
have supporters? Who will be the detractors? The steps in political action are shown
in Box 8-3.

Try to find out what other people who are involved—the stakeholders—want.
Maybe you could piggyback on their ideas. Members of Congress do this all the time
by adding amendments to proposed bills in an attempt to satisfy their opponents.

Start telling your supporters about your idea and see if they will join with you in
a coalition. This is not necessarily a formal group, but it allows you to know who you
can count on in the discussions.

Find out exactly what objections your opponents have. Try to figure out a way to
alter your plan accordingly or help your opponents understand how your proposal
might help them. Political action is never easy, but the most politically astute people
accomplish goals far more often than those who don’t even try.

A case study that exemplifies a nurse using organizational politics is shown in
Case Study 8-1.

Box 8-3 Steps in Political Action
1. Determine what you want.
2. Learn about the players and what they want.
3. Gather supporters and form coalitions.
4. Be prepared to answer opponents.
5. Explain how what you want can help them.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted
by permission.

Understanding Power and Politics 121

Influencing Public Policies
What happens in the workplace both depends upon and influences what is happening
in the larger community, professional organizations, and government. Developing
influence in each of these three groups takes time and a long-range plan of action.
Although the nurse’s first priority should be to establish influence in the workplace,
the nurse can gradually increase connections and influence with other groups and,
later on, make these other groups a priority.

In order to influence public policies, nurses need to know how to work with the
public officials who enact those policies. Box 8-4 lists guidelines for working with pub-
lic officials.

CaSe STUdy 8-1 | Using Organizational Politics for Personal
advantage
Juanita Pascheco has been nurse manager of medical and
surgical ICUs in a large, urban, for-profit hospital for the
past 7 years. Two years ago, Juanita completed her mas-
ter’s degree in nursing administration. Her thesis research
centered on the acceptance of standardized and comput-
erized documentation methods for critical care units. Juan-
ita is well respected in her current role and is a member of
several key committees addressing the need for a replace-
ment health information system (HIS) for the hospital. She
reports directly to the director of critical care services.

Although Juanita enjoys her work as nurse manager,
she believes she is ready to assume additional responsibili-
ties at the director level. Through her work on the hospital’s
HIS selection team and as the nursing representative to the
physician’s technology committee, Juanita identifies the
need for a clinical informatics director role. One of Juanita’s
responsibilities on the HIS selection team is to identify tal-
ented staff from clinical areas who could support the HIS
implementation. Juanita has also agreed to chair several
working committees that will assist in determining required
clinical functionality for the HIS.

During her tenure at the hospital, Juanita has cultivated
solid working relationships with several key decision makers
within the organization. The human resources director, Ken
Harding, has worked with Juanita on several large projects

over the past 2 years, including implementation of multidis-
ciplinary teams in the ICUs. Juanita schedules a lunch with
Ken to discuss growth opportunities in the information tech-
nology department, the process for creating new roles, and,
in particular, who will determine the need for and approval of
new information technology positions. Using this knowledge
and her experience on the HIS selection team and the phy-
sicians’ technology committee, Juanita develops a proposal
for the clinical informatics director position.

As the HIS selection team draws closer to selecting a
final vendor for the computerized HIS and an implementa-
tion timeline is established by the information technology
department, Juanita approaches her supervisor, Sherrie
Wright, with her proposal. Juanita also provides Sherrie
with an overview of the clinical support that will be neces-
sary for successful implementation of the HIS product.
Since the critical care units are targeted for the initial phase
of implementation, Sherrie is aware that Juanita’s high
interest in technology and her clinical expertise in the ICU
would be invaluable for successful implementation. As a
strong manager, Juanita can build acceptance of this change
among the nurses, physicians, and other members of the
healthcare team.

Sherrie agrees to take Juanita’s proposal to the chief
nursing officer for formal consideration.

Box 8-4 How to Work with Public Officials
1. Be respectful.
2. Build relationships.
3. Keep in touch.
4. Arrive informed.

5. Understand the issue.
6. Be a constructive opponent.
7. Be realistic.
8. Be helpful.

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Reprinted by permission.

122 Chapter 8

FIRSt, BE RESPECtFuL Public officials have many constituents and demands for
their support. Build relationships with officials. Do not just contact them when you
have a request. Keep in touch at other times.

CommunICatIng wIth ELECtEd oFFICIaLS Nurses often wish to contact elected
officials to support or oppose legislation. You can call, email, or write to public officials.

Find members of Congress listed as follows:
For the House of Representatives—www.house.gov
For the Senate—www.senate.gov
For individual states’ legislators—National Conference of State Legislatures:

www.ncsl.org
Call the official’s staff and ask to speak to the person who handles the issue that

concerns you. Tell the aide that you support or oppose a certain bill and state the rea-
sons why. Name the bill by number.

Email or write directly to the official. Identify the bill in question, state your posi-
tion on the bill, and explain why you support or oppose it. Keep your comments brief,
and address only one issue per correspondence. Handwritten letters get more atten-
tion than form letters distributed by organizations.

Use the following format to address members of the U.S. Senate:

The Honorable (full name of senator)
__(Rm.#)__(name of) Senate Office Building
United States Senate
Washington, DC 20510

Dear Senator:

To contact members of the U.S. Congress, use a similar format.

The Honorable (full name)
__(Rm.#)__(name of) House Office Building
United States House of Representatives
Washington, DC 20515

Dear Representative:

Interestingly, a recent report by the Congressional Management Foundation found
that social media were more effective than expected in influencing senators and con-
gressional members (Congressional Management Foundation, 2015). Staffers report
that as few as 30 comments triggered notice. In addition, such interactions are improv-
ing relationships between lawmakers and constituents.

mEEtIng wIth ELECtEd oFFICIaLS To meet in person with an elected official,
make an appointment, arrive on time, and come prepared. Understand the pros and
cons of the issue you are bringing to the person’s attention. Be a constructive oppo-
nent. Argue for your position and be prepared with additional information and alter-
native suggestions. Still, be realistic. What you want may not be possible, or it may not
be likely at the present time. Always be helpful. Show how your issue benefits the
official’s constituents and, thus, the representative.

The American Association of Critical-Care Nurses suggests pointers for working
with public officials (American Association of Critical-Care Nurses, 2010). In addition,
the American Nurses Association provides legislative and government information
for nurses (American Nurses Association, 2011).

http://www.house.gov

http://www.senate.gov

http://www.ncsl.org

Understanding Power and Politics 123

How Nurses Can Influence
the Future
Nurses can have a tremendous impact on healthcare policy. The best impact is often
made with a bit of luck and timing—but never without knowledge of the whole sys-
tem. This includes knowledge of the policy agenda, the policy makers, and the politics
that are involved. Once you gain this knowledge, you are ready to move forward with
a political base to promote nursing.

To convert your policy ideas into political realities, consider the following power
points:

• Use persuasion over coercion. Persuasion is the ability to share reasons and ratio-
nale when making a strong case for your position while maintaining a genuine
respect for another’s perspective.

• Use patience over impatience. Despite the inconveniences and failings caused by
healthcare restructuring, impatience in the nursing community can be detrimen-
tal. Patience, along with a long-term perspective on the healthcare system, is
needed.

• Be open-minded rather than closed-minded. Acquiring accurate information is
essential if you want to influence others effectively.

• Use compassion over confrontation. In times of change, errors and mistakes are
easy to pinpoint. It takes genuine care and concern to change course and make
corrections.

• Use integrity over dishonesty. Honest discourse must be matched with kind
thoughts and actions. Control, manipulation, and malice must be pushed aside for
change to occur.

By using their political skills, nurses can improve patient care in individual insti-
tutions, help organizations survive and thrive, and influence public officials.

What You Know Now
• Power is the potential ability to influence others.

• Power can be positional or personal.

• Types of power include reward, coercive, legiti-
mate, expert, referent, information, and connection.

• Image is a source of power.

• Power can be overused, underused, or used inap-
propriately. To be effective, the power used must
be appropriate to the situation.

• Shared visioning is an interactive process in
which both leaders and followers commit to the
organization’s goals.

• Politics is the art of influencing others to achieve
a goal.

• Policy is the decision that determines action. Poli-
cies result from political action.

• Nurses can use political action to influence policies
in the organization and to influence public policies.

124 Chapter 8

Tools for Using Power and Politics
1. Learn the formal lines of authority within your

organization.
2. Identify key decision makers and build strong

and credible relationships with them.
3. Identify decision makers’ priorities and how

those affect any new initiatives.
4. Learn the rules for using power and put them

into practice.

5. Offer solutions to problems and take advantage
of new opportunities.

6. Exhibit a willingness to take on new and chal-
lenging tasks that may lead to more responsi-
bility.

7. Pay attention to people who are influential and
adopt their strategies if appropriate.

8. Learn strategies for working with public officials.

Questions to Challenge You
1. Consider a person you believe to have power.

What are the bases of that person’s power?
2. Evaluate how the person you named uses his or

her power. Is it positive or negative?
3. Have you observed people using power inappro-

priately? Describe what they did and what hap-
pened as a result.

4. Assess your own power using the seven types of
power discussed in the chapter. Name three ways
you could increase your power.

5. How politically savvy are you? Did you discover
areas to challenge you?

6. Have you been involved in developing policies in
your organization or have you worked with pub-
lic officials? Explain.

References
American Association of Critical-Care Nurses. (2010).

Advocacy 101: Golden rules for those who work
with public officials. Retrieved July 17, 2015, from
http://www.aacn.org/wd/practice/content/
publicpolicy/goldenrules.pcms?menu=practice

American Nurses Association. (2011). Activist toolkit.
Retrieved March 7, 2016, from http://www.
rnaction.org/site/PageServer?pagename=nstat_
take_action_activist_tool_kit&ct=1

Berlinger, J. E. (2015). Designing tomorrow:
Transitioning from participation to governance.
Journal of Nursing Administration, 45(3), 128–129.

Congressional Management Foundation. (2015).
#SocialCongress 2015. Retrieved October 26,
2015, from http://www.congressfoundation.
org/projects/communicating-with-congress/
social-congress-2015

Covey, S. R. (1991). Principle-centered leadership. New
York: Simon & Schuster.

Hersey, P. H. (2013). Management of organizational
behavior (10th ed.). Upper Saddle River, NJ:
Pearson.

Ikeda, J. (2009). Principle centered power. Retrieved
March 24, 2016, from http://www.leadwithhonor.
com/principle-centered-power

Kantabutra, S. (2008). What do we know about
vision? Journal of Applied Business Research, 24(2),
323–342.

Kantabutra, S. (2009). Toward a behavioral theory
of vision in organizational settings. Leadership
& Organizational Development Journal, 30(4),
319–337.

Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2014).
Policy and politics in nursing and health care (6th ed.).
Philadelphia, PA: W. B. Saunders.

Reardon, K. K. (2011). It’s All Politics: Winning in a
World Where Hard Work and Talent Aren’t Enough.
New York, NY: Crown Business.

Sullivan, E. J. (2013). Becoming influential: A guide
for nurses (2nd ed.). Upper Saddle River, NJ:
Pearson.

Weberg, D. & Weberg, K. (2014). Seven behaviors
to advance teamwork. Nursing Administration
Quarterly, 38(3), 230–237.

http://www.aacn.org/wd/practice/content/publicpolicy/goldenrules.pcms?menu=practice

http://www.rnaction.org/site/PageServer?pagename=nstat_take_action_activist_tool_kit&ct=1

http://www.congressfoundation.org/projects/communicating-with-congress/social-congress-2015

http://www.leadwithhonor.com/principle-centered-power

http://www.rnaction.org/site/PageServer?pagename=nstat_take_action_activist_tool_kit&ct=1

http://www.congressfoundation.org/projects/communicating-with-congress/social-congress-2015

http://www.leadwithhonor.com/principle-centered-power

Chapter 9

Thinking Critically,
Making Decisions,
Solving Problems

Learning Outcomes

After completing this chapter, you will be able to:

1. Summarize ways to use the critical-thinking process.

2. Compare and contrast individual and collective decision-making
processes in various situations.

3. Develop a plan to improve your problem-solving skills.

4. Evaluate stumbling blocks to making decisions and solving
problems.

5. Foster innovation in your work and in the work of others.

Critical Thinking
Critical Thinking in Nursing

Using Critical Thinking

Creativity

Decision Making
Types of Decisions

Decision-making Conditions

The Decision-making Process

Decision-making Techniques

Group Decision Making

Problem Solving
Problem-solving Methods

The Problem-solving Process

Group Problem Solving

Stumbling Blocks
Personality

Rigidity

Preconceived Ideas

Innovation

125

126 Chapter 9

Key Terms
adaptive decisions

artificial intelligence

brainstorming

creativity

critical thinking

decision making

descriptive rationality model

experimentation

expert systems

groupthink

innovation

innovative decisions

objective probability

political decision-making model

probability

probability analysis

problem solving

rational decision-making model

routine decisions

satisficing

subjective probability

trial-and-error method

Introduction
Nurse managers are expected to use knowledge from various disciplines to solve
problems with patients, staff, and the organization as well as problems in their own
personal and professional lives. They must make decisions in dynamic situations, such
as these:

• After an employee leaves a position, should the nurse manager refill it, given the
tighter economy?

• Is the present policy requiring 12-hour shifts adequate for both patients and nurses?

• Which is the best staffing pattern to prevent turnover and ensure quality patient
care?

• What is the best time to have staff meetings and council meetings in order to
involve the night shift?

This chapter explains and differentiates critical thinking, decision making, and
problem solving, and describes processes and techniques for using each.

Critical Thinking
Critical thinking is the process of examining underlying assumptions, interpreting
and evaluating arguments, imagining and exploring alternatives, and developing a
reflective criticism for the purpose of reaching a conclusion that can be justified. Criti-
cal thinking is not the same as criticism, though it does call for inquiring attitudes,
knowledge about evidence and analysis, and skills to combine them.

Critical-thinking skills can be used to resolve problems rationally. Identifying,
analyzing, and questioning the evidence and implications of a problem stimulate and
illuminate critical thought processes. Critical thinking is also an essential component of
decision making. However, compared to problem solving and decision making, which
involve seeking a single solution, critical thinking is a higher level cognitive process
that includes creativity, problem solving, and decision making (see Figure 9-1).

Thinking Critically, Making Decisions, Solving Problems 127

Critical Thinking in Nursing
The need for critical thinking in nursing has long been accepted. Zori, Nosek, and
Musil (2010) used the California Critical Thinking Disposition Inventory to measure
critical thinking in nurses. The researchers found that the nurses supervised by man-
agers with higher critical-thinking skills perceived their work environment to be more
positive than those whose managers scored lower on critical-thinking skills.

Ryan and Tatum (2012) found that RNs’ critical-thinking skills correlated with
their clinical competence. In a follow-up study, the researchers report that orientation
programs customized to new hires’ abilities improved their critical-thinking skills,
which transferred to their clinical competence (Ryan & Tatum, 2013). Furthermore,
Ashcraft (2010) found that critical-thinking classes for new nurses improved patient
safety, job satisfaction, and retention.

Using Critical Thinking
The critical-thinking process seems abstract unless it can be related to practical experi-
ences. One way to develop this process is to consider a series of questions when exam-
ining a specific problem or making a decision, such as the following:

• What are the underlying assumptions? Underlying assumptions are unquestioned
beliefs that influence an individual’s reasoning. They are perceptions that may or
may not be grounded in reality.

• How is evidence interpreted? What is the context? Interpretation of information
also can be value laden. Is the evidence presented completely and clearly? Can the
facts be substantiated? Are the people presenting the evidence using emotional or
biased information? Are there any errors in reasoning?

• How are the arguments to be evaluated? Is there objective evidence to support
the arguments? Have all value preferences been determined? Is there a good
chance that the arguments will be accepted? Are there enough people to support
decisions? Healthcare organizations were able to change to smoke-free environ-
ments once societal values favored nonsmokers, and public policies reflected
those values.

Problem
solving

Creativity

Decision
making

Critical
thinking

Figure 9-1 Critical-thinking model.

128 Chapter 9

• What are the possible alternative perspectives? Using different basic assumptions
and paradigms can help the critical thinker develop several different views of an
issue. Compare how a nurse manager who assumes that more RNs equal better
care will deal with a budget cut with a manager who is committed to adding assis-
tive personnel instead. What evidence supports the alternatives? What solutions
do staff members, patients, physicians, and others propose? What would be the
ideal alternative?

Critical-thinking skills are used throughout the nursing process (see Table 9-1).
Nurses can build on the knowledge base they began acquiring in school to make the
critical-thinking process a conscious one in daily activities. Learning to be a critical
thinker requires a commitment over time, but the skills can be learned.

Creativity
Creativity is an essential part of the critical-thinking process. Creativity is the ability to
develop and implement new and better solutions. Creativity demands a certain
amount of exposure to outside contacts, receptiveness to new and seemingly strange
ideas, a certain amount of freedom, and some permissive management.

Most nurses, however, are employed in bureaucratic settings that do not fos-
ter creativity. Control is exercised over staff, and rigid adherence to formal chan-
nels of communication jeopardizes innovation. In addition, there is little room for
failure, and when failures do occur, they are not well tolerated. When staff are
afraid of the consequences of failure, their creativity is inhibited and innovation
does not take place.

Table 9-1 Critical Thinking Through the Nursing Process

The Nursing Process Critical-Thinking Skills

Assessment Observing

Distinguishing relevant from irrelevant data

Distinguishing important from unimportant data

Validating data

Organizing data

Categorizing data

Diagnosis Finding patterns and relationships

Making inferences

Stating the problem

Suspending judgment

Planning Generalizing

Transferring knowledge from one situation to another

Hypothesizing

Implementation Applying knowledge

Testing hypotheses

Evaluation Deciding whether hypotheses are correct

Making criterion-based evaluations

From Wilkinson, J. (1992). Nursing process in action: A critical thinking approach. Redwood City, CA: Addison-Wesley Nursing, p. 29.

Thinking Critically, Making Decisions, Solving Problems 129

Maintaining a certain level of creativity is one way to keep an organization alive.
New employees who are not encumbered with details of accepted practices often can
make suggestions based on their prior experiences or insights before they get set in their
ways or have their innovative ideas “turned off.” The advantages offered by new employ-
ees should be explored because all staff gain from such use of valuable human resources.

The climate must promote the survival of potentially useful ideas. The nurse man-
ager can foster a climate of support by giving new ideas a fair and adequate hearing,
thereby reducing the tendency to discourage the creative process in individuals and
within groups. The challenge for nurse managers is to know when, for whom, and to
what extent control is appropriate. If creativity does have a priority in the healthcare set-
ting, then the reward system should be geared to, and commensurate with, that priority.

Creativity has four stages: preparation, incubation, insight, and verification. Even
people who think they are not naturally creative can learn this process (see Figure 9-2).

1. Preparation. A carefully designed planning program is essential. First, acquire
information necessary to understand the situation. Individuals can do this on
their own, or groups can work together.

The process follows this sequence:

• Pick a specific task.
• Gather relevant facts.
• Challenge every detail.
• Develop preferred solutions.
• Implement improvements.

2. Incubation. After all the information available has been gathered, allow as much
time as possible to elapse before deciding on solutions.

3. Insight. Often solutions emerge after a period of reflection that would not have
occurred to anyone without this time lapse.

4. Verification. Once a solution has been implemented, evaluate it for effectiveness.
You may need to restart the process, or go back to another step and create a
different solution.

Preparation

Steps Definition

Information
gathering

Incubation

Insight

Verification

Unconscious
work going on

Solutions
emerge

Solutions
evaluated

Figure 9-2 The creative process.

130 Chapter 9

Case Study 9-1 describes how one nurse manager used creativity to solve a
problem.

CaSe STuDy 9-1 | Creative Problem Solving
Jeffrey was just promoted to manager of an acute care clinic,
which recently expanded its hours from 6:00 a.m. until
10:00 p.m. He soon realizes that staff nurses are reluctant to
sign up on the schedule and do quality chart audits, an
important process used to review clinic operations and
patient care. He gathers information about quality improve-
ment, reviews the literature on motivation and incentives, and
discusses the issue with other nurse managers (preparation).

Jeffrey continues to manage the clinic, thinking about
the information he has gathered but does not consciously
make a decision or reject new ideas (incubation). When

working on a new problem, self-scheduling for the change
in hours, he realizes a connection between the two prob-
lems. Many nurses complain that by the time they receive
the schedule, the day shifts are filled.

Jeffrey decides to review the chart audits. Nurses who
regularly participate in quality improvement projects will
receive a perk: They will be allowed, on a rotating basis,
first choice at selecting the schedule they want to work (this
is the insight stage). He discusses the plan with the staff,
and proposes a 2-month trial period to determine whether
the solution is effective (verification).

Decision Making
Considering all the practice individuals get in making decisions, it would seem they
might become very good at it. However, the number of decisions a person makes does
not correspond to the person’s skill at making them. The assumption is that decision
making comes naturally, like breathing. It does not.

The decision-making process described in this chapter provides nurses with a sys-
tem for making decisions that is applicable to any decision. It is a useful procedure for
making practical choices. A decision not to solve a problem is also a decision.

Although decision making and problem solving appear similar, they are not syn-
onymous. Decision making may or may not involve a problem, but it always
involves selecting one of several alternatives, each of which may be appropriate
under certain circumstances. Problem solving, on the other hand, involves diagnos-
ing a problem and solving it, which may or may not entail deciding on one correct
solution. Most of the time, decision making is a subset of problem solving. However,
some decisions are not of a problem-solving nature, such as decisions about schedul-
ing, equipment, or in-services.

Types of Decisions
The types of problems nurses and nurse managers encounter and the decisions they
must make vary widely and determine the problem-solving or decision-making meth-
ods they should use. Relatively well-defined, common problems can usually be solved
with routine decisions, often using established rules, policies, and procedures. For
instance, when a nurse makes a medication error, the manager’s actions are guided by
policy and the report form. Routine decisions are more often made by first-level man-
agers than by top administrators.

Adaptive decisions are necessary when both problems and alternative solutions are
somewhat unusual and only partially understood. Often they are modifications of other
well-known problems and solutions. Managers must make innovative decisions when
problems are unusual and unclear, and when creative, novel solutions are necessary.

Thinking Critically, Making Decisions, Solving Problems 131

Decision-making Conditions
The conditions surrounding decision making can vary and change dramatically. Con-
sider the total system. Whatever solutions are created will succeed only if they are
compatible with other parts of the system. Decisions are made under conditions of
certainty, risk, or uncertainty.

Decision Making UnDer certainty When you know the alternatives and the
conditions surrounding each alternative, a state of certainty is said to exist. Suppose a
nurse manager on a unit with acutely ill patients wants to decrease the number of
venipunctures a patient experiences when an IV is started, as well as reduce costs
resulting from failed venipunctures. Three alternatives exist:

• Establish an IV team on all shifts to minimize IV attempts and reduce costs.

• Establish a reciprocal relationship with the anesthesia department to start IVs
when nurses experience difficulty.

• Set a standard of two insertion attempts per nurse per patient, although this does
not substantially lower equipment costs.

The manager knows the alternatives (IV team, anesthesia department, standards)
and the conditions associated with each option (reduced costs, assistance with starting
IVs, minimum attempts and some cost reduction). A condition of strong certainty is
said to exist, and the decision can be made with full knowledge of what the payoff
probably will be.

Decision Making UnDer Uncertainty anD risk Seldom do decision mak-
ers know everything there is to know about a subject or situation. If everything was
known, the decision would be obvious to everyone.

Most critical decision making in organizations is done under conditions of uncer-
tainty and risk. The individual or group making the decision does not know all the
alternatives, attendant risks, or possible consequences of each option. Uncertainty and
risk are inevitable because of the complex and dynamic nature of healthcare organiza-
tions. For example, if the weather forecaster predicts a 40% chance of snow, the nurse
manager is operating in a situation of risk when trying to decide how to staff the unit
for the next 24 hours.

In a risk situation, the availability of each alternative, potential successes, and
costs are all associated with probability estimates. Probability is the likelihood,
expressed as a percentage, that an event will or will not occur. If something is certain
to happen, its probability is 100%. If it is certain not to happen, its probability is 0%. If
there is a 50—50 chance, its probability is 50%.

Here is another example: Suppose a nurse manager decides to use agency nurses
to staff a unit during heavy vacation periods. Two agencies look attractive, and the
manager must decide between them. Agency A has had modest growth over the past
10 years and offers the manager a 3-month contract, freezing wages during that time.
In addition, the unit will have first choice of available nurses. Agency B is much more
dynamic and charges more, but explains that the reason for its high rate of growth is
that its nurses are the best and the highest paid in the area. The nurse manager can
choose Agency A, which will provide a safe, constant supply of nursing personnel, or
B, which promises better care but at a higher cost.

The key element in decision making under conditions of risk is to determine the
probabilities of each alternative as accurately as possible. The nurse manager can use a

132 Chapter 9

probability analysis, whereby expected risk is calculated or estimated. Using the
probability analysis shown in Table 9-2, it appears as though Agency A offers the best
outcome. However, if the second agency had a 90% chance of filling shifts and a 50%
chance of fixing costs, a completely different situation would exist.

The nurse manager might decide that the potential for increased costs was a small
trade-off for having more highly qualified nurses and the best probability of having
the unit fully staffed during vacation periods. Objective probability is the likelihood
that an event will or will not occur based on facts and reliable information. Subjective
probability is the likelihood that an event will or will not occur based on a manager’s
personal judgment and beliefs.

Janeen, a nurse manager of a specialized cardiac intensive care unit, faces the task of
recruiting scarce and highly skilled nurses to care for coronary artery bypass graft
patients. The obvious alternative is to offer a salary and benefits package that rivals
that of all other institutions in the area. However, this means Janeen will have costly
specialized nursing personnel in her budget who are not easily absorbed by other
units in the organization. The probability that coronary artery bypass graft procedures
will become obsolete in the future is unknown. In addition, other factors (e.g.,
increased competition, government regulations regarding reimbursement) may
contribute to conditions of uncertainty.

The Decision-making Process
The rational decision-making model is a series of steps that managers take in an effort
to make logical, well-grounded rational choices that maximize the achievement of
objectives. First, identify all possible outcomes, examine the probability of each alter-
native, then take the action that yields the highest probability of achieving the most
desirable outcome. Not all steps are used in every decision, nor are they always used
in the same order. The rational decision-making model is thought of as the ideal, but
often cannot be fully used.

Individuals seldom make major decisions at a single point in time, and often are
unable to recall when a decision was finally reached. Some major decisions are the
result of many small actions or incremental choices the person makes without regard-
ing larger issues. In addition, decision processes are likely to be characterized more by
confusion, disorder, and emotionality than by rationality. For these reasons, it is best to
develop appropriate technical skills and the capacity to find a good balance between
lengthy processes and quick, decisive action.

The descriptive rationality model, developed by Simon in 1955 and supported by
research in the 1990s (Simon, 1993), emphasizes the limitations of the rationality of the
decision maker and the situation. It recognizes three ways in which decision makers
depart from the rational decision-making model:

Table 9-2 Probability Analysis

Probability Analysis

Agency A 60% Filling shifts

100% Fixed wages

Agency B 50% Filling shifts

70% Fixed wage

Thinking Critically, Making Decisions, Solving Problems 133

• The decision maker’s search for possible objectives or alternative solutions is lim-
ited because of time, energy, and money.

• People frequently lack adequate information about problems and cannot control
the conditions under which they operate.

• Individuals often use a satisficing strategy.

Satisficing is not a misspelled word; it is a decision-making strategy whereby the
individual chooses an alternative that is not ideal but either is good enough (suffices)
under existing circumstances to meet minimum standards of acceptance or is the first
acceptable alternative. Many problems in nursing are ineffectively solved with satisfic-
ing strategies.

Elena, a nurse manager in charge of a busy neurosurgical floor with high turnover rates
and high patient acuity levels, uses a satisficing alternative when hiring replacement staff.
She hires all nurse applicants in order of application until no positions are open. A better
approach would be for Elena to replace staff only with nurse applicants who possess the
skills and experiences required to care for neurosurgical patients, regardless of the number
of applicants or desire for immediate action. Elena also should develop a plan to promote job
satisfaction, the lack of which is the real reason for the vacancies.

Individuals who solve problems using satisficing may lack specific training in
problem solving and decision making. They may view their units or areas of responsi-
bility as drastically simplified models of the real world, and be content with this sim-
plification because it allows them to make decisions with relatively simple rules of
thumb or from force of habit.

The political decision-making model describes the process in terms of the par-
ticular interests and objectives of powerful stakeholders, such as hospital boards, med-
ical staffs, corporate officers, and regulatory bodies. Power is the ability to influence or
control how problems and objectives are defined, what alternative solutions are con-
sidered and selected, what information flows, and, ultimately, what decisions are
made (see Chapter 7).

The decision-making process begins when a gap exists between what is actually hap-
pening and what should be happening, and it ends with action that will narrow or close
this gap. The simplest way to learn decision-making skills is to integrate a model into
one’s thinking by organizing the components into individual steps. The seven steps of the
decision-making process (see Box 9-1) are as applicable to personal problems as they are to
nursing management problems. Each step is elaborated by pertinent questions clarifying
the statements, and they should be followed in the order in which they are presented.

Decision-making Techniques
Decision-making techniques vary according to the nature of the problem or topic, the
decision maker, the context or situation, and the decision-making method or process. For
routine decisions, choices that are tried and true can be made for well-defined, known
situations or problems. Well-designed policies, rules, and standard operating procedures
can produce satisfactory results with a minimum of time. Artificial intelligence—
including programmed computer systems such as expert systems that can store, retrieve,
and manipulate data—can diagnose problems and make limited decisions.

For adaptive decisions involving moderately ambiguous problems and modifica-
tion of known and well-defined alternative solutions, there are a variety of techniques.

134 Chapter 9

Many types of decision grids or tables can be used to compare outcomes of alternative
solutions. Decisions about units or services can be facilitated, with analyses comparing
output, revenue, and costs over time or under different conditions.

Regardless of the decision-making model or strategy chosen, data collection and
analysis are essential. In many healthcare organizations, quality teams are using a vari-
ety of tools, such as decision grids, flowcharts, or cause-and-effect diagrams to gather,
organize, and analyze data about their work. Figure 9-3 illustrates a cause-and-effect

Cause

Equipment

Effect

Materials Methods

People

Staff
MDs

Chart
design

Lack
of chart
racks

Inadequate
forms

Treatment
nurses

Lack of
focus

Clinicians

Fellows

Poor
communication

Unclear
chemotherapy
orders

Less than
adequate
nursing

documentation
Patient chart
movement
from clinics

Lack of
procedures
and guidelines

Lack of
appropriate
documentation
forms

Figure 9-3 Brainstorming session of a nursing quality focus team.

Box 9-1 Steps in Decision Making
1. Identify the purpose. Why is a decision necessary? What needs to be determined? State the issue in the broadest

possible terms.

2. Set the criteria. What needs to be achieved, preserved, and avoided by whatever decision is made? The
answers to these questions are the standards by which solutions will be evaluated.

3. Weigh the criteria. Rank each criterion on a scale of values from 1 (totally unimportant) to 10 (extremely important).

4. Seek alternatives. List all possible courses of action. Is one alternative more significant than another? Does one
alternative have weaknesses in some areas? Can these be overcome? Can two alternatives or
features of many alternatives be combined?

5. Test alternatives. First, using the same methodology as in step 3, rank each alternative on a scale of 1 to 10.
Second, multiply the weight of each criterion by the rating of each alternative. Third, add the
scores and compare the results.

6. Troubleshoot. What could go wrong? How can you plan? Can the choice be improved?

7. Evaluate the action. Is the solution being implemented? Is it effective? Is it costly?

Thinking Critically, Making Decisions, Solving Problems 135

diagram that a team of nurses created to help them improve the documentation process
for their ambulatory oncology unit.

Another example of a decision tool is the Dynamic Network Analysis Decision
Support (DyNADS) project at the University of Arizona College of Nursing. DyNADS
is a decision support tool that improves predictability in today’s complex environ-
ment. This simulation product enables the manager to predict the consequences of
decisions on patient safety and quality outcomes. The tool simulates virtual nursing
units, identifies potential errors, and predicts the likely result. Using the tool, the man-
ager can discover if an innovation or a combination of innovations is likely to be suc-
cessful (Effken, Verrn Logue, & Hsu, 2010).

Group Decision Making
The widespread use of participative management, quality improvement teams, and
shared governance in healthcare organizations requires every nurse manager to deter-
mine when group, rather than individual, decisions are desirable, and how to use
groups effectively. A number of studies have shown that professional people do not
function well in a micromanaged environment. As an alternative, group problem solv-
ing of substantial issues casts the manager in the role of facilitator and consultant.
Compared to individual decision making, groups can provide more input, often pro-
duce better decisions, and generate more commitment. One group decision-making
technique is brainstorming.

In brainstorming, group members meet together and generate many diverse ideas
about the nature, cause, definition, or solution to a problem without consideration
of their relative value. The focus team whose work is shown in Figure 9-3 used
brainstorming.

With brainstorming, a premium is placed on generating lots of ideas as quickly as
possible and on coming up with unusual ideas. Most important, members do not cri-
tique ideas as they are proposed. Evaluation takes place after all the ideas have been
generated. Members are encouraged to improve on each other’s ideas. These sessions
are enjoyable but are often unsuccessful because members inevitably begin to critique
ideas, and as a result, meetings shift to the ordinary interacting group format. Criti-
cisms of this approach are the high cost factor, the time consumed, and the superficial-
ity of many solutions.

Problem Solving
People use problem solving when they perceive a gap between an existing state (what
is going on) and a desired state (what should be going on). How one perceives the situ-
ation influences how the problem is identified or solved. Therefore, perceptions must
be clarified before problem solving can occur.

Problem-solving Methods
A variety of methods can be used to solve problems. People with little management
experience tend to use the trial-and-error method, applying one solution after
another until the problem is solved or appears to be improving. These managers
often cite lack of experience, of time, and of resources to search for alternative
solutions.

136 Chapter 9

In a step-down unit with an increasing incidence of medication errors, Max, the nurse
manager, uses various strategies to decrease errors, such as posting dosage and medication
charts in the unit or having the charge nurse check medications. After a few months, by
which time none of the methods has worked, it occurs to Max that perhaps making nurses
responsible for their actions would be more effective. Max develops a point system for
medication errors: When nurses accumulate a certain number of points, they are required
to take a medication test; repeated failure of the test may eventually lead to termination.
Max’s solution is effective, and a low level of medication errors is restored.

As the preceding example shows, a trial-and-error process can be time-consuming
and may even be detrimental. Although some learning can occur during the process,
the nurse manager risks being perceived as a poor problem solver who has wasted
time and money on ineffective solutions.

experimentation, another type of problem solving, is more rigorous than trial and
error. Pilot projects or limited trials are examples of experimentation. Experimentation
involves testing a theory (hypothesis) or hunch to enhance knowledge, understand-
ing, or prediction. A project or study is carried out in either a controlled setting (e.g., in
a laboratory) or an uncontrolled setting (e.g., in a natural setting such as an outpatient
clinic). Data are collected and analyzed and results interpreted to determine whether
the solution tried has been effective.

Lin, a nurse manager of a pediatric floor, has received many complaints from mothers of
children who think the nurses are short-tempered. Lin has a hunch that 12-hour shifts,
which have been recently implemented on her floor, are contributing to the problem; she
believes that nurses who must interact frequently with families would perform better on
8-hour shifts. She can test her theory by setting up a small study comparing the two
staffing patterns with patient satisfaction.

Experimentation may be creative and effective or uninspired and ineffective,
depending on how it is used. As a major method of problem solving, experimentation
may be inefficient because of the amount of time and control involved. However, a
well-designed experiment can be persuasive in situations in which an idea or activity,
such as a new staffing system or care procedure, can be tried in one of two similar
groups and results objectively compared.

Still other problem-solving techniques rely on past experience and intuition. Every-
one has various and countless experiences. Individuals build a repertoire of these
experiences and base future actions on what they have considered successful solutions
in the past. If a particular course of action consistently resulted in positive outcomes,
the person will try it again when similar circumstances occur. In some instances, an
individual’s past experience can determine how much risk he or she will take in pres-
ent circumstances.

The nature and frequency of the experience also contribute significantly to the
effectiveness of this problem-solving method. How much the person has learned
from these experiences, positive or negative, can affect the current viewpoint and
can result in either subjective, narrow judgments or wise ones. This is especially true
in human relations problems. Intuition relies heavily on past experience and trial
and error. The extent to which past experience is related to intuition is difficult to
determine, but nurses’ wisdom, sensitivity, and intuition are known to be valuable in
solving problems.

Some problems are self-solving: If permitted to run a natural course, they are
solved by those personally involved. This is not to say that a uniform laissez-faire

Thinking Critically, Making Decisions, Solving Problems 137

management style solves all problems. The nurse manager must not ignore manage-
rial responsibilities, but often, difficult situations become more manageable when par-
ticipants are given time, resources, and support to discover their own solutions.

This typically happens, for example, when a newly graduated nurse joins a unit
where most of the staff are associate-degree RNs who resent the new nurse’s level of
education as well as the nurse’s lack of experience. If the nurse manager intervenes, a
problem that the staff might have worked out on their own becomes an ongoing source
of conflict. The important skill required here is knowing when to act and when not to act.

The Problem-solving Process
Many nursing problems require immediate action. Nurses usually do not have time
for the formalized processes of research and analysis specified by the scientific method.
Therefore, learning an organized method for problem solving is invaluable. One prac-
tical method for problem solving is to adhere to the seven-step process that follows,
which is also summarized in Box 9-2.

Box 9-2 Steps in Problem Solving
1. Define the problem.
2. Gather information.
3. Analyze the information.
4. Develop solutions.

5. Make a decision.
6. Implement the decision.
7. Evaluate the solution.

1. Define the problem. The definition of a problem should be a descriptive statement
of the state of affairs, not a judgment or conclusion. If one begins the statement of
a problem with a judgment, the solution may be equally judgmental, and critical
descriptive elements could be overlooked.

Suppose a nurse manager reluctantly implements a self-scheduling process
and finds that each time the schedule is posted, evenings and some weekend shifts
are not adequately covered. The manager might identify the problem as the imma-
turity of the staff and their inability to function under participative governance.
The causes may be lack of interest in group decision making, minimal concern
over providing adequate patient coverage, or, perhaps more correctly, a few
nurses’ lack of understanding of the process.

Premature interpretation can alter one’s ability to deal with facts objectively. If
the nurse manager defines the problem as immaturity and reverts to making out the
schedules without further fact-finding, a minor problem could develop into a major
upheaval. Instead, the manager might consider other explanations for the apparent
behavior that do not entail negative assumptions about the maturity of the staff.

Accurate assessment of the scope of the problem also determines whether the
manager needs to seek a lasting solution or just a stopgap measure. Is this just a situ-
ational problem requiring only intervention with a simple explanation, or is it more
complex, involving the leadership style of the manager? The manager must define
and classify problems in order to take action. To define a problem, ask the following:

• Do I have the authority to do anything about this myself?
• Do I have all the information? Do I have enough time?

138 Chapter 9

• Who else has important information and can contribute?
• What benefits can be expected? A list of potential benefits provides the basis for

comparison and choice of solutions. The list also serves as a means for evaluat-
ing the solution.

2. Gather information. Problem solving begins with collecting facts. This informa-
tion gathering initiates a search for additional facts that provides clues to the scope
and solution of the problem. This step encourages people to report facts accu-
rately. Everyone involved can contribute. Although this may not always provide
objective information, it reduces misinformation and allows everyone an opportu-
nity to tell what he or she thinks is wrong with a situation.

Experience is another source of information—one’s own experience as well as
the experience of other nurse managers and staff. The people involved usually
have ideas about what should be done. Some data will be useless, and some inac-
curate, but some will be useful to develop innovative ideas worth pursuing.

3. Analyze the information. Analyze the information only when all of it has been
sorted into some orderly arrangement, as follows:

• Categorize information in order of reliability.
• List information from most important to least important.
• Set information into a time sequence. What happened first? Next? What came

before what? What were the concurrent circumstances?
• Examine information in terms of cause and effect. Is A causing B, or vice versa?
• Classify information into categories: human factors, such as personality, matu-

rity, education, age, relationships among people, and problems outside the
organization; technical factors, such as nursing skills or the type of unit; temporal
factors, such as length of service, overtime, type of shift, and double shifts; and
policy factors, such as organizational procedures or rules applying to the prob-
lem, legal issues, and ethical concerns.

• Consider how long the situation has been going on.
Because no amount of information is ever complete or comprehensive enough,

critical-thinking skills help the manager examine the assumptions, evidence, and
potential value conflicts.

4. Develop solutions. As an individual or a group analyzes information, numerous
possible solutions will suggest themselves. Do not consider only simple solutions,
because that may stifle creative thinking and cause overconcentration on detail.
Developing alternative solutions makes it possible to combine the best parts of
several solutions into a superior one. Also, alternatives are valuable in case the
first-order solutions prove impossible to implement.

When exploring a variety of solutions, maintain an uncritical attitude toward
the way the problem has been handled in the past. Some problems have had a
long-standing history by the time they reach you, and attempts may have been
made to resolve them over time. “We tried this before, and it didn’t work” is often
said and may apply—or more likely, may not apply—in a changed situation. Past
experience does not always supply an answer, but it can aid the critical-thinking
process and help prepare for future problem solving.

5. Make a decision. After reviewing the list of potential solutions, select the one that
is most applicable, feasible, satisfactory, and has the fewest undesirable conse-
quences. Some solutions have to be put into effect quickly; matters of discipline or
compromises in patient safety, for example, need immediate intervention. You

Thinking Critically, Making Decisions, Solving Problems 139

must have legitimate authority to act in an emergency and know the penalties to
be imposed for various infractions.

If the problem is a technical one and its solution brings about a change in the
method of doing work or using new equipment, expect resistance. Changes that
threaten individuals’ personal security or status are especially difficult. In those
cases, the change process must be initiated before solutions are implemented. If
the solution involves change, the manager should fully involve those who will be
affected by it, if possible, or at least inform them of the process.

6. Implement the decision. Implement the decision after selecting the best course of
action. If unforeseen new problems emerge after implementation, evaluate these
impediments. Be careful, however, not to abandon a workable solution just
because a few people object; a minority always will. If the previous steps in the
problem-solving process have been followed, the solution has been carefully
thought out, and potential problems have been addressed, implementation should
move forward.

7. Evaluate the solution. After the solution has been implemented, review the plan
and compare the actual results and benefits to those of the idealized solution. Peo-
ple tend to fall back into old patterns of habit, only giving lip service to change. Is
the solution being implemented? If so, are the results better or worse than
expected? If they are better, what changes have contributed to its success? How
can we ensure that the solution continues to be used and to work? Such a periodic
checkup gives you valuable insight and experience to use in other situations and
keeps the problem-solving process on course.

See Case Study 9-2 to learn how one nurse manager used critical thinking to solve
a problem.

Case study 9-2 | Critical thinking and Problem solving
Latonia Wilson is nurse manager for a busy 20-bed telem-
etry unit. In addition to providing postsurgical care for car-
diac patients, nurses also prepare patients for cardiac
catheterization lab procedures. Latonia’s staff include eight
new graduate nurses, which make up almost half of her
nursing staff. The new nurses have attended most of the
required nursing orientation for the hospital.

Three times in one month, telemetry unit patients who
had orders for heparin drips were administered heparin
flush instead. Premixed IV bags for heparin drips as well as
heparin flush for indwelling arterial catheters are stocked on
the IV solutions cart in the medication room. While no
adverse patient outcomes had been reported, procedures
have been delayed.

Geena Donati is a graduate nurse on the telemetry unit.
Recently, she took a bag of heparin drip from the IV cart and
started to attach it to the IV tubing. She noticed that the
label stated heparin flush instead of heparin. Upon returning
to the med room, she checked the heparin drip bin and

found heparin flush bags mixed in with the heparin drip. The
pharmacy technician came into the med room and began
stocking the IV cart. Geena noticed that the pharmacy tech-
nician put extra heparin drip bags in the heparin flush bin.
She questioned the pharmacy technician, and he told
Geena that since the unit used a lot of heparin solution, he
had started bringing extra to decrease his trips to the unit.

Geena met with Latonia later during her shift. She told
her manager about the extra heparin bags being mixed into
the wrong bins. Latonia asked Geena if she would be inter-
ested in working with two other RNs on the unit to develop
new procedures to decrease heparin medication errors.
Geena and the task force worked with the pharmacy
department to change the label color for heparin drip and
heparin flush solutions, physically separated the bins on the
IV cart onto different shelves, and provided a short educa-
tional segment at the monthly staff meeting. Since the new
procedures were developed, no further heparin errors have
occurred on the telemetry unit.

140 Chapter 9

Group Problem Solving
Traditionally, managers solved most problems in isolation. This practice, how-
ever, is outdated. Both the complexity of problems and the staff’s desire for mean-
ingful involvement create the impetus for using group approaches to problem
solving. Today, consensus-based problem solving, inherent in shared governance,
is the norm.

ADvAntAges of groUP ProbleM solving Groups collectively possess
greater knowledge and information than any single member, and may produce more
strategies to solve a problem. Under the right circumstances and with appropriate
leadership, groups can deal with more complex problems than a single individual,
especially if there is no single right or wrong solution. Individuals tend to rely on a
small number of familiar strategies; a group is more likely to try several approaches.

Group members may have a greater variety of training and experiences and
approach problems from more diverse points of view. Together, a group may generate
more complete, accurate, and less biased information than one person. Groups may
deal more effectively with problems that cross organizational boundaries or involve
change that requires support from other units or departments. Participative problem
solving has additional advantages: It increases the likelihood of acceptance and under-
standing of the decision, and it enhances cooperation in implementation.

DisADvAntAges of groUP ProbleM solving Group problem solv-
ing also has disadvantages: It takes time and resources, and may create conflict.
Group problem solving can lead to the emergence of benign tyranny within the
group. Members who are less informed or less confident may allow stronger mem-
bers to control group discussion and problem solving. A disparity in participation
can contribute to a power struggle between the nurse manager and a few assertive
group members.

Managers might resist using groups to make decisions. They may fear that they
will not agree with the decision the group makes or will not be needed if all deci-
sions are made by the group. Neither is the case. Some decisions are rightfully the
managers’ (e.g., handling the budget), others are staff decisions (e.g., peer review, self-
scheduling), and some are shared (e.g., joint hiring decisions).

Group problem solving also can be affected by groupthink. groupthink is a nega-
tive phenomenon that occurs in highly cohesive groups that become isolated. Through
prolonged close association, group members come to think alike and have similar prej-
udices and blind spots, such as stereotypical views of outsiders. They exhibit a strong
tendency to seek concurrence, which interferes with critical thinking about important
decisions. In addition, the leadership of such groups suppresses open, freewheeling
discussion and controls what ideas will be discussed and how much dissent will be
tolerated. Groupthink seriously impairs critical thinking and can result in erroneous
and damaging decisions.

Another drawback of group problem solving is that groups tend to make riskier
decisions than individuals. Groups are more likely to support unusual or unpopular
positions (e.g., public demonstrations). Groups tend to be less conservative than indi-
vidual decision makers, and frequently display more courage and support for unusual
or creative solutions to problems. Individuals who lack information about alternatives
may make a safe choice, but during group discussion, they often acquire additional
information and become more comfortable with a less secure alternative.

Thinking Critically, Making Decisions, Solving Problems 141

The group setting allows for the diffusion of responsibility. If something goes
wrong, others can be assigned the blame or risk. Leaders may be greater risk takers
than individuals, and group members might attach a social value to risk taking because
they identify it with leadership.

Stumbling Blocks
The leader’s personality traits, inexperience, lack of adaptability, and preconceived
ideas may be obstacles to decision making and problem solving.

Personality
The leader’s personality can and often does affect how and why certain decisions are
made. Managers are often selected because of their expert clinical, not managerial,
skills. Inexperienced in management, they may resort to various unproductive actions.
On the one hand, a nurse manager who is insecure may base decisions primarily on
approval seeking. When a truly difficult situation arises, the manager, rather than face
rejection from the staff, makes a decision that will placate people rather than one that
will achieve the larger goals of the unit and organization.

On the other hand, a nurse manager who demonstrates an authoritative type of
personality might make unreasonable demands on the staff, fail to reward staff for
long hours because he or she has a “workaholic” attitude, or give the staff little control
over unit decisions. Similarly, an inexperienced manager who is not inclined to act on
new ideas or solutions to problems may cause a unit to flounder. Optimism, humor,
and a positive approach are crucial to energizing staff and promoting creativity.

Rigidity
Rigidity, an inflexible management style, is another obstacle to problem solving. It
may result from ineffective trial-and-error solutions, fear of risk taking, or inherent
personality traits. Avoid ineffective trial-and-error problem solving by gathering suf-
ficient information and determining a means for early correction of wrong or inade-
quate decisions. Also, to minimize risk in problem solving, understand alternative
risks and expectations.

The person who uses a rigid style in problem solving easily develops tunnel
vision—the tendency to look at new things in old ways and from established frames of
reference. It then becomes difficult to see things from another perspective, and prob-
lem solving becomes a process whereby one person makes all of the decisions with
little information or data from other sources. In today’s rapidly changing healthcare
setting, rigidity can be a barrier to effective problem solving.

Preconceived Ideas
Effective leaders do not start out with the preconceived idea that one proposed course
of action is right and all others wrong. Nor do they assume that only one opinion can
be voiced and others will be silent. They start out with a commitment to find out why
others disagree. If the staff, other professionals, or patients see a different reality or
even a different problem, leaders need to integrate this information into developing
additional problem-solving alternatives.

142 Chapter 9

Leading at the Bedside: Applying Critical Thinking
We make many decisions in our lives. Seldom do our deci-
sions result in exactly what we expect; outcomes some-
times surprise us. In some cases, results turn out better
than expected—sometimes not so well. You may or may
not have used the strategies described in this chapter, but
you now have a variety of skills to help you make decisions
and solve problems.

You might be inspired to test your creative ability and
to try out innovative solutions to problems. Explore your
ability to apply critical thinking to your work or your life. Now
that you know about stumbling blocks, you’ll have an eas-
ier time avoiding them. And remember that if you thought
you couldn’t use the techniques described in this chapter,
you would be wrong.

Innovation
Innovation is a strategy to bridge the gap between an existing state and a desired
state (Porter-O’Grady & Malloch, 2010). Organized nursing has recognized the impor-
tance of innovation to solve healthcare’s many problems (Lachman, Glasgow, & Don-
nelly, 2009). The American Academy of Nursing’s campaign “Raise the Voice”
highlights “edge runners,” those nurses who create innovative solutions for the
healthcare system.

The following are several techniques to stimulate innovation:

• Simulations—high-tech mannequins or actors representing standardized patients

• Case studies—participants using critical thinking to analyze actual patient situations

• Problem-based learning—information being added to a case study over time

• Debate—participants examining an issue from more than one viewpoint (Lachman
et al., 2009)

One university has even developed a post-master’s certificate program in innova-
tion. Using a case-study model, Drexel University’s College of Nursing offers an online
program in innovation and entrepreneurship designed to foster creative thinking to
solve internal and external problems (Lachman et al., 2009).

Critical thinking, creativity, and innovative thinking, along with the appropriate
tools and techniques, will enable nurses and their managers to make decisions and
solve problems in the least time and with the best outcomes.

What You Know Now
• Critical thinking requires examining underlying

assumptions about current evidence, interpreting
information, and evaluating the arguments pre-
sented to reach a new and exciting conclusion.

• The creative process involves preparation, incu-
bation, insight, and verification, which can be
learned by individuals and groups.

• Problem-solving and decision-making processes
use critical-thinking skills.

Thinking Critically, Making Decisions, Solving Problems 143

• The decision-making process may employ sev-
eral models: rational, descriptive rationality, sat-
isficing, and political.

• Decision-making techniques vary according to
the problem and the degree of risk and uncer-
tainty in the situation.

• Methods of problem solving include trial and
error, intuition, experimentation, past experience,
tradition, and recognizing that some problems
are self-solving.

• The problem-solving process involves defining
the problem, gathering information, analyzing

information, developing solutions, making a
decision, implementing the decision, and evalu-
ating the solution.

• Group problem solving can be positive, provid-
ing more information and knowledge than an
individual. It can also be negative if it generates
disruptive conflict or groupthink.

• Stumbling blocks to making decisions and solv-
ing problems include the leader’s personality,
rigidity, or preconceived ideas.

• Innovation helps bridge the gap between the
existing state and the desired state.

Tools for Making Decisions and Solving Problems
1. Identify problem areas.
2. Ask questions, interpret data, and consider alter-

natives to make decisions and solve problems.
3. Evaluate the level of certainty, uncertainty, and

risk, and consider appropriate alternatives.

4. Identify opportunities to use groups appropri-
ately to make decisions and solve problems.

5. Follow the problem-solving process described in
this chapter.

6. Challenge yourself to look for creative and inno-
vation solutions.

Questions to Challenge You
1. Identify someone you believe has critical-think-

ing skills. What critical thinking attributes does
this person possess?

2. Describe a situation during which you made an
important decision. What content in the chapter
applied to that situation? What was the outcome?

3. Have you been involved in group decision mak-
ing at school or at work? What techniques were
used? Were they effective?

4. A number of ways that problem solving might fail
were discussed in this chapter. Name three more.

5. Have you ever proposed a creative or innovative
idea at work or school? Describe the idea and
explain what happened.

References
Ashcraft, T. (2010). Solving the critical thinking

puzzle. Nursing Management, 41(1), 8—10.
Effken, J. A., Verrn, J. A., Logue, M. D., & Hsu, Y.

C. (2010). Nurse managers’ decisions. Journal of
Nursing Administration, 40(4), 188—195.

Lachman, V. D., Glasgow, M. E. S., & Donnelly,
G. F. (2009). Teaching innovation. Nursing
Administration Quarterly, 33(3), 205—211.

Porter-O’Grady, T., & Malloch, K. (2010).
Innovation leadership: Creating the

144 Chapter 9

landscape of healthcare. Sudbury, MA:
Jones & Bartlett.

Ryan, C., & Tatum, K. (2012). Objective measurement
of critical-thinking ability in registered nurse
applicants. Journal of Nursing Administration, 42(2),
89—94.

Ryan, C., & Tatum, K. (2013). Customizing
orientation to improve the critical thinking ability
of newly hired pediatric nurses. Journal of Nursing
Administration, 43(4), 208—214.

Simon, H. A. (1993). Decision making: Rational,
nonrational, and irrational. Education
Administration Quarterly, 29(3), 392—411.

Wilkinson, J. (1992). Nursing process in action: A critical
thinking approach. Redwood City, CA: Addison-
Wesley Nursing, p. 29.

Zori, S., Nosek, L. J., & Musil, C. M. (2010). Critical
thinking of nurse managers related to staff RNs’
perceptions of the practice environment. Journal of
Nursing Scholarship, 42(3), 305—313.

Chapter 10

Communicating
Effectively

Learning Outcomes

After completing this chapter, you will be able to:

1. Identify the factors that influence communication.

2. Describe how difference in gender, generation, culture, and
organization can affect communication.

3. Explain how communication content and medium selection vary
according to the situation (context), goals, and relationship of those
involved.

4. Explain what principles must be followed for collaborative
communication to take place.

5. Develop a plan to improve your communication skills.

Communication
Transactional Model of Communication

Channels of Communication

Nonverbal Messages

Directions of Communication

Effective Listening

Effects of Differences
in Communication

Gender Differences in Communication

Generational and Cultural Differences in Communication

Differences in Organizational Culture

The Role of Communication
in Leadership

Employees

Administrators

Coworkers

Medical Staff

Other Healthcare Personnel
Patients and Families

Collaborative Communication

Enhancing Your Communication Skills

145

146 Chapter 10

Key Terms
communication

channels of communication

diagonal communication

downward communication

lateral communication

negative inquiry

synchronous and asynchronous channels

upward communication

Leading at the Bedside: Communicating Effectively
You might think you don’t have anything to learn about com-
munication. You’ve been communicating all your life. But do
you know when it’s best to contact someone in person? By
phone? Is voice mail appropriate? When is texting the right
way? Social media post? Email? Or is a formal letter required?
Deciphering communication makes it possible for you to
choose the best method to use in a variety of different situa-
tions and, thus, to make your communications more effective.

You will learn that one size does not fit all people or
all situations. You will learn that communication is not
static; it is always evolving. Finally, you will learn how to
adapt your communication to circumstances as they
develop, being ever mindful of your role, your goals, and
your purpose.

All set? Let’s talk!

Introduction
Communication is a complex, ongoing, dynamic process in which the participants
simultaneously create shared meaning in an interaction. It is a process in which indi-
viduals employ symbols (both verbal and nonverbal) to establish and interpret mean-
ing within their environment (West & Turner, 2014). As you will see by the end of this
chapter, communication is simple, but it is not easy. However, careful consideration of
factors influencing the communication process when you design messages in any
encounter will increase the likelihood that you will communicate effectively (see Lead-
ing at the Bedside: Communicating Effectively).

Communication
Effective communication is more challenging than it may appear on the surface
because in any one situation we are trying to achieve at least three goals simultane-
ously: instrumental, relational, and identity (Clark & Delia, 1979). An instrumental
goal is what we want to have happen or the focus of the interaction (e.g., I want Chris
to get to work on time). Second, in any particular interaction we are trying to build or
maintain a relationship (e.g., I want to build or maintain goodwill with Chris). Last,
we want to enhance our own identity and protect the identity, or face, of the other per-
son (e.g., I want to be perceived as a competent manager, and I want Chris to feel that
she is a valued employee). The importance of each goal in relation to the other goals
will vary with the situation and people involved, but all three goals always are
involved in any one interaction. Instrumental goals would be relatively easy to achieve
through coercion, if an instrumental goal were our singular goal. However, if we also
want to achieve the other two goals at the same time, then communication becomes
much more challenging.

Communicating Effectively 147

Transactional Model of Communication
The basic components of any communicative process are illustrated in the transac-
tional communication model (see Figure 10-1). All participants are influenced by past
experiences, the present situation, the contexts in which the interaction is occurring,
each person’s goals in the current encounter, the channel selected, noise, feedback, and
each person’s attitudes toward self, the topic, and each other. While it is difficult to
demonstrate in a two-dimensional model, it is important to keep in mind that the com-
munication process is dynamic (duPre, 2014), irreversible (Russo, 1995), and contex-
tual (West and Turner, 2014).

The communication process is dynamic in the sense that it is ever moving for-
ward. The sharing and creating of meaning is a process of continually refining what
we say and listening attentively, all the while thinking carefully about with whom we
are talking or for whom we are writing, as well as the situation we are in, our goals,
and the background of our audience (receiver).

The communication process is also irreversible. How many times have we wished
we could take back what we said or recapture the email or text we just sent? It is an
ongoing process of framing and reframing what we say or write to try to share with
our audience what we mean.

Last, communication is contextual. Every interaction in which we participate is
enmeshed in multiple contexts and environments that help shape or influence the
meanings we create with others. A conversation we have with a colleague at work is
framed differently from a conversation we have with the same colleague in a social
setting. Our work setting is enmeshed in our unit or agency, our institution, our health-
care system, and our various cultures. All of these contexts must be carefully consid-
ered as we design messages of any kind.

Context

F

ield of Experience

Field of Experience

Feedback

Message
Communicator

Encodes/Decodes
EffectChannel

Feedback

Feedback

Noise Noise

Communicator
Encodes/Decodes

C
ompetence Competence

Figure 10-1 Transactional Model of Communication

148 Chapter 10

Channels of Communication
Messages may be sent and received through channels, or pathways. Channels of
communication may be described on a continuum with synchronous and asyn-
chronous channels as endpoints (Kalman & Rafaeli, 2007). In other words, the
more ability that a channel has to offer rapid feedback, multiple cues, natural lan-
guage, and personal focus, the more synchronous and rich the medium is (Daft,
Lengel, & Trevino, 1987; D’Urso & Rains, 2008). In this category, think of face-to-
face (one-to-one, dyads, or groups) and to some extent telephone, voicemail, and
video, such as FaceTime or Skype. Both communicators have more access to mes-
sage information and are more likely to share meaning more easily when more cues
are present.

When a medium offers slower feedback, fewer cues, less naturally occurring lan-
guage, and less personal focus, the more asynchronous the medium is. Examples of
asynchronous media include email, postal mail, fax, posts on a social media website,
or discussion boards. When fewer cues are present in a channel, messages are more
difficult to understand.

A combination of the goal of the message, the context, and the audience or people
involved influence the best channel to use (Sheer & Chen, 2004). In general, the more
important or delicate the issue, the more information you want available in your
channel to all parties in the conversation, so the more synchronous the medium
should be. Any difficult issue should be communicated face-to-face, such as terminat-
ing an individual’s employment or conducting a performance review. Conflict or
confrontation also is usually best handled in person so that the individual’s res-
ponse, especially nonverbal signals (to be discussed later), can be seen and addressed
appropriately.

What channel to use depends on the number of cues or information required
based on the person, your relationship, your goals, and the message. Channels with
more to less information, or cues, are ranked here from more synchronous to less
synchronous:

• In person

• By phone

• Voice mail

• Text

• Email

• Postal mail

• Posting on social media websites, including blogs

Meeting someone face-to-face offers the most opportunities for both parties to see
and hear cues or information in messages. Individuals can see each other’s face and
body movements and can hear words simultaneously. The telephone is slightly less
intimate than in-person communication. Tone of voice, for instance, can be conveyed,
and phone conversations can be two-way. Voice mail is the next level of communica-
tion. Voice mail is useful to convey information that is not necessarily sensitive and
may or may not require a reply.

Email is useful for information similar to that conveyed by voice mail and, like
some voice mail systems, can be broadcast to large groups at once. Announcing the
dates and times for a blood drive is a good example of a broadcast message.

Communicating Effectively 149

Conveying complicated information that may require thought before the receiver
replies is another value of using email. However, it is vital to remember that an email
message is essentially a public message. It easily can be forwarded to unintended
audiences. It is wise to consider email as postcards when deciding what to write in an
email. Texting is similar to email, although briefer, often with a quicker response time.
Posts on social media sites are the least personal communication.

The level of formality of the communication also affects the channel used. Apply-
ing for a position requires a written format, even if a letter is emailed or uploaded to a
website rather than mailed. The relationship between the sender and receiver also
affects the channel choice. If a staff nurse, for example, wants to nominate a coworker
for an award given by the hospital board of directors, a written letter or email often is
required. Memos are less formal than letters and can be emailed, faxed, or mailed.
Social media postings are public and impersonal. Email and texts between colleagues
who have worked together for a long time may be shorter than other situations since
the parties know each other and their past experiences well.

Nonverbal Messages
Oral messages are accompanied by a number of nonverbal messages. These behaviors
include head or facial agreement or disagreement; eye contact; tone, volume, and
inflection of the voice; gestures of the shoulders, arms, hands, or fingers; body posture
and position; dress and appearance; timing; and environment.

Nonverbal communication may be more powerful than the words one speaks and
can influence the meaning of the spoken words. When a verbal message is incongruent
with the nonverbal message, the recipient has difficulty interpreting the intended
meaning. For example, a manager who states “Come talk to me anytime” but keeps
typing at the keyboard while you talk, sends a conflicting message to the staff. A per-
son may receive conflicting messages from differing sources. For example, the risk
manager may encourage a nurse to report medication errors, but the nurse manager
follows up with discipline over the error. The nurse is caught between conflicting mes-
sages from the two managers.

The following are other common causes of unclear messages:

• Using inadequate reasoning

• Using strong, judgmental words

• Speaking too quickly or too slowly

• Using unfamiliar words

• Spending too much time on details

Messages become less clear when the recipient is busy or distracted, bases under-
standing on previous unsatisfactory experience with the sender, or has a biased per-
ception of the meaning of the message or the messenger. Email is particularly fraught
with opportunities for misunderstanding. From the greeting (e.g., dear, hi, hello, or no
salutation) to the sign-off (e.g., warm regards, best wishes, best, or no sign-off), the
sender conveys more than the choice of words. A speedy reply is expected and encour-
ages a response, sometimes without adequate thought. Finally, the possibility of send-
ing the message to the wrong person, especially the dreaded “reply to all,” is another
chance for your message to be misinterpreted. Texting shares many of the same dan-
gers as email and has the added pressure for a faster response.

150 Chapter 10

Directions of Communication
Formal or informal communication in an organization may be downward, upward,
lateral, or diagonal. Downward communication (manager to staff) is often directive.
The staff is told what needs to be done or given information to facilitate the job to be
done. Upward communication occurs from staff to management or from lower man-
agement to middle or upper management. Upward communication often involves
reporting pertinent information to facilitate problem solving and decision making.
Lateral communication occurs between individuals or departments at the same hier-
archical level (e.g., nurse managers, department heads). Diagonal communication
involves individuals or departments at different hierarchical levels (e.g., staff nurse to
chief of the medical staff). To a greater or lesser degree, communication in all of these
directions involves information sharing, discussion, and negotiation.

An informal channel commonly seen in organizations is the grapevine (e.g., con-
versations among members of an organization; these conversations may include
rumors and gossip). Grapevine communication is usually rapid, haphazard, and prone
to changes in interpretations. It can also be useful. Sometimes the only way to learn
about a pending change is through the grapevine. One problem with grapevine com-
munication, however, is that no one is accountable for any misinformation that is
relayed. Keep in mind, too, that information gathered this way is often a slightly
altered version of the original message, changing as the message passes from person to
person.

Effective Listening
Most nurses believe they are good listeners. Observing and listening to patients are
skills nurses learn early in their careers and use every day. Being a good listener, how-
ever, involves more than just hearing words and watching body language (Sullivan,
2013). Maintaining eye contact as a cue to effective listening is misleading; it may or
may not signal that a person is listening, although it helps. Barriers to effective listen-
ing include preconceived beliefs, lack of self-confidence, flagging energy, defensive-
ness, and habit (Donaldson, 2007).

PRECONCEIVED BELIEFS The longer your relationship with someone lasts, the
more apt you are to think you know what the person says or means and, thus, the
more likely you are not to listen. This holds true in personal as well as professional
relationships and also applies to groups of people (known as stereotyping). Not
expecting others to have anything worthwhile to say also is an example of preconcep-
tions about them.

LACK OF SELF-CONFIDENCE Listening is difficult if you are nervous, and low self-
confidence frequently is the cause. People tend to talk too much or think about what
they are planning to say next instead of paying attention to the person speaking.
Often their minds are racing, and they may not be listening even when they them-
selves are talking.

FLAGGING ENERGY Listening takes energy and sometimes we simply do not have
enough energy to listen carefully. Hearing too many people speaking at once, having too
much to do, being worried, or being too tired can all interfere with our ability to listen.

DEFENSIVENESS Survival required that we learned to hear danger approaching,
but today humans have translated defense mechanisms into a way to avoid hearing

Communicating Effectively 151

Table 10-1 Gender Differences in Communication

Men tend to . . . Women tend to . . .

Interrupt more frequently Wait to be noticed

Talk more, longer, louder, and faster Use qualifiers (prefacing and tagging)

Disagree more Use questions in place of statements

Focus on the issue more than the person Relate personal experiences

Boast about accomplishments Promote consensus

Use banter to avoid a one-down position Withdraw from conflict

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses. (2nd ed.). Upper Saddle River, NJ: Pearson, p. 57. Reprinted by
permission.

bad news. Then, we think, we do not have to deal with it. The opposite is true, how-
ever. Only when we can hear and consider information can we handle it.

HABIT Over time, many people develop the habit of thinking ahead during conver-
sations. Thinking ahead is valuable in most aspects of life, but it can be deadly when
you need to be listening. Like all behaviors that have become habits, changing this one
is not easy. Reminding yourself to refocus on the speaker can help.

Effects of Differences in Communication
Although the communication process may appear to be the same regardless of who
is involved, that is not the case. The individual’s gender, age, and culture all affect
the effectiveness of the communication. Furthermore, the culture of the organization
provides context for the communication and affects how messages are sent and
received.

Gender Differences in Communication
Men and women communicate somewhat differently (Feldhahn, 2009; Tannen, 2001).
They have become socialized through communication patterns that reflect their soci-
etal roles. Men tend to talk more, longer, and faster, whereas women tend to be more
descriptive, attentive, and perceptive. Women tend to use tag questions (e.g., “I can
take off this weekend, can’t I?”) and tend to self-disclose more than men. Women tend
to ask more questions and solicit more input than their male counterparts. Table 10-1
lists differences in the ways that men and women communicate.

Helgeson and Johnson (2010) suggest ways that women can improve their com-
munication at work. Neither men nor women should raise their voices no matter
what the provocation. Nor should one omit important details or assume that everyone
knows what you mean. Encouraging questions or objections will help keep the dialogue
moving forward. Finish what you are saying before you leave a conversation.

Using gender-neutral language in communication helps bridge the gap between
the way men and women communicate. Men and women can improve their ability to
communicate with each other by following the recommendations for gender-neutral
communication found in Table 10-2.

152 Chapter 10

Generational and Cultural Differences
in Communication
Generational differences affect communication styles, patterns, and expectations. Peo-
ple who describe themselves as traditionals tend to be more formal, following the
chain of command without question. People who identify as baby boomers question
more. They enjoy the process of group problem solving and decision making. Inde-
pendent generation Xers are just the opposite and want decisions made without exten-
sive discussion. People who identify as millennials (also sometimes called generation Y)
often expect more immediate feedback to their messages. Email, text, or voice mail is
often a good way to connect with them, depending on the situation and your goals.
Mutual respect and understanding of the unique differences between and among indi-
viduals in these groups will help to minimize conflict and maximize satisfaction for
both managers and staff (Hahn, 2009).

Cultural attitudes, beliefs, and behaviors also affect communication (Robertson-
Malt, Herrin-Griffith, & Davies, 2010). Such elements as body movement, gestures,
tone, and spatial orientation are culturally defined. A great deal of misunderstanding
results from a lack of understanding of each other’s cultural expectations. For exam-
ple, people of Asian descent often take great care in exchanges with supervisors so
there is no conflict or “loss of face” for either person.

Understanding the cultural heritage of employees and learning to interpret cul-
tural messages are essential to communicating effectively with staff from diverse
backgrounds. Personal and professional cultural competency training is recom-
mended. This includes reading the literature and history of the culture; participating
in open, honest, respectful communication; and exploring the meaning of behavior.
It is important to recognize, however, that subcultures exist within all cultures;
therefore, what applies to one individual will not be true for everyone else in that
culture.

Differences in Organizational Culture
As discussed in Chapter 2, the customs, norms, and expectations within an organiza-
tion are powerful forces that shape behavior. Focusing on relevant issues regarding the
organizational culture can identify problems in communication. Poor communication
is a frequent source of job dissatisfaction as well as a powerful determinant of an orga-
nization’s effectiveness. Just as violation of other norms within the organization results
in repercussions, so does violation of communication rules.

Table 10-2 Recommendations for Gender-Neutral Communication

Men may need to . . . Women may need to . . .

Listen to objections and suggestions State your message clearly and concisely

Listen without feeling responsible Solve problems without personalizing them

Suspend judgment until information is in Say what you want without hinting

Explain your reasons Eliminate unsure words (“sort of”) and nonwords (“truly”)

Not yell Not cry

From Sullivan, E. J. (2013). Becoming influential: A guide for nurses, 2nd ed. Upper Saddle River, NJ: Pearson, p. 58. Reprinted by
permission.

Communicating Effectively 153

To discover what rules affect communication in your organization, ask yourself
the following:

• Who has access to what information? Is information withheld? Is it shared widely?

• What channels of communication are used for which messages? Are they used
appropriately?

• How clear are the messages? Do the messages reveal the senders to be more or less
transparent?

• Does everyone receive the same information? If not, why not?

• Do you receive too much information? Not enough?

• How effective is the message?

The Role of Communication
in Leadership
Although communication is inherent in the manager’s role, the manager’s ability to
effectively communicate often determines his or her success as a leader. Leaders often
are viewed as informative when they engage in frank, open, two-way communication
and when their nonverbal communication reinforces the verbal messages. Communi-
cation is enhanced when the manager listens carefully and is sensitive to others’ back-
grounds and needs. The major underlying factor, however, is an ongoing relationship
between the manager and employees.

Successful leaders are able to persuade others, solicit input from them, and enlist
their support. One of the most effective means of engaging others is the leader’s per-
sonal characteristics. Competence, emotional control, assertiveness, consideration,
and respect promote perceptions of trustworthiness and credibility. A participative
leader is seen as a careful listener who is open, frank, trustworthy, informative, and
encourages and acts upon others’ ideas whenever possible.

Employees
Depending on the organization’s policies, the nurse manager’s responsibilities may
include selecting, interviewing, evaluating, counseling, and disciplining employees;
handling their complaints; and settling conflicts. The principles of effective communi-
cation are especially pertinent in these activities because effective communication is
the adhesive that builds and maintains an effective work group.

Giving direction is not, in itself, communication. If the manager receives an appro-
priate response from the subordinate, however, understanding or shared meaning
likely has occurred. To give directions and achieve the desired results, develop a mes-
sage strategy. The techniques that follow can help improve effective responses from
others.

• Know the context of the instruction. Be certain you know exactly what you want
done, by whom, within what time frame, and what steps should be followed to do
it. Be clear in your own mind what information a person needs to carry out your
instruction, what the outcome will be if the instruction is carried out, and how that
outcome can or will be evaluated. When you have thought through these ques-
tions, you are ready to give the proper instruction.

154 Chapter 10

• Get positive attention. Avoid factors that interfere with effective listening. Inform-
ing the person that the instructions will be given is one simple way to try to get
positive attention. Highlighting the background, giving a justification, or indicat-
ing the importance of the instructions also may be appropriate.

• Give clear, concise instructions. Use an inoffensive and nondefensive style and
tone of voice. Be precise, and give all the information receivers need to carry out
your expectations. Follow a step-by-step procedure if several actions are needed.

• Verify through feedback. Make sure the receiver has understood your specific
request for action. Allow a short time for the listener to absorb the information
and ask questions. Ask for a repeat of the instructions.

• Provide follow-up messages. Understanding does not guarantee performance.
Follow up to discover if your instructions were clear and if the person has any
questions.

The nurse manager is responsible both for the quality of the work life of individual
employees, and for the quality of patient care in the entire unit. To carry out this job,
acknowledge the needs of individual employees, especially if the needs of one conflict
with needs of the unit, speak directly with those involved, and state clearly and accu-
rately the rationale for the decisions made.

Administrators
The manager’s interaction with administration higher in the organizational chart is
comparable to the interaction between the manager and an employee, except that the
manager reports to the administrator. Higher administration is responsible for the con-
sequences of decisions made for a larger area, such as all of nursing service or the entire
organization. The principles used in communicating with subordinates are equally
appropriate here. Managers should be organized and prepared to state their needs
clearly, explain the rationale for requests, suggest benefits for the larger organization,
and use appropriate channels. Listen objectively to your supervisor’s response and be
willing to consider reasons for possible conflict with the needs of other areas.

Working effectively with an administrator is important because this person directly
influences personal success in a career and within the organization. Managing a super-
visor, or managing upward, is a crucial skill for nurses. To manage upward, remember
that the relationship requires participation from both parties. Managing upward is suc-
cessful when power and influence move in both directions. Rules for managing your
supervisor are found in Box 10-1.

Box 10-1 Rules for Managing Your Boss
• Never let your supervisor be surprised; keep her or

him informed.
• Always tell the truth.
• Find ways to compensate for your supervisor’s weak-

nesses. Fill in weak areas tactfully. Volunteer to do
something the supervisor dislikes doing.

• Be your own publicist. Don’t brag, but keep your
supervisor informed of what you achieve.

• Keep aware of your supervisor’s achievements and
acknowledge them.

• If your supervisor asks you to do something, do it well
and ahead of the deadline if possible. If appropriate,
add some of your own suggestions.

• Establish a positive relationship with the supervisor’s
assistant.

Communicating Effectively 155

One aspect of managing upward is understanding the supervisor’s position
from her or his frame of reference. This will make it easier to propose solutions and
ideas that the supervisor will accept. Understand that a supervisor is a person with
much responsibility and pressure. Learn about the supervisor from a personal per-
spective: What pressures, both personal and professional, does the supervisor
face? How does the supervisor respond to stress? What previous experiences are
liable to affect today’s issues? This assessment will allow you to identify ways to
help your supervisor with his or her job and for your supervisor to help you with
yours.

INFLUENCING YOUR SUPERVISOR Nurses need to approach their supervisor to
exert their influence on a variety of issues and problems. Support for the purchase of
capital equipment, for changes in staffing, or for a new policy or procedure all require
communicating with a supervisor. Your rationale, choice of form or format, and pos-
sible objections all are important factors to consider as you prepare to make such a
request. Timing is critical; a good opportunity is when the supervisor has time and
appears receptive. Also, consider the impact of your ideas on other events occurring at
that time on your unit and/or organization-wide.

Should ideas be presented in spoken or written form? Usually some combination
is used. Even if you have a brief meeting about a relatively small request, it is a good
idea to follow up with an email, detailing your ideas and the plans to which you both
agreed. Sometimes the procedure works in reverse. If you provide the supervisor with
a written proposal prior to a meeting, both of you will be familiar with the idea at the
start. In the latter case, careful preparation of the written material is essential.

What can be done if, in spite of careful preparation, your supervisor says no? First,
make sure you have understood the objections and associated feelings. Negative
inquiry (e.g., “I don’t understand”) is a helpful technique to use. Do not interrupt or
become defensive or distraught; remain diplomatic.

The next step is confrontation. Keep your voice low and measured; use “I” lan-
guage; and avoid absolutes, why questions, put-downs, inflammatory statements, and
threatening gestures. Finally, if you feel you have lost and compromise is unlikely,
table the issue by saying “Could we continue discussing this at another time?” Then,
think through your supervisor’s reasoning and evaluate it. Afterward, ask yourself
“What new information did I get from the supervisor?” “What are ways I can renegoti-
ate?” “What do I need to know or do to overcome objections?” Once you can answer
these questions, approach your supervisor again with the new information. This
behavior shows that the proposal is a high priority, and the new information may
cause him or her to reevaluate.

Managers often succeed in influencing supervisors through persistence and repe-
tition, especially if supporting data and documentation are supplied. If the issue is
important enough, you may want to take it to a higher authority. If so, tell your super-
visor you would like an administrator at a higher level to hear the proposal. Keep an
open mind, listen, and try to meet objections with suggestions of how to solve prob-
lems. Be prepared to compromise, which is better than no movement at all, or to be
turned down.

TAKING A PROBLEM TO YOUR SUPERVISOR No one wants to hear about a prob-
lem, and your boss is no different. Nonetheless, work involves problems, and the man-
ager’s job is to solve them. Go to your supervisor with a goal to problem solve together.
Have some ideas about solving the problems in hand if you can, but do not be so

156 Chapter 10

wedded to them that you are unable to listen to your supervisor’s ideas. Keep an open
mind. Use the following steps to take a problem to your supervisor:

• Find an appropriate time to discuss a problem, scheduling an appointment if
necessary.

• State the problem succinctly, and explain why it is interfering with work.

• Listen to your supervisor’s response, and provide more information if needed.

• If you agree on a solution, offer to do your part to solve it. If you cannot discover
an agreeable solution, schedule a follow-up meeting or decide to gather more
information.

• Schedule a follow-up appointment, if appropriate.

By solving the problem together and, if necessary, by taking active steps together,
you and your supervisor are more likely to accept the decision and be committed to it.
Setting a specific follow-up date can prevent a solution from being delayed or
forgotten.

IF ALL ELSE FAILS Sometimes no matter what you do, working with your supervi-
sor seems nearly impossible. Some managers foster a negative work environment, and
employees become dissatisfied, angry, and depressed. High absenteeism and turnover
result. As a manager, you are charged with supporting your supervisor. If working
with that person is too difficult for you to manage your work satisfactorily, you may
have to transfer elsewhere or leave.

Coworkers
Interactions with coworkers are inevitable. Relationships can vary from comfortable
and easy to challenging and complex. Coworkers often share similar concerns. Cama-
raderie may be present; coworkers can exchange ideas and address problems cre-
atively. They can provide social support in difficult situations.

Conversely, there may also be competition or conflicts (e.g., battles over territory,
personality clashes, differences of opinion) affected by history, the organization’s
norms, or generational or cultural differences. Even during conflicts, coworkers should
interact on a professional level.

Medical Staff
Communication with the medical staff may be difficult for the nurse manager because
the relationship of physicians and nurses historically has been that of superior and
subordinate. Complicating physician–nurse relationships is the employee status of the
medical staff. They may not be employees of the organization but still have consider-
able power because of their ability to attract patients to the organization. Finally, the
medical staff is in itself diverse, consisting of physicians who are organizational
employees, residents, physicians in private practice, and consulting physicians, all
with their own cultural, gender, and generational backgrounds.

Other Healthcare Personnel
The nurse manager has the overwhelming task of coordinating the activities of a num-
ber of personnel with varied levels and types of preparation and different kinds of
tasks. The patient may receive regular care from a registered nurse, unlicensed

Communicating Effectively 157

assistive personnel, a respiratory therapist, a physical therapist, and a dietician, among
others. The nurse manager may supervise all of them. Regardless, the manager needs
considerable skill to communicate effectively with diverse personnel, recognize their
commonalities, and deal with their differences.

Patients and Families
Nurse managers deal with many difficult issues, such as complaints about delivery of
care, a staff member, or violations of policy. When dealing with patient or family com-
plaints (e.g., about a staff member or violations of policy), keep the following princi-
ples in mind:

• The patient and family are the principal customers of the organization. Treat
patients and families with respect; keep communication open and honest. Dissat-
isfied customers fail to continue to use a service and inform their friends and fam-
ilies about their negative experiences. Handle complaints or concerns tactfully
and expeditiously. Many times lawsuits can be avoided if the patient or family
feels that someone has taken the time to listen to their complaints.

• Most individuals are unfamiliar with medical jargon. Use words that are appro-
priate to the recipient’s level of understanding. However, take care not to be con-
descending or intimidating. It is just as important to assess the person’s knowledge
base and level of understanding as it is to know his or her vital signs or liver
status.

• Maintain privacy and identify a neutral location for dealing with difficult inter-
actions.

• Make special efforts to find interpreters if a patient or family does not speak Eng-
lish. Have readily available a list of individuals who are able to communicate in a
variety of languages, including sign language and Braille. Another resource is
AT&T’s language line service, which provides interpreters for seven languages
24 hours a day.

• Recognize cultural differences in communicating with patients and their families.
People in some cultures do not ask questions for fear of imposing on others
(Huber, 2009). Some cultures prefer interpreters from their own culture; others do
not. Cultural education for the staff can help them identify some of these differ-
ences and teach them appropriate, culturally sensitive responses (Raingruber
et al., 2010).

Collaborative Communication
Collaboration is central to patient safety, according to a study by Vitalsmarts (Maxfield,
Grenny, Lavandero, & Groah, 2005). The researchers found seven areas where health-
care workers found it difficult to speak up, including seeing colleagues make mistakes,
perform incompetently, disrespect others, break rules, fail to support colleagues,
exhibit poor teamwork, or micromanage inappropriately.

Propp and colleagues (2010) found that two processes were critical to ensuring
collaboration with physicians and other members of the healthcare team: ensuring
quality decisions and promoting team synergy. By developing a collaborative practice
model, nurses can build their credibility with physicians and enhance the workplace
environment.

158 Chapter 10

Another study found communication and role understanding crucial to collabora-
tive practice (Suter et al., 2009). Appreciation of one another’s roles was key to improv-
ing communication and positive patient outcomes. Focusing educational objectives on
communication and understanding others’ roles, rather than more diffuse skills, such
as respect, is more likely to lead to better practices, the researchers assert.

To support greater collaboration between nurses and physicians and to improve
the product of nursing service—patient care—keep these principles in mind:

• Respect physicians as persons, and expect them to respect you.

• Consider yourself and your staff equal partners with physicians in healthcare.

• Build your staff’s clinical competence and credibility. Ensure that your staff has
the clinical preparation necessary to meet required standards of care.

• Actively listen and respond to physician complaints as customer complaints. Cre-
ate a problem-solving structure. Stop blaming physicians exclusively for commu-
nication problems.

• Consider implementing Team Strategies and Tools to Enhance Performance and
Patient Safety (TeamSTEPPS), an evidence-based series of team-building phrases
available at www.ahrq.gov that help promote collaborative interactions among
healthcare professionals.

• Use every opportunity to increase your staff’s contact with physicians and to
include your staff in meetings that include physicians. Remember that limited
interactions contribute to poor communication.

• Establish a collaborative practice committee on your unit with membership com-
posed equally of nurses and physicians. Identify problems, develop mutually sat-
isfactory solutions, and learn more about each other. Emphasize similarities and
the need for quality care. Begin with those physicians who have a positive attitude
toward collaboration.

• Serve as a role model to your staff in nurse–physician communication.

• Support your staff by your words and by your actions when participating in col-
laborative efforts.

Case Study 10-1 shows how one nurse manager handled a problem with a physi-
cian. Table 10-3 offers strategies for responding to power plays or intimidation.

Enhancing Your Communication Skills
Communication skills can be developed. To improve your communication skills, take
the following steps.

1. Consider your relationship to the receiver. This could be a boss, employee, or
patient.

2. Craft your message, including your goal and how to answer responses. Be clear
about your goal. Think about how the other person might interpret your message
and what he or she is liable to say in return. Consider how you might respond.

3. Decide on the medium, based on your relationship, the content, and the setting. Is
the message best conveyed in person, by phone, email, or text? Should you leave
a message if the person is not available? Note the number of cues available through
a particular channel for guidance. Generally, the more likely a message might be

http://www.ahrq.gov

Communicating Effectively 159

Table 10-3 Assertive Communication Strategies

If you are confronted with power plays or intimidation, what is the best way to respond? Intimidation can be
counteracted by increasing self-confidence and personal feelings of power. Four strategies that generate
feelings of personal power are outlined below.

Word choices Use the other person’s name frequently.
Use strong statements.
Avoid discounters, such as “I’m sorry, but . . .”
Avoid clichés, such as “hit the nail on the head,” “goes without saying,” “easier said than
done.”
Avoid fillers (such as “ah,” “uh,” and “um”).

Through delivery Be enthusiastic.
Speak clearly and forcefully.
Make one point at a time.
Do not tolerate interruptions.

By listening Listen for facts.
Pay attention to emotions.
Listen for what is not being said (e.g., body language, mixed messages, hidden
messages).

Through body
posture and body
language

Sit next to your antagonist; turn 30 degrees toward the person when you address him or her.
Lean forward.
Expand your personal space.
Use gestures.
Stand when you talk.
Smile when you are pleased, not in order to please.
Maintain eye contact, but do not stare.

CASE STUDY 10-1 | Communication
Josie Randolph is nurse manager of a perioperative unit,
which includes responsibility for the preoperative testing
unit, 18 OR suites, pre-op holding, and sterile processing.
The OR department supports the hospital’s Level I trauma
service as well as all other surgical services.

Dr. Jonas Welborne is a plastic surgeon with a history
of aggressive behavior. He has several cases on today’s
OR schedule. While he is in his first surgery, a trauma case
is brought to the OR. Susan Richardson, the OR charge
nurse, decides to bump Dr. Welborne’s second case out of
OR #3 in order to make room for the trauma case. When
Dr. Welborne has finished his first case, he is informed of
the delay in his second case. Dr. Welborne storms into the
OR scheduling office and begins yelling at Susan. The situ-
ation quickly escalates to the point where Dr. Welborne
uses obscenities and throws several charts on the floor.
Loretta Donnelly, an OR tech, runs to Josie’s office and
asks her to come immediately to the OR scheduling office.

Susan and Dr. Welborne continue to yell at one
another, in full view of patients in the pre-op area. Josie
immediately steps between Dr. Welborne and Susan and

firmly asks both of them to lower their voices. She instructs
Susan to wait in the staff lounge while she speaks with
Dr. Welborne. Josie asks Dr. Welborne to step into her
office so they can calmly discuss the situation. Dr. Welborne
is still visibly agitated but agrees to discuss the problem.

After hearing his side of the story, Josie apologizes for
the inconvenience but reminds him of the OR policies.
Emergent cases take precedence over elective cases, and
no other elective cases were on the schedule at that time.
She asks Dr. Welborne if there are alternatives to schedul-
ing his cases that would minimize delays or bumps. As they
talk, Dr. Welborne becomes calmer.

Josie informs Dr. Welborne that his earlier behavior
is unacceptable. Within a few minutes, he apologizes to
Josie and asks to speak with Susan. He also apologizes
to Susan. Josie and Susan discuss the incident and ways
Susan can help diffuse similar situations in the future. As
with Dr. Welborne, Josie indicates that Susan’s behavior
was unprofessional and, as the OR charge nurse, she is
always expected to act as a nursing professional and
role model.

160 Chapter 10

interpreted in a variety of ways (increased equivocality), then the more important
it is to select a channel with many cues (as synchronous a channel as possible).

4. Check your timing. Timing plays a critical role in successful communication. Catch
your boss in the midst of planning for a budget shortfall and you are less apt to get
a receptive hearing.

5. Deliver your message. Be prepared when you deliver your message. The best-
crafted message, delivered by the appropriate medium can misfire by a sender
who fails to listen carefully, avoids responding out of fear of consequences, or
undermines the message with qualifiers such as “I don’t know if you’re interested.”

6. Attend to verbal or written responses.

7. Reply appropriately.

8. Conclude when both parties’ messages have been understood.

9. Evaluate the communication process.

(For more information on communicating effectively, see Sullivan, E. J. [2013].
Becoming influential: A guide for nurses [2nd ed.]. Upper Saddle River, NJ: Pearson.)

What You Know Now
• Communication is a complex, ongoing, dynamic

process.

• How to deliver a message depends on the goal,
the context, the content, and the relationship.

• Messages can be misconstrued.

• Gender, generation, cultural background, and the
organizational culture influence communication
and its outcomes.

• Expert communication skills are essential for a
leader to be successful.

• Communication strategies vary according to the
situation and the roles of people involved.

• Collaborative communication is challenging, and
specific skills can help.

• Nurses can enhance their communication skills
with effort and practice.

Tools for Communicating Effectively
1. Identify and use the appropriate channel (in per-

son, phone, voice mail, text, email, letter) for your
messages.

2. Evaluate your communication skills in various
situations. Seek out ways to improve.

3. Practice using the skills described in specific situ-
ations, such as with your coworkers, with the
medical staff, and with patients and their families.

4. Become sensitive to others’ responses, both verbal
and nonverbal, and craft your messages approp-
riately.

5. Gather feedback and continue to assess the effec-
tiveness of your communications.

6. Strive to improve your communication skills.

Communicating Effectively 161

Questions to Challenge You
1. Consider a recent interaction you witnessed:

• What appeared to be the situation and the con-
texts that framed what was going on?

• Did the sender express the message clearly?
• Did the sender use the appropriate medium?
• Listen and respond to questions and com-

ments?
• How did the receiver respond?
• What was the outcome?

2. Now think about a recent interaction where you
were the sender using the above questions. If you
could replay the interaction, what would you do
differently?

3. How well does communication function in your
workplace, school, or clinical site?

4. To improve your communication, practice the
skills described in the chapter by role playing or
recording yourself (Sullivan, 2013).

References
Clark, R. A., & Delia, J. G. (1979). Topoi and rhetorical

competence. Quarterly Journal of Speech, 65,
187–206.

Daft, R. L., Lengel, R. H., & Trevino, L. K. (1987).
Message equivocality, media selection, and
manager performance: Implications for
information systems. MIS Quarterly, 11, 355–366.

Donaldson, M. C. (2007). Negotiating for dummies
(2nd ed.). New York, NY: Wiley Publishing.

duPre, A. (2014). Communicating about health: Current
issues and perspectives. New York, NY: Oxford
University Press.

D’Urso, S. C., & Rains, S. A. (2008). Examining
the scope of channel expansion: A test of
channel expansion with new and traditional
communication media. Management
Communication Quarterly, 21(4), 486–507.

Feldhahn, S. (2009). The male factor: The unwritten
rules, misperceptions, and secret beliefs of men in the
workplace. New York, NY: Crown Business.

Hahn, J. (2009). Effectively manage a
multigenerational staff. Nursing Management,
40(9), 8–10.

Helgeson, S., & Johnson, J. (2010). The female vision:
Women’s real power at work. San Francisco, CA:
Berrett-Koehler Publishers.

Huber, L. M. (2009). Making community health care
culturally correct. American Nurse Today, 4(5),
13–15.

Kalman, Y., & Rafaeli, R. (2007). Modulating
synchronicity in computer mediated communication.
Paper presented at the International Commu-
nication Association annual conference, San
Francisco, CA.

Maxfield, D., Grenny, J., Lavandero, R., & Groah,
L. (2005). The silent treatment: Why safety tools and
checklists aren’t enough to save lives. Retrieved April
11, 2011, from http://www.silencekills.com/
UPDL/SilenceKillsExecSummary

Propp, K. M., Apker, J., Zabava Ford, W. S.,
Wallace, N., Servenski, M., & Hofmeister,
N. (2010). Meeting the complex needs of the
health care team: Identification of nurse-team
communication practices perceived to enhance
patient outcomes. Qualitative Health Research,
20(1), 15–28.

Raingruber, B., Teleten, O., Curry, H., Vang-Yang,
B., Kuzmenko, L., Marquez, V., & Hill, J. (2010).
Improving nurse-patient communication and
quality of care: The transcultural, linguistic care
team. Journal of Nursing Administration, 40(6),
258–260.

Robertson-Malt, S., Herrin-Griffith, D. M., & Davies,
J. (2010). Designing a patient care model with
relevance to the cultural setting. Journal of Nursing
Administration, 40(6), 277–282.

Russo, T. (1995). Introduction to communication.
Lecture. Lawrence, KS: University of Kansas.

http://www.silencekills.com/UPDL/SilenceKillsExecSummary

http://www.silencekills.com/UPDL/SilenceKillsExecSummary

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Sheer, V. C., & Chen, L. (2004). Improving media
richness theory. Management Communication
Quarterly, 18(1), 76–93.

Sullivan, E. J. (2013). Becoming influential: A guide
for nurses (2nd ed.). Upper Saddle River, NJ:
Pearson.

Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor,
E., & Deutschlander, S. (2009). Role understanding
and effective communication as core competencies

for collaborative practice. Journal of Interprofessional
Care, 23(1), 41–51.

Tannen, D. (2001). Talking from 9 to 5: How women’s and
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gets credit, and what gets done at work. New York, NY:
Harper.

West, R., & Turner, L. H. (2014). Introducing
communication theory: Analysis and application
(5th ed.). New York, NY: McGraw-Hill Education.

Chapter 11

Delegating
Successfully

Learning Outcomes

After completing this chapter, you will be able to:

1. Explain delegation and distinguish between responsibility,
accountability, and authority.

2. Describe how effective delegation benefits the delegator, the
delegate, the unit, and the organization.

3. Explain how following the five rights of delegation can reduce
nurses’ fears about delegation.

4. Evaluate the delegation process, including the steps in delegation,
key behaviors for successful delegation, and the implications of
accepting delegation.

5. Assess the factors that contribute to ineffective delegation.

Delegation

Benefits of Delegation
Benefits to the Nurse

Benefits to the Delegate

Benefits to the Manager

Benefits to the Organization

The Five Rights of Delegation

The Delegation Process
Steps in the Delegation Process

Key Behaviors for Successful Delegation

Accepting Delegation

Ineffective Delegation
Organizational Culture

Lack of Resources

An Insecure Delegator

An Unwilling Delegate

Underdelegation

Reverse Delegation

Overdelegation

163

164 Chapter 11

Key Terms
accountability

assignment

authority

delegation

overdelegation

responsibility

reverse delegation

underdelegation

Introduction
It is easy to say delegate, but delegation is a difficult leadership skill for nurses to
learn. Most would rather do all their patients’ nursing care themselves than assign
others to do it (Case, 2015). A leader who models delegation promotes collaboration
between nurses and support personnel (Orr, 2010). Never before, however, has delega-
tion been for nurses and nurse managers as critical a skill to perfect as it is today, with
the emphasis on doing more with less.

Delegation
Delegation is the process by which responsibility and authority for performing a task
(function, activity, or decision) are transferred to another individual who accepts that
authority and responsibility. Although the delegator remains accountable for the task,
the delegate is also accountable to the delegator for the responsibilities assumed.
Delegation can help others to develop or enhance their skills, promote teamwork, and
improve productivity (Weydt, 2010).

An American Nurses Association (ANA) publication (2012) delineates the princi-
ples for delegation, as shown in Box 11-1. Based on the scope and standards of nursing
practice, these principles make clear that the ultimate responsibility for the patient’s
care rests with the RN. In addition, the organization is responsible for providing neces-
sary resources and competency information and to develop organizational policies
with the involvement of RNs.

Responsibility, accountability, and authority are concepts related to delegation.
Although responsibility and accountability are often used synonymously, the two
words represent different concepts that go hand in hand. Responsibility denotes
an obligation to accomplish a task, whereas accountability is accepting ownership
for the results or lack thereof. Responsibility can be transferred, but accountability
is shared.

You can delegate only those tasks for which you are responsible. If you have no
direct responsibility for the task, then you cannot delegate that task. For instance, if a
manager is responsible for filling openings in the staffing schedule, the manager can
delegate this responsibility to another individual. However, if staffing is the responsi-
bility of a central coordinator, the manager can make suggestions or otherwise assist
the staffing coordinator but cannot delegate the task.

Likewise, if an orderly who is responsible for setting up traction is detained
and a nurse asks a physical therapist on the unit to assist with traction, this is not

Delegating Successfully 165

delegation because setting up traction is not the responsibility of the nurse.
However, if the orderly (the person responsible for the task) had asked the physi-
cal therapist to help, this could be an act of delegation if the other principles of
delegation are met.

Along with responsibility, you must transfer authority. Authority is the right to
act. Therefore, by transferring authority, the delegator is empowering the delegate to
accomplish the task. Too often this principle of delegation is neglected. Nurses retain
authority, crippling the delegate’s abilities to accomplish the task, setting the individ-
ual up for failure, and minimizing efficiency and productivity.

Delegation is often confused with work assignment. Delegation involves transfer
of responsibility and authority. In assignment no transfer of authority occurs. Instead,
assignments are a bureaucratic function that reflects job descriptions and patient or
organizational needs. Effective delegation benefits the delegator, the delegate, the
manager, and the organization.

Benefits of Delegation
The nurse, the delegate, the manager, and the organization all benefit from delegation.
Nurses save time when work is delegated appropriately to others. The delegate has
the opportunity to learn new skills. When delegation is used correctly, the manager
can better utilize time and resources. Delegation improves the functioning of the orga-
nization as a whole.

Box 11-1 Principles for Delegation
The following principles provide guidance and inform the
registered nurse’s decision making about delegation:

• The nursing profession determines the scope and
standards of nursing practice.

• The RN takes responsibility and accountability for the
provision of nursing practice.

• The RN directs care and determines the appropriate
utilization of resources when providing care.

• The RN may delegate tasks or elements of care but
does not delegate the nursing process itself.

• The RN considers facility/agency policies and proce-
dures and the knowledge and skills, training, diversity
awareness, and experience of any individual to whom
the RN may delegate elements of care.

• The decision to delegate is based upon the RN’s judg-
ment concerning the care complexity of the patient,

the availability and competence of the individual
accepting the delegation, and the type and intensity of
supervision required.

• The RN acknowledges that delegation involves the
relational concept of mutual respect.

• Nurse leaders are accountable for establishing sys-
tems to assess, monitor, verify, and communicate
ongoing competence requirements in areas related to
delegation.

• The organization/agency is accountable to provide
sufficient resources to enable appropriate delegation.

• The organization/agency is accountable for ensuring
that the RN has access to documented competency
information for staff to whom the RN is delegating
tasks.

• Organizational/agency policies on delegation are devel-
oped with the active participation of registered nurses.

Source: American Nurses Association. (2012). ANA’s principles for practice. Retrieved August 20, 2015 from http://www.nursingworld.org/MainMenuCategories/
ThePracticeofProfessionalNursing/NursingStandards/ANAPrinciples/PrinciplesofDelegation

http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards/ANAPrinciples/PrinciplesofDelegation

http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards/ANAPrinciples/PrinciplesofDelegation

166 Chapter 11

Benefits to the Nurse
Nurses benefit from delegation. If the nurse is able to delegate some tasks to unli-
censed assistive personnel (UAP), more time can be devoted to those tasks that cannot
be delegated, especially complex patient care. Thus, patient care is enhanced, the
nurse’s job satisfaction increases, and retention is improved.

Nancy, RN, has three central-line dressing changes to complete as well as two patients
to transfer to another unit before the end of shift in 1 hour. Nancy delegates the transfer
duties to Shelley, LPN, and completes the central-line dressing changes.

Benefits to the Delegate
The delegate also benefits from delegation. The delegate gains new skills and abil-
ities that can facilitate upward mobility. In addition, delegation can bring trust
and support, and thereby build self-esteem and confidence. Subsequently, job sat-
isfaction and motivation are enhanced as individuals feel stimulated by new chal-
lenges. Morale improves, and a sense of pride and belonging develops as well as
greater awareness of responsibility. Individuals feel more appreciated and learn to
appreciate the roles and responsibilities of others, increasing cooperation and
enhancing teamwork.

Benefits to the Manager
Delegation yields benefits for the manager as well. If staff use UAPs appropriately, the
manager will have a better functioning unit. Also the manager may be able to delegate
some tasks to staff members and devote more time to management tasks that cannot
be delegated. With more time available, the manager can develop new skills and abili-
ties, facilitating the opportunity for career advancement.

Benefits to the Organization
As teamwork improves, the organization benefits by achieving its goals more effi-
ciently. Overtime and absences decrease. Subsequently, productivity increases, and
the organization’s financial position may improve. As delegation increases effi-
ciency, the quality of care improves. As quality improves, patient satisfaction
increases.

The Five Rights of Delegation
Fear of liability often keeps nurses from delegating. State nurse practice acts determine
the legal parameters for practice, professional associations set practice standards, and
organizational policy and job descriptions define delegation appropriate to the specific
work setting. In addition, each state board of nursing has its own rules regarding
delegation.

Guidelines from the ANA and the National Council of State Boards of Nursing
(NCSBN) can also help. Their Joint Statement on Delegation (American Nurses Asso-
ciation [ANA] and the National Council of State Boards of Nursing [NCSBN], 2012)
identified the five rights of delegation shown in Box 11-2.

Delegating Successfully 167

Source: American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN). (2015). Joint Statement on Delegation. Retrieved http://www.ncsbn.org/1625.htm

Box 11-2 The Five Rights of Delegation
• Right task
• Right circumstances
• Right person

• Right direction and communication
• Right supervision

• The right task specifies what can be safely delegated to a specific patient. These are
commonly assigned tasks. Tasks that require nursing assessment or judgment
should not be delegated.

• The right circumstances include an appropriate setting and available resources.
Evaluate the patient’s needs and the skills of personnel who could be assigned to
meet those specific needs.

• The right person refers to both the delegator and the delegate. The delegator must
have the authority and responsibility for the patient’s care and for the task to be
assigned. The delegate must be capable of performing the task and be available to
assist. Give the right task to the right person for the right patient.

• The right direction and communication require the delegator to give clear, concise
description of the task as well as to describe the objectives, limits, and expecta-
tions as a result. The delegate should be able to recognize that the patient is
responding as expected.

• The right supervision includes monitoring the delegate, evaluating the person’s
performance, giving feedback as required, and intervening if necessary. The del-
egator remains responsible for the patient’s care regardless of who delivers it
(Knox, 2013).

The Joint Statement on Delegation decision tree can help guide nurses’ decisions
about delegation (see Figure 11-1).

The Delegation Process
The delegation process begins with a series of steps that include defining the task,
deciding on the delegate, describing the task to the delegate, securing the delegate’s
agreement, monitoring the delegate’s performance, and providing feedback to the
individual (see Box 11-3). Following key behaviors will assist nurses to delegate
effectively.

Box 11-3 The Delegation Process
1. Define the task.
2. Decide on the delegate.
3. Determine the task.

4. Reach agreement.
5. Monitor performance and provide feedback.

http://www.ncsbn.org/1625.htm

168 Chapter 11

Is the task consistent with the recommended criteria
for delegation to nursing assistive personnel (NAP)?

Are there agency policies, procedures and/or
protocols in place for this task/activity?

Is appropriate supervision available?

Proceed with delegation.

Does the nursing assistive personnel have the
appropriate knowledge, skills, and abilities (KSA) to
accept the delegation?

Does the ability of the NAP match the care needs of
the client?

Is the delegating nurse competent to make
delegation decisions?

Has there been assessment of the client
needs?

Is the task within the scope of the
delegating nurse?

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Are there laws and rules in place that
support the delegation?

Do not delegate.

Do not delegate.

Do not delegate.

Do not delegate.

Do not delegate.

Do not delegate.

Assess client needs then
delegate appropriately.

Figure 11-1 Decision tree for delegation to nursing assistive personnel

Source: Adapted from National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved
December 2007 from www.ncsbn.org/Joint_statement

Steps in the Delegation Process

1. Define the task. Delegate only an aspect of your own work for which you have
responsibility and authority, including the following:

• Routine tasks
• Tasks for which you do not have time
• Tasks that have moved down in priority

Define the aspects of the task. Ask yourself these questions:

• Does the task involve technical skills or cognitive abilities?
• Are specific qualifications necessary?
• Is performance restricted by practice acts, standards, or job descriptions?
• How complex is the task?

http://www.ncsbn.org/Joint_statement

Delegating Successfully 169

• Is training or education required?
• Are the steps well defined, or are creativity and problem solving required?
• Would a change in circumstances affect who could perform the task?

While you are trying to define the complexity of the task and its components, it is
important not to fall into the trap of thinking no one else is capable of performing
it. Often others can be prepared to perform a task through education and training.
The time taken to prepare others can be recouped many times over. Also, know
well the task to be delegated.

An alternative would be to subdivide the task into component parts and
delegate the components congruent with the available delegate’s capabilities.
For example, developing a budget is a managerial responsibility that cannot be
delegated, but someone else could explore the types of tympanic thermometers
on the market, their costs, advantages, and so on. A committee of staff nurses
could evaluate the options and make a recommendation that you could include
in the budget justification.

But how do you know what should not be delegated?
Before a task is delegated, determine what areas of authority and what

resources you control to achieve the expected results. A unit manager who is
responsible for maintaining adequate supplies needs budget authority. The
authority to spend money on supplies, however, may be limited to a specific
amount for specific supplies or may be allocated to supplies in general.

Certain tasks should never be delegated. For example, discipline should not
be delegated, nor should a highly technical task. In addition, any situation that
involves confidentiality or controversy should not be delegated to others.

2. Decide on the delegate. Match the task to the individual. Analyze individuals’ skill
levels and abilities to evaluate their capability to perform the various tasks; also,
determine characteristics that might prevent them from accepting responsibility for
the task. Conversely, experience and individual characteristics, such as initiative,
intelligence, and enthusiasm, can expand the individual’s capabilities. A rule of
thumb is to delegate to the lowest person in the hierarchy who has the requisite
capabilities and who is allowed to do the task legally and by organizational policy.

Next, determine availability. For example, Su Ling might be the best candi-
date, but she leaves for vacation tomorrow and will not be back before the project
is due. Then ask who would be willing to assume responsibility. Delegation is an
agreement that is entered into voluntarily.

3. Determine the task. The next step in delegation is to clearly define your expecta-
tions for the delegate. Also, plan when to meet. Attempting to delegate in the mid-
dle of a crisis is not delegation—that is directing. Provide for enough time to
describe the task and your expectations and to entertain questions. It is best to
meet in an environment as devoid of distractions as possible.

• Describe the task using “I” statements, such as “I would like . . .”, and appro-
priate nonverbal behaviors—open body language, face-to-face positioning, and
eye contact. The delegate needs to know what is expected, when the task should
be completed, and where and how, if that is appropriate. The more experienced
delegates may be able to define for themselves the where and how. Decide
whether written reports are necessary or if brief oral reports are sufficient. If
written reports are required, indicate whether tables, charts, or other graphics

170 Chapter 11

are necessary. Be specific about reporting times. Identify critical events or mile-
stones that might be reached and brought to your attention. For patient care
tasks, determine who has responsibility and authority to chart certain tasks.
For example, UAPs can enter vital signs, but if they observe changes in patient
status, the RN must investigate and chart the assessment.

• Discuss the importance to the organization, you, the patient, and the delegate.
Provide the delegate with an incentive for accepting both the responsibility and
the authority to do the task.

• Explain the expected outcome and the timeline for completion. Establish how
closely the assignment will be supervised. Monitoring is important because
you remain accountable for the task, but controls should never limit an indi-
vidual’s opportunity to grow.

• Identify any constraints for completing the task or any conditions that could
change. For example, you may ask an assistant to feed a patient for you as long
as the patient is coherent and awake, but you might decide to feed the patient if
he becomes confused.

• Validate understanding of the task and your expectations by eliciting questions
and providing feedback.

4. Reach agreement. Once you have outlined your expectations, you must be sure
that the delegate agrees to accept responsibility and authority for the task. You
need to be prepared to equip the delegate to complete the task successfully. This
might mean providing additional information or resources or informing others
about the arrangement as needed to empower the delegate. Before meeting with
the individual, anticipate areas of negotiation, and identify what you are pre-
pared and able to provide.

5. Monitor performance and provide feedback. Monitoring performance provides a
mechanism for feedback and control, which ensures that the delegated tasks are
carried out as agreed. Give careful thought to monitoring efforts when objectives
are established. When defining the task and expectations, clearly establish the
where, when, and how. Remain accessible. Support builds confidence and
reassures the delegate of your interest in the delegate and negates any concerns
about dumping undesirable tasks.

Monitoring the delegate too closely, however, conveys distrust. Analyze per-
formance with respect to the established goal. If problem areas are identified, pri-
vately investigate and explain the problem, provide an opportunity for feedback,
and inform the individual how to correct the mistake in the future. Provide addi-
tional support as needed. Also, be sure to give the praise and recognition due, and
do not be afraid to do so publicly.

Key Behaviors for Successful Delegation
Following specific guidelines helps the delegation be successful. Success is
achieved when the delegate completes the assigned tasks to the satisfaction of the
delegator. These key behaviors require the delegator to focus on the delegate’s
experience and skills and to give the individual specific, concrete instructions
(see Box 11-4).

Delegating Successfully 171

Accepting Delegation
Accepting delegation means that you accept full responsibility for the outcome and its
benefits or liabilities. Just as the delegator has the option to delegate parts of a task,
you also have the option to negotiate for those aspects of a task you feel you can
accomplish. Recognize, however, that this may be an opportunity for growth. You may
decide to capitalize on it, obtaining new skills or resources in the process.

When you accept delegation, you must understand what is being asked of you.
First, acknowledge the delegator’s confidence in you, but realistically examine whether
you have the skills and abilities for the task and the time to do it. If you do not have the
skills, you must inform the delegator. However, it does not mean you cannot accept
the responsibility. See whether the person is willing to train or otherwise equip you to
accomplish the task. If not, then you need to refuse the offer.

Once you agree on the role and responsibilities you are to assume, make sure you
are clear on the time frame, feedback mechanisms, and other expectations. Don’t
assume anything. As a minimum, repeat to the delegator what you heard said; better
yet, outline the task in writing.

Throughout the project, keep the delegator informed. Report any concerns you
have as they come up. Foremost, complete the task as agreed. Successful completion
can open more doors in the future.

If you are not qualified or do not have the time, do not be afraid to say no. Thank
the delegator for the offer and clearly explain why you must decline at this time.
Express your interest in working together in the future.

See how a school nurse handled delegation in Case Study 11-1.

CASE STUDY 11-1 | Delegation
Lisa Ford is a school nurse for a suburban school district. She
has responsibility for three school buildings, including a mid-
dle school, a high school, and a vocational rehabilitation
workshop for mentally and physically handicapped second-
ary students. Her management responsibilities include pro-
viding health services for 1,000 students, 60 faculty members,
and 25 staff members, as well as supervising two unlicensed
school health aides and three special education health aides.
The logistics of managing multiple school sites results in the
delegation of many daily health room tasks, including medi-
cation administration, to the school-based health aides.

Nancy Andrews is an unlicensed health aide at the
middle school. This is her first year as a health aide and
she has a limited background in healthcare. The nurse
practice act in the state allows for the delegation of med-
ication administration in the school setting. Lisa is respon-
sible for training Nancy to safely administer medication to
students, documenting the training, evaluating Nancy’s
performance, and providing ongoing supervision. Part of
Nancy’s training will also include a discussion of those
medication-related decisions that must be made by a
registered nurse.

Box 11-4 Key Behaviors in Delegating Tasks
• Describe the task using “I” statements.
• Discuss the importance to the organization.
• Explain the expected outcome and timeline for completion.

• Identify any constraints for completing the task.
• Validate understanding of the task and your expectations.

172 Chapter 11

Ineffective Delegation
Ineffective delegation results in missed or omitted routine care, such as feeding, turn-
ing, ambulating, and toileting (Gravlin & Bittner, 2010). Poor communication and
interpersonal relationships between nurses and UAPs have been found to result in
ineffective delegation (Bittner, Gravlin, Hansten, & Kalisch, 2011).

The RN/UAP unit is a microsystem in healthcare. When that unit is dysfunctional
or functioning at less than optimal performance, the quality of care suffers. One reason
for problems with delegation is the assignment of a single UAP to more than one RN.
The UAP’s workload may be more than one person can handle, but each nurse may be
unaware of the assistant’s overload.

Another reason for ineffective delegation is that nurses define delegation differently
(Bittner et al., 2011). Some nurses define delegation as explicit instructions to carry out
a specific task. Others think that delegation is both specific and implicit in expected
tasks, such as ambulating or toileting. Potential barriers to effective delegation include
organizational factors or the delegator’s or delegate’s beliefs or inexperience.

Organizational Culture
The culture within the organization may restrict delegation. Hierarchies, management
styles, and norms may all preclude delegation. Rigid chains of command and auto-
cratic leadership styles do not facilitate delegation and rarely provide good role mod-
els. The norm is to do the work oneself because others are not capable or skilled. An
atmosphere of distrust prevails as well as a poor tolerance for mistakes. Norms such as
inadequate crisis management or poorly defined job descriptions or chains of com-
mand also impede successful delegation.

Lack of Resources
Another difficulty frequently encountered is a lack of resources. For example, there
may be no one to whom you can delegate. Consider the sole registered nurse in a
skilled nursing facility. If practice acts define a task as one that only a registered nurse
can perform, there is no one else to whom that nurse can delegate that task.

Financial constraints also can interfere with delegation. For instance, someone
from your department must attend the annual conference in your nursing specialty
area. However, the organization will only pay the manager’s travel and conference
expenses, which precludes anyone else from attending.

Educational resources may be another limiting factor. Perhaps others could learn
how to do a task if they could practice with the equipment, but the equipment or a
trainer is not available.

Time can also be a limiting factor. For example, it is Friday, and the schedule
should be posted on Monday. No one on your staff has experience developing sched-
ules, and you need to go out of town for a family emergency, so there is no one else to
prepare the schedule.

An Insecure Delegator
The majority of the barriers to delegation arise from the delegator. Reasons people give
for failing to delegate include the following:

Delegating Successfully 173

“I can do it better.”
“I can do it faster.”
“I’d rather do it myself.”
“I don’t have time to delegate.”

Often underlying these statements are erroneous beliefs, fears, and inexperience
in delegation. Certainly, the experienced person can do the task better and faster.
Indeed, delegation takes time, but failing to delegate is a time waster. Time invested in
developing staff today is later repaid many times over.

The following are common fears:

• Fear of competition or criticism. What if someone else can do the job better or
faster than I? Will I lose my job? Be demoted? What will others think? Will I lose
respect and control? This fear is unfounded if the delegator has selected the right
task and matched it with the right individual. In fact, the delegate’s success in the
task provides evidence of the delegator’s leadership and decision-making abilities.

• Fear of liability. Some individuals are not risk takers and shy away from delega-
tion for this reason. Yes, risks are associated with delegation, but the delegator can
minimize these risks by following the steps of delegation. A related concern is a
fear of being blamed for the delegate’s mistakes. If the delegator selected the task
and the delegate appropriately, then the responsibility for any mistakes made are
solely those of the delegate; it is not necessary to be afraid of repercussions or to
take on guilt for another’s mistakes.

Review the five rights of delegation and the decision tree from the Joint State-
ment for Delegation from ANA and NCSBN (2012) as well as the state’s nurse
practice act and the organization’s policies. RNs often fear blame from manage-
ment if something goes wrong when a task has been delegated to an LPN or UAP,
but those fears can be relieved if state law, organizational policies, and job descrip-
tions are followed.

• Fear of loss of control. Will I be kept informed? Will the job be done right? How
can I be sure? The more insecure and inexperienced in delegation one is, the more
fear is an issue. This is also a predominant concern in individuals who tend toward
autocratic styles of leadership and perfectionism. The key to retaining control is to
clearly identify the task and expectations and then to monitor progress and pro-
vide feedback.

Leading at the Bedside: Delegation
When you first become an RN, delegation may seem for-
eign to you. Yes, you learned the concepts and you’ve
accepted delegation even as a student. But to delegate to
others—UAPs, other staff—you’d rather do it yourself. You
have no choice, however. If you are to be productive, pro-
vide good care to your patients, and advance in your
career, you must learn to delegate.

Fortunately, you have this chapter’s specific guide-
lines, your experiences, and your observations of others

to help you. Note your experience as a delegate. Did
your delegator follow these guidelines? If not, how could
you do it better? Pay attention to how others delegate
and accept delegation. Always ask yourself if you could
do better.

Follow this advice and you’ll soon be as proficient at
delegating as you are as a clinician.

174 Chapter 11

• Fear of overburdening others. “They already have so much to do; how can I sug-
gest more?“ Such a statement belittles the decisional capabilities of others. Every-
one has work to do. Recall that delegation is a voluntary, contractual agreement;
acceptance of a delegated task indicates the availability and willingness of the
delegate to perform the task. Often, the delegate welcomes the diversion and stim-
ulation, and what the delegator perceives as a burden is actually a blessing. The
onus is on the delegator to select the right person for the right reason.

• Fear of decreased personal job satisfaction. Because the tasks recommended to
delegate are those that are familiar and routine, the delegator’s job satisfaction
should actually increase with the opportunity to explore new challenges and
obtain other skills and abilities.

An Unwilling Delegate
Inexperience and fear of failure can motivate a potential delegate to refuse to accept
a delegated task. Much reassurance and support are needed. In addition, the dele-
gate should be equipped to handle the task. If proper selection criteria are used and
the steps of delegation followed, then the delegate should not fail. The delegator can
boost the delegate’s lack of confidence by building on simple tasks. The delegate
needs to be reminded that everyone was inexperienced at one time. Another com-
mon concern is how mistakes will be handled. When describing the task, the delega-
tor should provide clear guidelines for handling problems—guidelines that adhere
to organizational policies.

Another barrier is the individual who avoids responsibility or is overdependent
on others. Success breeds success; therefore, it is important to use an enticing incentive
to engage the individual in a simple task that guarantees success.

When the steps of delegation are not followed or barriers remain unresolved, del-
egation is often ineffective. Inefficient delegation can result from unnecessary duplica-
tion, underdelegation, reverse delegation, and overdelegation.

Underdelegation
Underdelegation occurs when any of the following happens:

• The delegator fails to transfer full authority to the delegate.

• The delegator takes back responsibility for aspects of the task.

• The delegator fails to equip and direct the delegate.

As a result, the delegate is unable to complete the task, and the delegator must
resume responsibility for its completion.

Sharon, RN, is a school nurse with three separate buildings under her direction. UAPs,
called health clerks, operate in the school health office when Sharon is at another building.
Joye, a first-year health clerk, has had minimal medication administration instruction and
experience. During the first week of school, Joye tries to “speed up” the medication
administration process and sets out all of the noon medications in individual, unlabeled
cups for the students. The cups are rearranged by students trying to find their meds, and
Joye cannot identify what meds belong to which students. Sharon is called back to the
school to administer the correct medications, students are late to class, and Joye is
frustrated that she couldn’t handle the task.

Delegating Successfully 175

It may be that the RN fears liability or lacks confidence or experience in dele-
gating and decides to do all the tasks rather than delegate to an assistant (Mitty et
al., 2010). Conversely, the assistant may not be prepared for the tasks or may not
believe the task is within the assistant’s scope of practice. In addition, the assistant
may not be able to complete all the tasks, especially if the person is assigned to sev-
eral nurses.

Reverse Delegation
In reverse delegation, someone with a lower rank delegates to someone with more
authority.

Thomas is a nurse practitioner for the burn unit. He recently arrived on the unit to find
several patients whose dressing changes had not been completed due to a code earlier that
morning. Dawn, LPN, asks Thomas to help the staff complete dressing changes before
physician rounds begin.

Overdelegation
Overdelegation occurs when the delegator loses control over a situation by providing
the delegate with too much authority or too much responsibility. This places the dele-
gator in a risky position, increasing the potential for liability. In this instance, the nurse
assumes that any task that does not involve nursing assessment or judgment should
be assigned to assistive personnel.

Ellen, GN, is in her sixth week of orientation in the trauma ICU. Her mentor, Dolores,
RN, notes that Mr. Anderson is scheduled for an MRI off the unit. Dolores delegates the
task of escorting Mr. Anderson to the MRI unit to Ellen, who is not ACLS certified.
During the MRI, Mr. Anderson is accidentally extubated and suffers respiratory and
cardiac arrest. A code is called in the MRI suite, and ER nurses must respond since an
ACLS-certified nurse is not with the patient.

Not delegating appropriately negatively affects other staff on the unit as well, as
the next two examples illustrate.

Sally, RN, always says she “likes to do everything herself” for her patients. She does
not like to ask aides for assistance. Her patients are usually happy, but Sally is extremely
busy all day and does not ever have time to help a peer RN when asked or answer call
lights to help the team. Sally’s peers get frustrated because her lack of delegating
appropriate tasks to her nurse’s aide partner makes the aide feel not valued, Sally feels too
busy in her job, and her peers feel like they get no help from Sally when needed.

Bridgett, RN, feels that she has spent her time doing aide work while she was in nursing
school. Now that she has taken NCLEX boards and is working as a nurse, she will not
help patients to the bathroom, or empty a bedpan, or change bed linens. She will call an
aide to do these tasks even if she is in the room and has time to do the tasks herself.
Bridgett’s inappropriate delegation causes aides to be angry, peer RNs to be frustrated
because the aides do not have time to help them because they are always doing Bridgett’s
work, and results in inconsistency in the practice between Bridgett and other nurses,
which Bridget’s patients’ notice.

Delegation is a skill that can be learned. Like other skills, successfully delegating
requires practice. Sometimes it seems it might be easier to do it yourself—but it is not.

176 Chapter 11

Once you learn how to delegate, you will extend your ability to accomplish more by
using others’ help.

By delegating appropriately, managers can role model this behavior and teach
their staff to do likewise. It is the best use of their time.

No one in healthcare today can afford not to delegate.

What You Know Now
• Delegation is a contractual agreement in which

authority and responsibility for a task are trans-
ferred by the person accountable for the task to
another individual.

• Delegation benefits the delegator, delegate, man-
ager, unit, and organization.

• The five rights of delegation are right task, right
circumstances, right person, right direction, and
right supervision.

• Delegation involves skill in identifying and deter-
mining the task and level of responsibility, decid-
ing who has the requisite skills and abilities,
describing expectations clearly, reaching mutual
agreement, and monitoring performance and
providing feedback.

• Delegable tasks are personal, routine tasks that
the delegator can perform well; that do not
involve discipline, highly technical tasks, or con-
fidential information; and that are not
controversial.

• To accept delegation, the delegator and delegate
must agree on roles and responsibilities, the time
frame for completion, feedback mechanisms, and
expectations.

• Ineffective delegation can occur with organiza-
tional constraints or the lack of experience or
beliefs of the delegate or delegator.

• Managers can role model appropriate delegation.

• Delegation is essential in healthcare today.

Tools for Delegating Successfully
1. Delegate only tasks for which you have responsi-

bility.
2. Transfer authority when you delegate responsi-

bility.
3. Be sure you follow state regulations, job descrip-

tions, and organizational policies when delegating.

4. Follow the delegation process and key behaviors
for delegating described in this chapter.

5. Accept delegation when you are clear about the
task, time frame, reporting, and other expectations.

6. Review the five rights of delegation and the
NCSBN’s decision tree to delegate appropriately.

Questions to Challenge You
1. Review your state’s nurse practice act. How is

delegation defined? What tasks can and cannot
be delegated? How is supervision defined? Are

there any other guidelines for supervision? Are
responsibilities regarding advanced practice
delineated? How does the scope of practice differ

Delegating Successfully 177

between registered and licensed practical/
vocational nurses? What is the scope of practice
of other healthcare providers?

2. What are your organization’s policies on delega-
tion?

3. Describe a situation when you delegated a task to
someone else. Did you follow the steps of

delegation explained in this chapter? Was the
outcome positive? If not, what went wrong?

4. Describe a situation when someone else delegated
a task to you. Did your delegator explain what to
do? Did you receive too much information? Not
enough? Was supervision appropriate to the task
and to your abilities? What was the outcome?

References
American Nurses Association. (2012). ANA’s

principles for practice. Retrieved March 10, 2016,
from http://www.nursingworld.org/principles

American Nurses Association (ANA) and the
National Council of State Boards of Nursing
(NCSBN). (2015). Joint statement on delegation.
Retrieved March 11, 2016, from http://www.
ncsbn.org/1625.htm

Bittner, N. P., Gravlin, G., Hansten, R., & Kalisch,
B. J. (2011). Unraveling care omissions. Journal of
Nursing Administration, 39(3), 142–146.

Case, B. (2015). Delegation skills. Advance Healthcare
Network for Nurses. Retrieved March 10, 2016,
from http://nursing.advanceweb.com/Article/
Delegation-Skills.aspx

Gravlin, G., & Bittner, N. P. (2010). Nurses’ and
nursing assistants’ reports of missed care and

delegation. Journal of Nursing Administration,
40(7/8), 329–335.

Knox, C. (2013). The five rights of delegation.
Essentials of correctional nursing.
Retrieved August 20, 2015, from http://
essentialsofcorrectionalnursing.com/2013/01/03/
a-case-example-the-five-rights-of-delegation

Mitty, E., Resnick, B., Bakerjian, D., Gardner, W.,
Rainbard, S., Mezey, M. (2010). Nursing delegation
and medication administration in assisted living.
Nursing Administration Quarterly, 34(2), 162–171.

Orr, S. E. (2010). Characteristics of positive working
relationships between nursing and support service
employees. Journal of Nursing Administration, 40(3),
129–134.

Weydt, A. (2010). Developing delegation skills. Online
Journal of Issues in Nursing, 15(2), Manuscript 1.

http://www.nursingworld.org/principles

http://www.ncsbn.org/1625.htm

http://nursing.advanceweb.com/Article/Delegation-Skills.aspx

http://essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-the-five-rights-of-delegation

http://essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-the-five-rights-of-delegation

http://www.ncsbn.org/1625.htm

http://nursing.advanceweb.com/Article/Delegation-Skills.aspx

178 Chapter 12

Learning Outcomes

After completing this chapter, you will be able to:

1. Describe how groups and teams function.

2. Explain the norms and roles in groups and teams.

3. Describe various methods of team building.

4. Discuss factors that influence team management.

5. Explain why the nurse manager’s leadership skills are essential
to team performance.

6. Discuss how to lead groups, task forces, and patient care
conferences.

Groups and Teams
Group Interaction

Group Leadership

Group and Team Processes:
Homans Framework

Norms

Roles

Building Teams
Assessment

Team-building Activities

Managing Teams
Task

Group Size and Composition

Productivity and Cohesiveness

Development and Growth

Shared Governance

The Nurse Manager as
Team Leader

Communication

Evaluating Team Performance

Leading Committees
and Task Forces

Guidelines for Conducting Meetings

Managing Task Forces

Patient Care Conferences

178

Chapter 12

Building and
Managing Teams

Building and Managing Teams 179

Key Terms
additive task
adjourning
cohesiveness
committees
conjunctive task
disjunctive task
divisible task
formal committees
formal groups
forming
group
hidden agendas
informal committees
informal groups
norming
norms

ordinary interacting groups
performing
pooled interdependence
productivity
real (command) groups
reciprocal interdependence
re-forming
role
sequential interdependence
status
status incongruence
storming
task forces
task group
teams
team building

Introduction
Most often, nursing occurs in a team environment. Work groups that share common
objectives function in a harmonious, coordinated, purposeful manner as teams. The staff
nurse is constantly involved in teamwork. The nurse/aide/unit secretary team works
together every day on a nursing unit or in a clinic setting. With shared governance more
often the norm and interprofessional team work common, the nurse may participate or
lead a team broader in scope than one unit. For example, a nurse might lead the acute
care practice council or be on a team to implement supplies at the bedside.

Teamwork is essential in healthcare’s demanding environment. Kalisch and Lee
(2010) found that poor teamwork contributed to both the quality of care provided and,
often, in missed care.

High-performance teams require expert leadership skills. In a healthcare delivery sys-
tem integrated across settings, a team environment becomes increasingly essential. Nurse
managers must skillfully orchestrate the activity and interactions of interprofessional
teams as well as conventional nursing work groups. Understanding the nature of groups
and how groups are transformed into teams is essential for the nurse to be effective.

Groups and Teams
A group is an aggregate of individuals who interact and mutually influence each other.
Both formal and informal groups exist in organizations. Formal groups are clusters of
individuals designated temporarily or permanently by an organization to perform
specified organizational tasks. Formal groups may be structured laterally, vertically, or
diagonally. Task groups, teams, task forces, and committees may be structured in all of
these ways, whereas command groups generally are structured vertically.

180 Chapter 12

Group members may include the following:

• Individuals from a single work group (e.g., nurses on one unit) or individuals at
similar job levels from more than one work group (e.g., all professional staff)

• Individuals from different job levels (e.g., nurses and UAPs)

• Individuals from different work groups and different job levels in the organization
(e.g., committee to review staff orientation classes)

Groups may be permanent or temporary. Command groups, teams, and commit-
tees usually are permanent, whereas task groups and task forces are often temporary.

Informal groups evolve naturally from social interactions. Groups are informal in
the sense that they are not defined by an organizational structure. Examples of infor-
mal groups include individuals who regularly eat lunch together or who convene
spontaneously to discuss a clinical dilemma.

Real (command) groups accomplish tasks in organizations and are recognized as
a legitimate organizational entity. Its members are interdependent, share a set of
norms, generally differentiate roles and duties among themselves, are organized to
achieve ongoing organizational goals, and are collectively held responsible for mea-
surable outcomes. The group’s manager has line authority in relation to group mem-
bers individually and collectively. The group’s assignments are usually routine and
designed to fulfill the specific mission of the agency or organization. The regularly
assigned staff who work together under the direction of a single manager constitute a
command group.

A task group is composed of several persons who work together, with or without
a designated leader, and are charged with accomplishing specific, time-limited assign-
ments. A group of nurses selected by their colleagues to plan an orientation program
for new staff constitutes a task group. Usually, several task groups exist within a ser-
vice area and may include representatives from several disciplines (e.g., nurse, physi-
cian, dietitian, social worker).

Other special groups include committees or task forces formed to deal with spe-
cific issues involving several service areas. A committee responsible for monitoring
and improving patient safety or a task force assigned to develop procedures to adhere
to patient privacy regulations is an example of a special work group.

Healthcare organizations depend on numerous committees, which nurses partici-
pate in and often lead (see Leading at the Bedside: Workplace Teams and Groups.)
Some of these committees are mandated by accrediting and regulatory bodies, such as
committees for education, standards, disaster, and patient care evaluation. Others are
established to meet a specific need (e.g., to formulate a new policy on substance abuse).

Leading at the Bedside: Workplace Teams and Groups
Teams and groups are not new to you. You may have been
on an athletic team, a debate team, or participated in religious
or community groups. Workplace teams and groups, how-
ever, carry the responsibility of providing care to patients,
supporting colleagues, and furthering the goals of the organi-
zation. These purposes—high-minded though they are—
need not intimidate you. As you find yourself a member of a

team or assigned to a committee, refer to this chapter for sug-
gestions on how to fulfill your role as a member or a leader.

What is the most exciting aspect of working with
teams and groups? You have the opportunity to learn from
others! Pay attention to how each individual participates in
the group. Use what you learn to improve your own ability
as a participant in groups.

Building and Managing Teams 181

Teams are real groups in which individuals must work cooperatively with each
other in order to achieve some overarching goal. Teams have command or line author-
ity to perform tasks, and membership is based on the specific skills required to accom-
plish the tasks. Similar to the groups previously described, teams may include
individuals from a single work group or individuals at similar job levels from more
than one work group; individuals from different job levels, or individuals from differ-
ent work groups and different job levels in the organization. They may have a short life
span or exist indefinitely.

Metropolitan Hospital has established a clinical ladder system for nursing staff.
Each quarter, members of the clinical excellence committee meet to review applica-
tions from staff nurses who are seeking promotion to the next clinical ladder level. The
committee is made up of staff nurses and nurse managers from each service line. Each
applicant is responsible for completing a comprehensive application. The committee
members evaluate each application and make recommendations to the vice president
for patient care on those nurses who should be considered for promotion.

A work group becomes a team when the individuals must apply group process
skills to achieve specific results. They must exchange ideas, coordinate work activities,
and develop an understanding of other team members’ roles in order to perform effec-
tively. Members appreciate the talents and contributions of each individual on the
team and find ways to capitalize on them. Most work teams have a leader who main-
tains the integrity of the team’s function and guides the team’s activities, performance,
and development. Teams may be self-directed—that is, led jointly by group members
who decide together about work objectives and activities on an ongoing basis.

In a given service area, the entire staff might not function as a team, but a sub-
group may. For example, case managers for the inpatient and ambulatory cystic fibro-
sis population in a children’s medical center might be called a team. Individual
members of an interdisciplinary team, such as this one, may report formally to differ-
ent managers, but in delivering care to the cystic fibrosis population there is no desig-
nated individual in charge. In meetings, the team members discuss patients’ problems
and jointly decide on plans of action.

Many different types of groups and teams are used throughout organizations.
Examples are ad hoc task groups, quality improvement teams, quality circles, self-
directed work teams, shared governance councils, and focus groups.

Nurse managers at a large university hospital are responsible for educating their staff
about patient satisfaction. Patient satisfaction surveys are sent to randomly selected
patients. Results are compiled, and each department receives a detailed report of the
results. Staff members review the data at monthly staff meetings, using both positive
and negative comments to guide their patient care activities. As needed, department
standards and protocols are updated to reflect improved processes.

Most groups are considered ordinary interacting groups. These groups usually
have a designated formal leader, but they may be leaderless. Work teams, task groups,
and committees are examples of ordinary interacting groups. Discussions usually
begin with a statement of the problem by the group leader followed by an open,
unstructured conversation. Normally, the final decision is made by consensus (with-
out formal voting; members indicate concurrence with a group agreement that mem-
bers can live with and support publicly). The decision may also be made by the leader

182 Chapter 12

or someone in authority, majority vote, an average of members’ opinions, minority
control, or an expert member. Interacting groups enhance the cohesiveness and esprit
de corps among group members. Participants are able to build strong social ties and
will be committed to the solution decided on by the group.

Infection control nurses have been tracking occurrences of MRSA infections among
patients in their hospital system. In addition to implementing patient care protocols
as recommended by federal and state infectious disease agencies, the nurses track com-
pliance in high-risk units and tailor education programs to meet the needs of nursing
and assistive staffs.

Group Interaction
Ordinary interacting groups may be dominated by one or a few members. If the group
is highly cohesive, its decision-making ability may be affected by groupthink (Shirey,
2012). Groupthink results in pressure for every member to conform, usually to the
leader’s beliefs, even to violating personal norms.

Sometimes groups spend excessive time dealing with socioemotional relation-
ships, thereby reducing the time spent on the problem and slowing consensus. Ordi-
nary groups may reach compromise decisions that may not really satisfy any of the
participants. Because of these problems, the functioning of ordinary groups is depen-
dent on the leader’s skills.

Group Leadership
Each type of group presents unique opportunities and challenges. An important role
of the nurse manager is to link service areas with groups at higher levels in the orga-
nization. This link facilitates problem solving, coordination, and communication
throughout the organization. Leadership roles in work groups are important and
may also be either formal or informal. For example, the nurse manager formally
leads the unit or service area staff but may also informally lead a support group of
nurse managers.

The leader’s influence on group processes, formal or informal, and the ability of
the group to work together as a team often determine whether the group accomplishes
its goals. Nurse managers may effectively manage work groups and turn them into
teams by understanding principles of group processes and applying them to group
decision making, team building, and leading committees and task forces.

Group and Team Processes:
Homans Framework
The modified version of Homans’s (1950, 1961) social system conceptual scheme, pre-
sented in Figure 12-1, provides a framework for understanding group inputs, pro-
cesses, and outcomes. The schematic depicts the effects of organizational and
individual background factors on group leadership, including dynamics (tasks, activi-
ties, interactions, attitudes) and processes (forming, storming, norming, performing,
adjourning). Elements of the required group system and processes influence each
other and the emergent group system and social structure.

Building and Managing Teams 183

This system determines the productivity of the group as well as members’ quality
of work life, such as job satisfaction, development, growth, and similarity in thinking.
The framework distinguishes required factors that are imposed by the external system
from factors that emerge from the internal dynamics of the group.

According to Homans’s framework, the three essential elements of a group sys-
tem are activities, interactions, and attitudes. Activities are the observable behaviors of
group members. Interactions are the verbal or nonverbal exchanges of words or objects
among two or more group members. Attitudes are the perceptions, feelings, and val-
ues held by individual group members, which may be both positive and negative. To
understand and guide group functioning, a manager should analyze the activities,
interactions, and attitudes of work group members.

Homans’s framework indicates that background factors, the manager’s leader-
ship style, and the organizational system influence the normal development of the
group. Groups, whether formal or informal, typically develop in these phases: form,
storm, norm, perform, and adjourn or re-form. In the initial stage, forming, individu-
als assemble into a well-defined cluster. Group members are cautious in approaching
each other as they come together as a group and begin to understand requirements of
group membership. At this stage, the members often depend on a leader to define pur-
pose, tasks, and roles.

As the group begins to develop, storming occurs. Members wrestle with roles and
relationships. Conflict, dissatisfaction, and competition arise on important issues related
to procedures and behavior. During this stage, members often compete for power and

Feedback

Feedback

Required system
Tasks
Activities
Interactions
Attitudes

Group processes
Form
Storm
Norm
Perform
Adjourn/Re-form

Consequences
Productivity
Satisfaction
Development
Conflict
Groupthink

Background factors
Organizational requirements
External status
Personal characteristics

Leadership style

AffectAffect

Affect

Results in

Affect

Influence

Emergent group system
Activities
Interactions
Sentiments
Roles
Status
Communication

Norms

Figure 12-1 Conceptual scheme of a basic social system.

Source: Adapted from Homans, G. (1950). The human group. New York: Harcourt Brace Jovanovich; and Homans,
G. (1961). Social behavior: Its elementary forms. New York: Harcourt Brace. By permission of Transaction Publishers

184 Chapter 12

status, and informal leadership emerges. During the storming stage, the leader helps the
group to acknowledge the conflict and to resolve it in a win–win manner.

In the third stage, norming, the group defines its goals and rules of behavior. The
group determines what are or are not acceptable behaviors and attitudes. The group
structure, roles, and relationships become clearer. Cohesiveness develops. The leader
explains standards of performance and behavior, defines the group’s structure, and
facilitates relationship building.

In the fourth stage, performing, members agree on basic purposes and activities
and carry out the work. The group’s energy becomes task oriented. Cooperation
improves, and emotional issues subside. Members communicate effectively and inter-
act in a relaxed atmosphere of sharing. The leader provides feedback on the quality
and quantity of work, praises achievement, critiques poor work and takes steps to
improve it, and reinforces interpersonal relationships within the group.

The fifth stage is either adjourning (the group dissolves after achieving its objec-
tives) or re-forming, when some major change takes place in the environment or in the
composition or goals of the group that requires the group to refocus its activities and
recycle through the four stages. When a group adjourns, the leader must prepare
group members for dissolution and facilitate closure through celebration of success
and leave-taking. If the group is to refocus its activities, the leader will explain the new
direction and provide guidance in the process of re-forming.

Norms
Norms are the informal rules of behavior shared and enforced by group members, and
they emerge whenever humans interact. Groups develop norms that members believe
must be adhered to for fruitful, stable group functioning. Nursing groups often estab-
lish norms related to how members deal with absences that affect the workload of col-
leagues. Norms may include not calling in sick on weekends, readily accommodating
requests for trading shifts, and returning from breaks in a timely manner. In a team
environment, norms are usually linked to each team member’s expected contribution
to the performance and products of the team’s efforts.

Group norms are likely to be enforced if they serve to facilitate group survival,
ensure predictability of behavior, help avoid embarrassing interpersonal problems,
express the central values of the group, and clarify the group’s distinctive identity. If
an individual agrees to take on a specific assignment on the team’s behalf and fails to
complete the assignment on time, a group norm has been violated.

Groups go through several stages in enforcing norms with deviant members. First,
members use rational argument or present reasons to the deviant individual for adher-
ing to the norms. Second, if rational argument is not effective, members may use per-
suasive or manipulative techniques, reminding the deviant of the value of the group.
The third stage is attack. Attacks may be verbal or even physical and sometimes
include sabotaging the deviant’s work. The final stage is ignoring the deviant.

It becomes increasingly difficult for a deviant to acquiesce to the group as these
strategies escalate. Agreeing to rational argument is easy, but agreeing after an attack
is difficult. When the final stage (ignoring) is reached, acquiescence may be impossi-
ble because group members refuse to acknowledge the deviant’s surrender. A nurse
manager has a responsibility to help groups deal with members who violate group
norms related to performance, including counseling the employee and preventing
destructive conflict.

Building and Managing Teams 185

Roles
Norms apply to all group members, whereas roles are specific to positions in the
group. A role is a set of expected behaviors that fit together into a unified whole and
are characteristic of persons in a given context. Roles commonly seen in groups can be
classified as either task roles or socioemotional (nurturing) roles. Often, individuals fill
several roles.

Individuals performing task roles attempt to keep the group focused on its goals.
Task roles include the following:

• Initiator–contributor: redefines problems and offers solutions, clarifies objectives,
suggests agenda items, and maintains time limits

• Information seeker: pursues descriptive bases for the group’s work

• Information giver: expands information given by sharing experiences and making
inferences

• Opinion seeker: explores viewpoints that clarify or reflect the values of other
members’ suggestions

• Opinion giver: conveys to group members what their pertinent values should be

• Elaborator: predicts outcomes and provides illustrations or expands suggestions,
clarifying how they could work

• Coordinator: links ideas or suggestions offered by others

• Orienter: summarizes the group’s discussions and actions

• Evaluator-critic: appraises the quantity and quality of the group’s accomplish-
ments against set standards

• Energizer: motivates group to accomplish, qualitatively and quantitatively, the
group’s goals

• Procedural technician: supports group activity by arranging the environment
(e.g., scheduling meeting room) and providing necessary tools (e.g., ordering
visual equipment)

• Recorder: documents the group’s actions and achievements

Nurturing roles facilitate the growth and maintenance of the group. Individuals
assuming these roles are concerned with group functioning and interpersonal needs.
Nurturing roles include the following:

• Encourager: compliments members for their opinions and contributions to the
group

• Harmonizer: relieves tension and conflict

• Compromiser: suppresses own position to maintain group harmony

• Gatekeeper: encourages all group members to communicate and participate

• Group observer: takes note of group processes and dynamics and informs group
of them

• Follower: passively attends meetings, listens to discussions, and accepts group’s
decisions

Status is the social ranking of individuals relative to others in a group based on
the position they occupy. Status comes from factors the group values, such as achieve-
ment, personal characteristics, the ability to control rewards, or the ability to control

186 Chapter 12

information. Status is usually enjoyed by members who most conform to group norms.
Higher-status members often exercise more influence than others in group decisions.

Status incongruence occurs when factors associated with group status are not
congruent, such as when a younger, less experienced person becomes the group leader.
Status incongruence can have a disruptive impact on a group. For example, isolates
are members who have high external status and different backgrounds from regular
group members. They usually work at acceptable levels but are isolated from the
group because they do not fit the group member profile. Sometimes status incongru-
ence occurs because the individual does not need the group’s approval and makes no
effort to obtain it.

The most important role in a group is the leadership role. Leaders are appointed
for most formal groups, such as command groups, teams, committees, or task forces.
Leaders in informal groups tend to emerge over time and in relation to the task to be
performed. Some of the factors contributing to the emergence of leadership in small
groups include the ability to accomplish the group’s goals, sociability, good communi-
cation skills, self-confidence, and a desire for recognition.

Building Teams
Team building focuses on both task and relationship aspects of a group’s functioning
and is intended to increase efficiency and productivity. The group’s work and
problem-solving procedures, member–member relations, and leadership are analyzed,
and exercises are prescribed to help members modify their patterns of interaction or
processes of decision making.

Assessment
The most important initial activities in team building are data gathering and diagno-
sis. Questions must be asked about the group’s context (organizational structure, cli-
mate, culture, mission, and goals); the characteristics of the group’s work, including
group members’ roles, styles, procedures, job complexity; and the team, its problem-
solving style, interpersonal relationships, and relations with other groups.

The following questions may be asked:

1. To what extent do the team’s members understand and accept the goals of the
organization?

2. What, if any, hidden agendas interfere with the group’s performance? (Hidden
agendas are members’ individual unspoken objectives that interfere with commit-
ment or enthusiasm.)

3. How effective is the group’s leadership?

4. To what extent do group members understand and accept their roles?

5. How does the group make decisions?

6. How does the group handle conflict? Are conflicts dealt with through avoidance,
forcing, accommodating, compromising, competing, or collaborating?

7. What personal feelings do members have about each other?

8. To what extent do members trust and respect each other?

9. What is the relationship between the team and other units in the organization?

Building and Managing Teams 187

Only after assessing and diagnosing problems can the leader take actions to
improve team functioning (Hill, 2010).

Team-building Activities
Team-building activities, originally designed to improve interpersonal workplace rela-
tionships, have expanded to include meeting goals and accomplishing tasks. Wil-
helmsson, Ponzer, Dahlgren, Timpka, and Faresjö (2011) found that female students in
medicine and nursing were more open-minded about cooperating with other health
professions than were male medical or nursing students. This is positive news for
those involved in team building with women, less so with male participants.

Team Strategies and Tools to Enhance Performance and Patient Safety (Team-
STEPPS) is a program developed by the Department of Defense and the Agency for
Healthcare Research and Quality (AHRQ) to integrate teamwork into practice (Agency
for Healthcare Research and Quality, 2015). TeamSTEPPS involves three phases:

1. Assessing the need

2. Training on-site

3. Implementing and sustaining training

TeamSTEPPS has been tested in nursing settings. One study found that teamwork
training improved RNs’ perceptions of leadership (Castner, Foltz-Ramos, Schwartz, &
Ceravolo, 2012). Vertino (2014) found that such training improved nurses’ attitudes
toward teamwork.

Thoughtful team-building strategies allow group members to acknowledge the
developmental process and respond to it in constructive ways. Team-building activi-
ties may also be used to facilitate the normal stages of group development (forming,
storming, norming, performing, and adjourning or re-forming), an important process
in managing teams.

In traditional work groups experiencing problems, team-building strategies
may help improve performance. Numerous techniques and commercial resources
are available.

A nurse manager may decide to assume personal responsibility for team building
when the team is basically functional and simply needs some fine-tuning to deal more
effectively with minor interpersonal issues or changing circumstances.

Managing Teams
Managing teams differs from team building and depends on the task, group size and
composition, productivity and cohesiveness, the group’s development and growth,
and the extent of shared governance in the organization.

Task
The size of the group can influence its effectiveness, depending on the type of task:
additive, disjunctive, divisible, or conjunctive (Steiner, 1972, 1976). The more people
who work on an additive task (group performance depends on the sum of individual
performance), the more inputs are available to produce a favorable result. For exam-
ple, the game tug-of-war involves the combined effort of the team.

188 Chapter 12

For a disjunctive task (the group succeeds if one member succeeds), the
greater the number of people, the higher the probability that one group member
will solve the problem. Consider the Olympics. The more athletes on one team, the
greater the opportunity for a gold medal. Regardless of the event, a medalist from
the team brings recognition to the nation, and every citizen is able to share the
honor.

With a divisible task (tasks that can break down into subtasks with division of
labor), more people provide a greater opportunity for specialization and interdepen-
dence in performing the tasks. For instance, the construction of a car is a complex task.
From design of the car to insertion of the last bolt, each individual involved has a spe-
cialized task.

With a conjunctive task (the group succeeds only if all members succeed), more
people increase the likelihood that one person can slow up the group’s performance
(e.g., a jury trial).

On many tasks, interdependence is important. There are three kinds:

• Pooled interdependence, in which each individual contributes but no one contri-
bution is dependent on any other (e.g., a committee discussion)

• Sequential interdependence, in which group members must coordinate their
activities with others in some designated order (e.g., an assembly line)

• Reciprocal interdependence, in which members must coordinate their activities
with every other individual in the group (e.g., team nursing)

Group Size and Composition
Groups with five to ten members tend to be optimal for most complex organizational
tasks, which require diversity in knowledge, skills, and attitudes and allow full partici-
pation. In larger groups, members tend to contribute less of their individual potential
while the leader is called on to take more corrective action, do more role clarification,
manage more disruption, and make recognition more explicit. Groups tend to perform
better with competent individuals as members. However, coordination of effort and
proper utilization of abilities and task strategies must occur as well. Homogeneous
groups tend to function more harmoniously, whereas heterogeneous groups may
experience considerable conflict.

Today’s healthcare settings employ multigenerational cohorts of nurses (Douglas,
Howell, Nelson, Pilkington, & Salinas, 2015). Traditionals, baby boomers, generation
Xers, and millennials comprise healthcare’s workforce. Differences among expecta-
tions of each cohort must be incorporated into team management (Keepnews, Brewer,
Kovner, & Shin, 2010).

Productivity and Cohesiveness
Productivity represents how well the work group or team uses the resources avail-
able to achieve its goals and produce its services. If patient care is satisfactorily
completed at the end of each shift in relation to the levels of staffing, supplies,
equipment, and support services used, the group has been productive. Productivity
is influenced by work-group dynamics, especially a group’s cohesiveness and
collaboration.

Building and Managing Teams 189

Cohesiveness is the degree to which the members are attracted to the group and
how much they are willing to contribute. Cohesiveness is also related to homogeneity
of interests, values, attitudes, and background factors. Strong group cohesiveness
leads to a feeling of “we” as more important than “I” and ensures a higher degree of
cooperation and interpersonal support among group members.

Group norms may support or subvert organizational objectives, depending on the
level of group cohesiveness. High group cohesiveness may foster high or low indi-
vidual performance, depending on the prevailing group norms for performance.
When cohesiveness is low, productivity may vary significantly. Although groups, in
general, tend toward lower productivity, nursing education and practice have espe-
cially high standards of performance that help to counter this tendency.

Groups are more likely to become cohesive when members are characterized by
the following:

• Share similar values and beliefs

• Are motivated by the same goals and tasks

• Interact to achieve their goals and tasks

• Work in proximity to each other (e.g., on the same unit and on the same shift)

• Have specific needs that can be satisfied by involvement in the group

Group cohesiveness is also influenced by the formal reward system. Groups tend
to be more cohesive when group members receive comparable treatment and pay and
perform similar tasks that require interaction among the members. Similarities in val-
ues, education, social class, gender, age, and ethnicity that lead to similar attitudes
strengthen group cohesiveness.

Cohesiveness can produce intense social pressure. Highly cohesive groups can
demand and enforce adherence to norms regardless of their practicality or effective-
ness. In this circumstance, the nurse manager may have a difficult time influencing
individual nurses, especially if the group norms deviate from the manager’s values
or expectations. For example, operating room nurses may be used to arriving at the
time their shift starts and then changing into scrubs. The nurse manager, in contrast,
may expect the staff to be changed and ready for work by the time the shift starts. In
addition, group dynamics can affect absenteeism and turnover. Groups with high
levels of cohesiveness exhibit lower turnover and absenteeism than groups with low
levels of cohesiveness.

For most individuals, the work group provides one of the most important social
contacts in life; the experience of working on an effective work team contributes sig-
nificantly to one’s professional confidence and to the quality of work life and job satis-
faction. The work group often provides the primary motivation for returning to the job
day after day, even when employees are dissatisfied with the employing organization
or other working conditions.

Work groups not only perform tasks but also provide the context in which nov-
ices learn basic skills and become socialized and experts engage in clinical mentor-
ship, standard setting, quality improvement, and innovation. Work-group relations
influence the satisfaction of staff with their jobs, the overall quality of work life, and
the quality of the environment for patient care. Managers play key roles in guid-
ing the tasks of work groups and ensuring efficient and effective performance; man-
agers also encourage relationships among members of work teams to promote
coordination and cooperation.

190 Chapter 12

Development and Growth
Groups can provide learning opportunities by increasing individual skills or abilities.
The group may facilitate socialization of new employees into the organization by
“showing them the ropes.” The nurse manager must establish an atmosphere that
encourages learning new skills and knowledge, creating a group-oriented learning
environment by continuously encouraging group members to improve their technical
and interpersonal skills and knowledge through training and development. Group
cohesiveness and effectiveness improve as staff members take responsibility for teach-
ing each other and jointly seeking new information or techniques.

Shared Governance
Shared decision making is a hallmark of shared governance. That is, both managers
and staff members participate in making decisions. Such participation can improve
collaboration, staff retention, job satisfaction, productivity, and patient outcomes.
Measuring the distribution of control, influence, power, and authority, Hess (2011)
found that managers perceived staff to have more power in making decisions than
staff perceived that they did. Workload issues offered opportunities for shared deci-
sion making in another study (MacPhee, Wardrop, & Campbell, 2010). As a require-
ment for Magnet certification, shared governance increases staff involvement in the
organization’s functioning and future planning and, at the same time, increases staff
allegiance to the organization.

The Nurse Manager as Team Leader
Because staff nurses work in close proximity and frequently depend on each other to
perform their work, the nurse manager’s leadership is vital. A positive climate is one
in which there is mutual high regard and in which group members may safely discuss
work-related concerns, critique and offer suggestions about clinical practice, and com-
fortably experiment with new behaviors. Maintaining a positive work group climate
and building a team make up a complex and demanding leadership task.

Communication
Communication is a central component of the nurse manager’s leadership. The Joint
Commission, the organization that accredits hospitals, found that poor interprofes-
sional communication was the cause of nearly 70% of unexpected events causing death
or serious injury (Joint Commission, 2015).

Effective nurse managers can facilitate communication in groups by maintaining
an atmosphere in which group members feel free to discuss concerns, make sugges-
tions, critique ideas, and show respect and trust. An important leadership function
related to communication is gatekeeping—that is, keeping communication channels
open, refocusing attention on critical issues, identifying and processing conflict, foster-
ing self-esteem, checking for understanding, actively seeking the participation of all
group members, and suggesting procedures for discussing group problems.

The manager’s communication style also affects group cohesiveness. If the man-
ager maintains a high degree of information power and controls not only what infor-
mation is received but also who receives it, group performance may suffer. By

Building and Managing Teams 191

interrupting, changing the subject, monopolizing the conversation, or ignoring the
feedback, problems escalate, and the leader remains uninformed; individuals in the
group and the group’s ability to function both suffer.

If, on the other hand, the manager shares information freely and encourages a
high degree of mutual communication and participative problem solving, perfor-
mance and job satisfaction improve. In participative groups, each individual has the
opportunity, and is encouraged, to seek and share information and to communicate
frequently with anyone and everyone in the group. Managers and staff alike check
with each other to ensure that information is clear, offer suggestions, and provide
feedback.

Evaluating Team Performance
The manager may be accustomed to evaluating individual performance, but evaluat-
ing how well a team performs requires different assessments. Patient outcomes and
team functioning are the criteria by which teams can be evaluated. Outcome data—
such as clinical pathway information, variances in critical paths, complication rates,
falls, and medication errors—can help evaluate team performance.

Group functioning can be assessed by the level of work-group cohesion, involve-
ment in the job, and willingness to help each other. Conversely, aggression, competi-
tion, hostility, aloofness, shaming, or blaming are characteristics of poorly functioning
groups. Stability of members is an additional measure of group functioning.

Influencing team processes toward the attainment of organizational objectives is
the direct responsibility of the nurse manager. By publicizing team accomplishments,
creating opportunities for team members to demonstrate new skills, and supporting
social activities, the manager can increase the perceived value of group membership.
Members of groups who have a history of success are attracted to each other more
than those who have not been successful. Case Study 12-1 shows how one nurse man-
ager handled introduction of multidisciplinary staff into an existing staff team.

Case sTudy 12-1 | Introducing Multidisciplinary Teams
Bruce Shapiro was promoted 6 months ago to nurse man-
ager for the stroke rehabilitation unit of a nationally owned
rehabilitation hospital chain. Patient care delivery systems
have been under intensive review at the corporate level,
and major changes in staffing are underway. Previously,
physical and occupational therapists were staffed out of a
separate department and reported to the director of physi-
cal therapy. Now, all therapists will be unit based and report
to the nurse manager. Documentation will now be team
centered instead of being split among nursing, therapists,
and other care providers.

Janice Pacheco has been a physical therapist for
25 years and has been at the rehab hospital for the past
6 years. She worked as a shift leader for physical therapy
until the new unit-based staffing was implemented. Janice
has been assigned to the stroke rehab unit and will report

to Bruce. She feels uncomfortable in her new role and is
concerned about how she will fit in with the established
nursing staff. Janice is also concerned that, with the new
documentation system, the physical therapy patient evalu-
ations will not be included in determining patient goals.

Bruce is eager for Janice to join the staff of the stroke
rehabilitation unit. He schedules individual meetings with
Janice and the three other therapists who will be assigned
to his unit. Bruce outlines the roles and expectations of staff
on the unit and listens attentively to their questions and
concerns. He also reviews the physical and occupational
therapy job descriptions and reviews their respective docu-
mentation standards. At the monthly staff meeting, Bruce
discusses the roles and responsibilities of the therapists
with the nursing staff. A mentor is assigned to meet daily
with each therapist for their first 2 weeks on the unit.

192 Chapter 12

Leading Committees and Task Forces
Committees are generally permanent and deal with recurring problems. Membership on
committees is usually determined by organizational position and role. Formal commit-
tees are part of the organization and have authority as well as a specific role. Informal
committees are primarily for discussion and have no delegated authority. Task forces are
ad hoc committees appointed for a specific purpose and a limited time. Task forces work
on problems or projects that cannot be readily handled by the organization through its
normal activities and structures. Task forces often deal with problems crossing depart-
mental boundaries. They tend to generate recommendations and then disband.

Nurses are often selected for leadership roles on committees and task forces.
In these leadership roles, and as unit managers and team leaders, they conduct
numerous meetings. The following section provides guidance for leading and con-
ducting meetings.

Guidelines for Conducting Meetings
Although meetings are vital to the conduct of organizational work, they should be
held principally for problem solving, decision making, and enhancing working rela-
tionships. Other uses of meetings, such as socializing, giving or clarifying information,
or soliciting suggestions must be thoroughly justified. Information that can be shared
via other means, such as email, should be used if possible. Meetings should be con-
ducted efficiently and should result in relevant and meaningful outcomes. Meetings
should not result in damaged interpersonal relations, frustration, or inconclusiveness.

PRePaRaTIoN The first key to a successful meeting is thorough preparation. Prepa-
ration includes clearly defining the purpose of the meeting. The leader should prepare
an agenda, determine who should attend, make assignments, distribute relevant mate-
rial, arrange for recording of minutes, and select an appropriate time and place for the
meeting. The agenda should be distributed well ahead of time—7 to 10 days prior to
the meeting—and it should include what topics will be covered, who will be respon-
sible for each topic, what prework should be done, what outcomes are expected in
relation to each topic, and how much time will be allotted for each topic.

Sometimes a “meeting before the meeting” is advisable (Sullivan, 2013). This is
especially important if you are going into a meeting where you expect dissension. It
may involve simply chatting with a few key people to identify any problems or issues
they expect, or you may need to actually sit down with a key decision maker who has
veto power. Asking people you expect might have opposing points of view their opin-
ion might be helpful as well.

PaRTICIPaTIoN In general, the meeting should include the fewest number of stake-
holders who can actively and effectively participate in decision making, who have the
skills and knowledge necessary to deal with the agenda, and who can adequately rep-
resent the interests of those who will be affected by decisions made. Too few or too
many participants may limit the effectiveness of a committee or task force.

PlaCe aNd TIme Meetings should be held where interruptions can be controlled and
when there is a natural time limit to the meeting, such as late in the morning or afternoon.
Meetings should be limited to 50 to 90 minutes, except when members are dealing with
complex, detailed issues in a one-time session. Meetings that exceed 90 minutes should
be planned to include breaks at least every hour. Meetings should start and finish on

Building and Managing Teams 193

time. Starting late positively reinforces latecomers, while penalizing those who arrive on
time or early. If sanctions for late arrival are indicated, they should be applied respectfully
and objectively. If it is the leader who is late, the cost of starting meetings late should be
reiterated, and an appropriate designee should begin the meeting on time.

membeR beHavIoRS The behavior of each member may be positive, negative, or
neutral in relation to the group’s goals. Members may contribute very little, or they
may use the group to meet personal needs. Some members may assume most of the
responsibility for the group action, thereby enabling less participative members to
avoid contributing.

Group members should adhere to the following:

• Be prepared for the meeting, having read pertinent materials ahead of time.

• Ask for clarification as needed.

• Offer suggestions and ideas as appropriate.

• Encourage others to contribute their ideas and opinions.

• Offer constructive criticism as appropriate.

• Help the discussion stay on track.

• Assist with implementation as agreed.

These behaviors facilitate group performance. All attendees should be familiar
with behaviors that they may employ to facilitate well-managed meetings. All meet-
ing participants must be helped to understand that they share responsibility for suc-
cessful meetings.

A leader can increase meeting effectiveness greatly by doing the following:

• Not permitting one individual to dominate the discussion

• Separating idea generation from evaluation

• Encouraging members to refine and develop the ideas of others (a key to the success
of brainstorming)

• Recording problems, ideas, and solutions on a white board or flip chart

• Checking for understanding

• Summarizing information and the group’s progress periodically

• Encouraging further discussion

• Bringing disagreements out into the open and facilitating their reconciliation

The leader is also responsible for drawing out members’ hidden agendas (personal
goals or needs). Revealing hidden agendas ensures that these agendas either contribute
positively to group performance or are neutralized. Guidelines for leading group meet-
ings are provided in Box 12-1.

Managing Task Forces
There are a few critical differences between task forces and formal committees. For
example, members of a task force have less time to build relationships with one
another, and, because task forces are temporary, there may be no desire for long-term
positive relationships. Formation of a task force may suggest that the organization’s
usual problem-solving mechanisms have failed. This perception may lead to tensions
among task force members and between the task force and other units in the

194 Chapter 12

organization. The various members of a task force usually come from different parts of
the organization and, therefore, have different values, goals, and viewpoints. The
leader will need to take specific action to efficiently familiarize task force members
with each other and create bonds in relation to the task.

PRePaRINg FoR THe FIRST meeTINg Prior to the task force’s first meeting, the
leader must clarify the objectives in specific measurable outcomes, determine its mem-
bership, set a task completion date, plan how often and to whom the task force should
report while working on the project, and ascertain the group’s scope of authority,
including its budget, availability of relevant information, and decision-making power.
The task force leader should communicate directly and regularly with the administra-
tor or governing body that commissioned the task force’s work so that ongoing clarifi-
cation of its charge and progress can be tracked and adjusted.

Task force members should be selected on the basis of their knowledge, skills, per-
sonal concern for the task, time availability, and organizational credibility. They should
also be selected on the basis of their interpersonal skills. Those who relish group activi-
ties and can facilitate the group’s efforts are especially good members. The group leader
should also plan to include one or two individuals who potentially may oppose task
force recommendations in order to solicit their input, involve them in the decision-mak-
ing process, and win their support. By holding personal conversations with task force
members before the first meeting, the group leader can explore individual expectations,
concerns, and potential contributions. That also provides the leader with an opportu-
nity to identify potential needs and conflicts and to build confidence and trust.

CoNduCTINg THe FIRST meeTINg The goal of the first meeting is to come to a
common understanding of the group’s task and to define the group’s working proce-
dures and relationships. Task forces must rely on the general norms of the organiza-
tion to function. The task force leader should legitimize the representative nature of
participation on the task force and encourage members to discuss the task force’s pro-
cess with the other members of the organization.

During the first meeting, a standard of total participation should be well estab-
lished. The leader should remain as neutral as possible and should prevent premature
decision making. Working procedures and relationships among the various members,
the subgroups, and the rest of the organization must be established. The frequency and
nature of full task force meetings and the number of subgroups must be determined.

Box 12-1 Guidelines for Leading Group Meetings
• Begin and end on time.
• Create a warm, accepting, and nonthreatening climate.
• Arrange seating to minimize differences in power,

maximize involvement, and allow visualization of all
meeting activities. (A U-shape is optimal.)

• Use interesting and varied visuals and other aids.
• Clarify all terms and concepts. Avoid jargon.
• Foster cooperation in the group.
• Establish goals and key objectives.
• Keep the group focused.
• Focus the discussion on one topic at a time.

• Facilitate thoughtful problem solving.
• Allocate time for all problem-solving steps.
• Promote involvement.
• Facilitate integration of material and ideas.
• Encourage exploration of implications of ideas.
• Facilitate evaluation of the quality of the discussion.
• Elicit the expression of dissenting opinions.
• Summarize discussion.
• Finalize the plan of action for implementing decisions.
• Arrange for follow-up.

Building and Managing Teams 195

Ground rules for communicating must be established, along with norms for decision
making and conflict resolution.

maNagINg SubSequeNT meeTINgS aNd SubgRouPS In running a task
force, especially when several subgroups are formed, the leader should hold full task
force meetings often enough to keep all members informed of the group’s progress.
Unless a task force is small, subgroups are essential. The leader must not be aligned
too closely with one position or subgroup. A work plan should be developed that
includes realistic interim project deadlines. The task force and subgroups should be
held to these deadlines. The leader plays a key role in coaching subgroups and the task
force to meet its deadlines.

The leader must also be sensitive to the conflicting loyalties sometimes created by
belonging to a task force. One of the leader’s most important roles is to communicate
information to task force members as well as the rest of the organization in a timely
and regular fashion. The leader should solicit feedback from other key organizational
representatives during the course of the task force’s work.

ComPleTINg THe TaSk FoRCe’S RePoRT In bringing a project to completion,
the task force should prepare a written report for the commissioning administrators
that summarizes the findings and recommendations. Drafts of this report should be
shared with the full task force prior to presentation. To identify any overlooked or sen-
sitive information and reduce defensive reactions, it is especially important that the
task force leader personally brief key administrators prior to presenting the report.
This gives administrators a chance to read and respond to the report before making
recommendations. The leader should consider involving a few task force members in
the administrative presentation.

Patient Care Conferences
Patient-related conferences are held to address the needs of individual patients or
patient populations. The purpose of the conference determines the composition of the
group. Patient-focused meetings are usually interprofessional and used for case man-
agement to discuss specific patient care problems. For example, an interprofessional
team may form to discuss the failure of a rehabilitation regimen for a home care patient
and to develop new plans for intervention.

Often nurses are also involved in activities associated with improving the quality
of care for various patient groups and their families. For example, a nurse manager
might organize meetings with primary care physicians and other managers to discuss
how to improve discharge planning, to explore strategies to reduce the length of inpa-
tient stays, or to improve coordination with outpatient clinics.

The team leader of a patient care conference often may not be a manager with
line responsibility to supervise, evaluate, or hire employees. Frequently in patient
rounds, the nurse is the person who can lead the conversation because the nurse has
spent the most amount of time with the patient. The team leader is, however, a coach,
teacher, and facilitator. Thus, the team leader needs to have excellent leadership
skills. The task of a team leader varies according to the task and the skill level of the
team members.

Nurses may be members of teams as well as leaders. Understanding how groups
and teams function (or do not) is essential to contribute to the organization, to be suc-
cessful in your position, and to garner satisfaction from your work.

What You Know Now
• A group is an aggregate of individuals who inter-

act and mutually influence each other.

• Groups may be classified as real or task, formal or
informal, permanent or temporary.

• A team is a group of individuals with comple-
mentary skills, a common purpose and perfor-
mance goals, and a set of methods for which they
hold themselves accountable.

• Assessment of problems should precede team-
building activities.

• Team building includes a focus on meeting goals
and accomplishing tasks as well as improving
interpersonal relationships.

• Team-building activities are more likely to be suc-
cessful if skills are reinforced on the job.

• The specifics of how to manage a team depend on
the task, group size and composition, productiv-
ity and cohesiveness, development and growth,
and the extent of shared governance in the
organization.

• The nurse manager’s communication skills affect
the team’s productivity and performance.

• Managing meetings involves preparing thor-
oughly, facilitating participation, and completing
the group’s work.

Tools for Building and Managing Teams
1. Notice how groups around you function. Use the

best ideas with your own groups.
2. Watch effective leaders. Identify skills you could

incorporate into your own leadership repertoire.
3. Recognize that you can develop good team leader-

ship skills. Practice those discussed in this chapter.

4. At the next opportunity, be prepared to follow the
directions for leading meetings.

5. Make a development plan to enhance your lead-
ership skills.

Questions to Challenge You
1. Identify the groups that include you in your work

or school. How are they different? Similar? Explain.
2. Describe an example of effective group leader-

ship and an example of poor leadership.
3. Evaluate your own leadership performance. How

could you improve?

4. Have you been involved in team building at work
or school? Was it effective? Explain.

5. What roles do you usually play in a group meet-
ing (or class)? What role would you like to play?
Describe it.

References
Agency for Healthcare Research and Quality. (2015).

TeamSTEPPS: Strategies and tools to enhance
performance and patient safety. Retrieved

August 24, 2015, from http://www.ahrq.gov/
professionals/education/curriculum-tools/
teamstepps/index.html

196 Chapter 12

http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html

http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html

Building and Managing Teams 197

Castner, J., Foltz-Ramos, K., Schwartz, D. G., &
Ceravolo, D. J. (2012). A leadership challenge:
Staff nurse perceptions after an organizational
TeamsSTEPPS initiative. Journal of Nursing
Administration, 42(10), 467–472.

Douglas, M., Howell, T., Nelson, E., Pilkington,
L., & Salinas, I. (2015). Improve the function of
multigenerational teams. Nursing Management,
46(1), 11–13.

Hess, R. G. (2011). Slicing and dicing shared
governance. Nursing Administration Quarterly,
35(3), 235–241.

Hill, K. S. (2010). Building leadership teams. Journal
of Nursing Administration, 40(3), 1031–1035.

Homans, G. (1950). The human group. New York, NY:
Harcourt Brace Jovanovich.

Homans, G. (1961). Social behavior: Its elementary
forms. New York, NY: Harcourt Brace.

Joint Commission. (2015). Sentinel event data:
Root causes by event type. Retrieved August 24,
2015, from http://www.jointcommission.org/
sentinel_event_statistics

Kalisch, B. J., & Lee, K. H. (2010). The impact of
teamwork on missed nursing care. Nursing
Outlook, 58(5), 233–241.

Keepnews, D. M., Brewer, C. S., Kovner, C. T., & Shin,
J. H. (2010). Generational differences among newly
licensed registered nurses. Nursing Outlook, 58(3),
155–163.

MacPhee, M., Wardrop, A., & Campbell, C. (2010).
Transforming work place relationships through
shared decision making. Journal of Nursing
Management, 18(8), 1016–1126.

Shirey, M. R. (2012). Group think, organization
strategy, and change. Journal of Nursing
Administration, 42(2), 67–71.

Steiner, I. D. (1972). Group process and productivity.
New York, NY: Academic Press.

Steiner, I. D. (1976). Task-performing groups. In
J. W. Thibaut, J. T. Spence, & R. C. Carson (Eds.),
Contemporary topics in social psychology
(pp. 94–108). Morristown, NJ: General Learning
Press.

Sullivan, E. J. (2013). Becoming influential: A guide for
nurses (2nd ed.). Upper Saddle River, NJ: Pearson.

Vertino, K. A. (2014). Evaluation of a TeamSTEPPS
initiative on staff attitudes toward teamwork.
Journal of Nursing Administration, 44(2),
97–102.

Wilhelmsson, M., Ponzer, S., Dahlgren,
L. O., Timpka, T., & Faresjö, T. (2011). Are
female students in general and nursing
students more ready for teamwork and
interprofessional collaboration in healthcare?
BMC Medical Education. Retrieved August
24, 2015, from http://www.biomedcentral.
com/1472-6920/11/15

http://www.jointcommission.org/sentinel_event_statistics

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http://www.jointcommission.org/sentinel_event_statistics

http://www.biomedcentral.com/1472-6920/11/15

198 Chapter 13

Learning Outcomes

After completing this chapter, you will be able to:

1. Explain how the various types of conflict can be positive or
negative.

2. Describe the conflict process.

3. Describe approaches that can be used to manage conflict.

Key Terms
accommodating

avoiding

collaboration

competing

compromise

conflict

confrontation

consensus

felt conflict

forcing

mediation

negotiation

perceived conflict

resistance

resolution

smoothing

suppression

withdrawal

Conflict
Interprofessional Conflict

Conflict Process Model
Antecedent Conditions

Perceived and Felt Conflict

Conflict Behaviors

Conflict Resolved or Suppressed

Outcomes

Managing Conflict
Conflict Responses

Alternative Dispute Strategies

198

Chapter 13

Handling Conflict

Handling Conflict 199

Introduction
Conflict is a natural, inevitable condition in organizations, and a manager’s communi-
cation frequently centers on conflict. It is often a prerequisite to change in people and
organizations. Effectively participating in conflict situations, as well as coaching oth-
ers in conflict situations, requires an understanding of conflict processes, your per-
sonal conflict style, and approaches to participating in conflict.

Conflict
Conflict is defined as the consequence of real or perceived differences in mutually
exclusive goals, values, ideas, attitudes, beliefs, feelings, or actions (a) within one indi-
vidual (intrapersonal conflict), (b) between two or more individuals (interpersonal con-
flict), (c) within one group (intragroup conflict), or (d) between two or more groups
(intergroup conflict). As a communication process, conflict is a dynamic process, rather
than a state. From this perspective, conflict is expressed “through communication
(verbal and nonverbal messages); likewise, the means to manage and address conflict
is through communication” (Oetzel & Ting-Toomey, 2013, p. viii). The outcomes of
conflict processes can be positive or negative, healthy or dysfunctional.

A certain amount of conflict is beneficial to an organization. It can provide height-
ened sensitivity to an issue, further piquing the interest and curiosity of others. Con-
flict can also increase creativity by acting as a stimulus for developing new ideas or
identifying methods for solving problems. Disagreements can help all parties become
more aware of the trade-offs, especially costs versus benefits, of a particular service,
process or technique.

Conflict also helps people recognize legitimate differences within the organization or
profession and may serve as a powerful motivator to improve performance, effectiveness,
and satisfaction. For example, during intergroup conflict, individual groups become
more cohesive and task oriented while communication between groups diminishes.

Leading at the Bedside: Dealing with Conflict
Conflict is inevitable. Conflict can take place at work, at
home, anywhere that you interact with one other person.
Sometimes conflict is helpful; you learn facts you didn’t
know, resolve differences between you, or find unique solu-
tions to common problems. More often, you will face conflict

involving difficult people and problem situations. In those
cases, learning to deal with disruptive conflict will help you
navigate the minefield of relationships and circumstances at
work and elsewhere. Heed the lessons in this chapter. Prac-
tice the skills presented. You and your career will benefit.

Interprofessional Conflict
Working in high-stress jobs, nurses often have conflicts with other healthcare profes-
sionals, administrators, or coworkers. Conflict in the interprofessional team often
occurs when coworkers feel their time is not respected. To do multidisciplinary rounds,
the doctor might want to meet at 1:00 p.m., the nurse at 1:30 p.m., and the social worker
at 10:00 a.m. Finding a time that fits the work flow of each job is important so that no
one feels undervalued or disrespected and consequently is better able to achieve his or
her goals for working with patients.

200 Chapter 13

Conflicts between physicians and nurses dominate the problems reported by both
professions (Leever, Hulst, Berendsen, Boendemaker, & Roodenburg, 2010). For example,
the physician may want to send the patient home today, the nurse knows the patient is
struggling to understand ordered medications, and the physical therapist tells the nurse
that the patient needs another day of practicing exercises before safely being discharged.

One approach a nurse manager can use to teach staff how to handle interprofes-
sional conversations is to advocate from the perspective of the patient, rather than
that of the nurse or other healthcare provider. The DESC script from the Agency for
Healthcare Research and Quality may be helpful (Agency for Healthcare Research
and Quality, 2015):

• D: Describe the specific situation or behavior; provide concrete data.

• E: Express how the situation makes you feel (e.g., uncomfortable), and what your
concerns are.

• S: Suggest other alternatives and seek agreement.

• C: Consequences should be stated in terms of impact on established goals; strive
for consensus.

This series of actions helps the participants to stay focused on understanding
and resolving the problem, rather than focusing on the people involved (Runde &
Flanagan, 2013).

Conflict Process Model
Several authors have proposed models for examining conflict (e.g., Filley, 1975; Pondy,
1967). Thomas and Kilmann (1974) developed the now-classic Thomas-Kilmann Con-
flict Mode Instrument, a tool for self-assessing one’s preferred approach to conflict
resolution. All follow a generalized format for examining the life span of a conflict.
These models provide a framework that helps explain how and why conflict occurs.

A conflict and its resolution develop according to a process that may be character-
ized as a life span (see Figure 13-1). This process begins with certain preexisting
conditions (antecedent conditions). The parties are influenced by their feelings or per-
ceptions about the situation (perceived or felt conflict), which initiates behavior, and
conflict is revealed in the messages used by all involved parties. The conflict is either
resolved or suppressed, and its outcome results in new or reinforced attitudes and
feelings among the parties.

Antecedent Conditions
Antecedent conditions propel a situation toward conflict; they may or may not be the
cause. In nursing, antecedent conditions include incompatible goals, differences in val-
ues and beliefs, task interdependencies (especially asymmetric dependencies, in which
one party is dependent on the other but not vice versa), unclear or ambiguous roles,
competition for scarce resources, differentiation or distancing mechanisms, and unify-
ing mechanisms.

InCompatIble Goals The most important antecedent condition to conflict is incom-
patible goals. As discussed in Chapter 2, goals are desired results toward which behavior
is directed. Even though the common goal in healthcare organizations is to give quality

Handling Conflict 201

patient care in a cost-effective manner, conflict in achieving these goals is inevitable
because individuals often view this from different perspectives. The dichotomy between
healthcare providers and third-party payers is an example. Healthcare providers want to
maximize the quality of care, whereas payers are concerned with minimizing costs.

A healthcare organization may have specific goals to achieve the best possible care
for patients and control costs to stay within budget and, at the same time, to provide
intrinsically satisfying jobs for its employees. These multiple goals will frequently con-
flict with each other, so they will have to be prioritized. Priority setting can be one of
the most difficult but important activities a healthcare manager must implement.
Goals are important because they become the basis for allocating resources and thus
become an important source (antecedent) of conflict in the organization.

Similarly, individuals themselves have multiple goals, and those goals may also
conflict. Individuals allocate scarce resources, such as their time, on the basis of prior-
ity and, therefore, might achieve one goal at the expense of others. The inability to
attain multiple (and in some cases mutually incompatible) goals—whether those goals
are personal or organizational—can cause conflict.

Role ConflICts Roles are defined as other people’s expectations regarding
behavior and attitudes. Roles become unclear when one or more parties have related
responsibilities that are ambiguous or overlapping. A manager might experience con-
flict between his or her responsibilities as an administrator and responsibilities as a
staff member. Similarly, unclear or overlapping job descriptions or assignments among
healthcare professionals may lead to conflict. For example, there could be conflict over
such mundane issues as who has responsibility to deliver a patient to the radiology
department: the nurse or the transport staff?

Task interdependence is another potential source of conflict. Nursing and house-
keeping, for example, are interdependent. Housekeeping cannot completely clean a
room until nursing has discharged the patient. Other examples of interdependence are
the relationships among shifts and those between physicians and nurses. Interdepen-
dent relationships have the potential to initiate conflict.

Antecedent conditions

Conflict behavior

Conflict resolved or
suppressed

Outcomes

Felt conflictPerceived conflict

Figure 13-1 The conflict process.

202 Chapter 13

stRuCtuRal ConflICt One conflict commonly seen in the healthcare environ-
ment is structural conflict. Structured relationships (manager to staff, peer to peer)
may generate conflict because of ineffective communication, competition for resources,
opposing interests, or a lack of shared perceptions or attitudes. A structural conflict
might occur when a nurse manager responds to a patient complaint about a staff nurse
by following up with corrective counseling or coaching. The staff nurse might dispute
the complaint and become defensive. In this situation, one strategy that the manager
could impose is positional power. Positional power involves using the authority inher-
ent in a certain position—for example, the nurse administrator has greater positional
power than a nurse manager.

CompetItIon foR ResouRCes Competition for scarce resources can be internal
(among different units in the organization) or external (among different organiza-
tions). Internally, competition for resources may involve assigning staff from one unit
to another or purchasing high-technology equipment when another unit is desperate
for staff.

Externally, healthcare organizations compete for finite external resources (e.g.,
designation as an accountable care organization for Medicare). Organizations are
using a variety of means, such as striving for documented high-quality care, develop-
ing new services, and advertising to try to capture the market in healthcare.

Values and belIefs Differences in values and beliefs frequently contribute to
conflict in healthcare organizations. An individual’s values and beliefs result from the
individual’s socialization experience. Conflicts between physicians and nurses,
between nurses and administrators, between nurses with associate degrees and those
with baccalaureate degrees, or between nurses and their patients often occur because
of differences in values, beliefs, and experiences.

Distancing mechanisms or differentiation serve to divide a group’s members into
small, distinct groups, thus increasing the chance for conflict. This tends to lead to a
“we–they” distinction. One frequently seen example is distancing between physicians
and nurses. Opposition between intensive care nurses and nurses on medical floors,
night versus day shifts, and unlicensed versus licensed personnel are also examples.
Differentiation among subunits also occurs and may arise due to differences in struc-
ture. The administrative unit may have a highly bureaucratic structure, the nursing
unit may have a shared governance structure, and the staff physicians may have a
contracting unit structure. Nonstaff physicians might be relatively independent of the
healthcare organization. These differences in structure might result in different report-
ing mechanisms, different priorities, and different goals, all of which increase the like-
lihood of conflict.

Unifying mechanisms also may contribute to the development of a conflict. Unify-
ing mechanisms occur when greater intimacy develops or when unity is sought. All
nurses might be expected to reach consensus over an issue, but they might experience
internal conflict if they are forced to accept a group position when individually they
may not be wholly committed to the decision. A nurse manager’s friendship with a
staff member may also lead to this type of conflict.

Perceived and Felt Conflict
Perceived and felt conflict account for the conflict that may occur when the parties
involved view situations or issues from differing perspectives, when they misunderstand

Handling Conflict 203

each other’s position, or when positions are based on limited knowledge. perceived
conflict occurs when each party’s perception of the other’s position is different from what
it actually is. felt conflict describes the negative feelings that exist between two or more
parties. It is often characterized by mistrust, hostility, and/or fear.

To understand how perceived and felt conflicts develop, consider two situa-
tions. A nurse manager and a surgeon have worked together for years. They have
mutual respect for each other’s abilities and skills, and they communicate fre-
quently. When their subordinates clash, they are left with conflicting accounts of an
event in which the only agreed-upon fact is that a patient received less-than-
appropriate care. Now consider the same scenario if the nurse and doctor have
never dealt with each other, or if one feels that the other will not approach the prob-
lem constructively.

In the first situation—perceived conflict—the positive regard the nurse and sur-
geon have for each other’s abilities and their history of a positive relationship enable
them to believe they can constructively solve the conflict. The nurse does not feel that
the physician will try to dominate, and the physician respects the nurse manager’s
leadership ability. With these preexisting attitudes, the physician and nurse can remain
neutral while helping their subordinates solve the conflict.

If the nurse and physician experience felt conflict, as they do in the second situa-
tion, they might approach the situation differently. Each might assume the other will
defend her or his subordinates at all costs; then communication likely will be inhib-
ited. The conflict will likely be resolved by domination of the stronger party, either in
personality or position. One wins, the other loses, often resulting in the conflict behav-
iors discussed in the next section.

Conflict Behaviors
Conflict behavior results from the parties’ perceived or felt conflict. Behaviors may be
overt or covert. Overt behavior may take the form of aggression, competition, debate,
or problem solving. Covert behavior may be expressed by a variety of indirect tactics,
such as scapegoating, avoidance, or apathy.

Conflict Resolved or Suppressed
When conflict behaviors occur, the conflict is resolved or suppressed. Resolution
occurs when a mutually agreed-upon solution is arrived at and both parties commit
themselves to carrying out the agreement. Suppression occurs when one person or
group defeats the other. Only the dominant side is committed to the agreement, and
the loser may or may not carry out the agreement.

Outcomes
The outcome of a conflict affects how the parties will address conflict in the future. The
optimal approach is to manage the issues in a way that will lead to a solution wherein
both parties see themselves as having achieved their goals while solving the problem.
This leaves a positive aftermath that will affect future relations and positively influ-
ence feelings and attitudes. In the example of conflict between the nurse manager and
the physician, consider the difference in the aftermath and how future issues would be
approached if both parties felt positive about the outcome, as compared to future
interactions if one or both parties felt they had lost.

204 Chapter 13

Managing Conflict
Managing conflict is an important part of the nurse manager’s job. Managers are often
involved in conflict management on several different structural levels. Managers may
be participants in the conflict as individuals, administrators, or representatives of a
unit—and sometimes on multiple levels simultaneously. They must often confront staff,
individually or collectively, when a problem develops but also serve as mediators or
judges to conflicting parties. Conflicts can occur within the unit, between parties from
different units, or between internal and external parties (e.g., a university nursing
instructor may have a conflict with staff on a particular unit).

Everyone involved in conflict negotiations must be realistic regarding the out-
come. Often inexperienced negotiators expect unrealistic outcomes. When two or
more parties hold what appear to be mutually exclusive ideas, attitudes, feelings, or
goals, it is extremely difficult, without the commitment and willingness of all con-
cerned, to arrive at an agreeable solution that meets the needs of both (e.g., battles
between Democrats and Republicans in Congress).

Conflict management begins with a decision regarding whether and when to
intervene. Failure to intervene can allow the conflict to get out of hand, whereas early
intervention may be detrimental to those involved, causing them to lose confidence in
themselves and reduce risk-taking behavior in the future.

Some conflicts are so minor, particularly if between two people, that they do not
require intervention and would be better handled only by the two people involved.
Allowing them to resolve their conflict might provide a developmental experience and
improve their abilities to resolve conflict in the future.

Increased intensity can motivate participants to seek resolution, so sometimes it is
best to postpone intervention purposely to allow the conflict to escalate. You could
escalate the conflict even further by exposing participants to each other more fre-
quently without the presence of others and without an easy means of escape. Partici-
pants are then forced to face the conflict between them.

Giving participants a shared task or shared goals not directly related to the con-
flict may help them understand each other better and increase their chances of resolv-
ing their conflicts by themselves. Using such a method is useful only if the conflict is
not of high intensity, if the participants are not highly anxious about it, and if the man-
ager believes that the conflict will not decrease the efficiency of the unit in the mean-
time. When the conflict might result in considerable harm, however, the nurse manager
must intervene.

If you decide to intervene in a conflict between two or more parties, you can apply
mediation techniques, deciding when, where, and how the intervention should take
place. Routine problems can be handled in either party’s office, but serious confronta-
tions should take place in a neutral location unless the parties involved are of unequal
power. In this case, the setting should favor the disadvantaged participant, thereby
equalizing their power.

The location for an intervention should have no distractions and be available for
an adequate length of time. Because conflict management takes time, the manager
must be prepared to allow sufficient time for all parties to explain their points of view
and arrive at a mutually agreeable solution. A quick solution that inexperienced man-
agers often resort to is to impose positional power and make a premature decision.
This results in a win–lose outcome, which leads to feelings of elation and eventual
complacency for the winners and loss of morale for the losers.

Handling Conflict 205

Runde and Flanagan (2013) describe a useful model for influencing conflict
processes developed in conjunction with the Center for Creative Leadership.
Grounded in work by Capobianco, Davis, and Kraus in 2001 (as cited in Runde and
Flanagan, 2013), this model illustrates messages that are constructive or destructive.
Constructive messages are behaviors that keep conflict to a minimum, such as
focusing on the task and problem solving. Destructive messages are behaviors that
escalate or prolong the conflict, such as focusing on the personalities involved
(Runde & Flanagan).

Constructive responses to conflict include perspective taking, creating solutions,
expressing emotions, reaching out, thinking reflectively, delaying response, and adapt-
ing. Destructive responses to conflict include winning at all costs, displaying anger,
demeaning others, retaliating, avoiding, yielding, hiding emotions, and criticizing
oneself (Runde & Flanagan, 2013). These responses are reflected in the basic guidelines
found in Box 13-1 for helping two or more parties navigate conflict processes.

These guidelines are provided with a caveat. As Runde and Flanagan (2013)
stated, “Every conflict is different. That is why conflict competent leaders cannot,
and do not, follow a script. Their effectiveness derives from an array of behaviors,
techniques, analysis, timing, and attitudes” (p. 217). Conflict management is a dif-
ficult process, consuming both time and energy from all parties. However, con-
structive conflict processes often result in positive outcomes that not only resolve
the immediate conflict but also help enhance trust among the parties for future
interactions.

These strategies require particular effort from the nurse manager as mediator. In
addition to carefully monitoring the situation according to the preceding guidelines
and participating as needed, conflict-competent nurse managers are also emotionally

Box 13-1 Guidelines for Navigating Conflict
1. Protect each party’s self-respect. Focus on the con-

flict of issues, not personalities.
2. Avoid putting blame or responsibility for the problem

on the participants. The participants are responsible
for developing a solution to the problem.

3. Allow open and complete discussion of the problem
from each participant.

4. Maintain equity in the frequency and duration of each
party’s presentation. A person of higher status tends
to speak more frequently and longer than a person of
lower status. If this occurs, you as the nurse manager
should intervene and ask the person of lower status
for a response and opinion.

5. Encourage full expression of positive and negative feel-
ings in an accepting atmosphere. The novice mediator
tends to discourage expressions of disagreement, so it
is helpful to remember that expressions of disagree-
ment play an important role in finding solutions.

6. Make sure both parties listen actively to each other’s
words. One way to do this is to ask one person to
summarize the other person’s comments before stat-
ing her or his own.

7. Identify key themes in the discussion and restate them
at frequent intervals.

8. Encourage the parties to provide frequent feedback to
each other’s comments; each must truly understand
the other’s position.

9. Help the participants develop alternative solutions,
select a mutually agreeable one, and develop a plan to
carry it out. All parties must agree to the solution for
successful resolution to occur.

10. At an agreed-upon interval, follow up on the progress
of the plan.

11. Give positive feedback to participants regarding their
cooperation in solving the conflict.

Source: Runde, C., & Flanagan, T. (2013). Becoming a conflict competent leader: How you and your organization can manage conflict effectively (2nd ed.). San Francisco, CA:
John Wiley & Sons, Inc.

206 Chapter 13

intelligent (Goleman, 2006). They monitor when their own emotions are rising, use
constructive behaviors to slow responses when emotions are running high, and later
work to determine what is really behind people’s actions (Runde & Flanagan, 2013).
This takes energy, self-awareness, self-development, and practice, but the results are
well worth the investment.

Conflict Responses
Patterns of conflict responses have been studied for more than 50 years. There is a
wide variety of conflict responses or conflict styles (e.g., Filley, 1975; Thomas &
Kilmann, 1974). These are briefly mentioned here so that you are aware of the lan-
guage used to describe these patterns.

Confronting often is considered the most effective means for resolving conflicts in
a time-constrained situation. This is a problem-oriented technique in which the con-
flict is brought out into the open and attempts are made to resolve it through knowl-
edge and reason. The goal of this technique is to achieve win–win solutions. Facts
should be used to identify the problem. The desired outcome should be explicit—for
example, “This is the third time this week that you have not been here for report.
According to hospital policy, you are expected to be changed, scrubbed, and ready for
report in the lounge at 7:00 a.m.”

Confrontation is most effective when delivered in private as soon as possible
after the incident occurs (Sullivan, 2013). Employee respect and manager credibility
are two important considerations when a situation warrants confrontation. A more
immediate confrontation also helps both the employee and manager sort out perti-
nent facts. In an emotionally charged situation, however, it may be best for the parties
to wait. Regardless of timing, the message is usually more effective if the manager
listens and is empathetic.

negotiating involves give-and-take on various issues among the parties. Its
purpose is to achieve agreement even though total agreement will never be reached.
Therefore, the best solution from the perspective of either party or the organization
may not be achieved. Negotiation often becomes a structured, formal procedure, as
in collective bargaining. However, negotiation skills are important in arriving at an
agreeable solution between any two parties. Staff members learn to negotiate sched-
ules, advanced practice nurses negotiate with third-party payers for reimbursement,
insurance companies negotiate with vendors and hospitals for discounts, and clinic
managers negotiate employment contracts with physicians. Although adept com-
munication skills are the tools needed for negotiation, their usefulness revolves
around issues of conflict. Without differences in opinion, there would be no need for
negotiation.

Collaborating implies mutual attention to the problem, in which the talents of all
parties are used. In collaboration, the focus is on solving the problem, not defeating the
opponent. The goal is to work to create a solution that addresses both parties’ con-
cerns. Collaboration is useful in situations in which the goals of both parties are too
important to be compromised.

Compromising is used to divide the rewards between both parties. Neither gets
what she or he wants. Compromise can serve as a backup to resolve conflict when col-
laboration is ineffective. It is sometimes the only choice when opponents of equal
power are in conflict over two or more mutually exclusive goals. Compromising is
also expedient when a solution is needed rapidly.

Handling Conflict 207

Competing is an all-out effort to win, regardless of the cost. Competing may be
needed in situations involving unpopular or critical decisions. Competing is also used
in situations in which time does not allow for more cooperative techniques.

accommodating is an unassertive, cooperative tactic used when individuals
neglect their own concerns in favor of others’ concerns. Accommodating frequently
is used to preserve harmony when one person has a vested interest in an issue that is
unimportant to the other party.

In situations where conflict is discouraged, suppressing is often used. Suppres-
sion could even include the elimination of one of the conflicting parties through trans-
fer or termination. Other, less effective techniques for managing conflict include
withdrawing, smoothing, and forcing, although each mode of response is useful in
given situations.

In avoiding, the participants never acknowledge that a conflict exists. Avoidance
is the conflict resolution technique often used in highly cohesive groups. The group
avoids disagreement because its members do not want to do anything that may inter-
fere with the good feelings they have for each other.

Withdrawing from the conflict means that one party removes itself, thereby mak-
ing it impossible to resolve the situation. The issue remains unresolved, and feelings
about the issue may resurface inappropriately. If the conflict escalates into a dangerous
situation, avoidance and withdrawing are appropriate strategies.

smoothing is accomplished by complimenting one’s opponent, downplaying dif-
ferences, and focusing on minor areas of agreement, as though little disagreement
existed. Smoothing may be appropriate in dealing with minor problems, but it pro-
duces the same results as withdrawing in response to major problems.

forcing is a method that yields an immediate end to the conflict but leaves the
cause of the conflict unresolved. A superior can resort to issuing orders, but the subor-
dinate will lack commitment to the demanded action. Forcing may be appropriate in
life-or-death situations but is otherwise inappropriate.

Resisting can be positive or negative. It may mean a resistance to change or dis-
obedience, or it may be an effective approach to handling power differences, especially
verbal abuse.

All of these responses are commonly discussed approaches to working through
conflict situations. Discovering your own preferences for engaging in conflict conver-
sations is an important first step in interacting with others, particularly in conflict situ-
ations. Resources for low-cost self-assessment instruments are provided at the end of
this chapter.

Being aware of your own style preferences for resolving conflict is the first step
toward working through a conflict conversation. It contributes to reflexivity, a level of
self-awareness, particularly awareness of the possible ways of understanding a conflict
and your own role in a conflict (Littlejohn & Dominici, 2007).

Working with the Littlejohn and Dominici (2007) model to tie together these con-
cepts, consider how a reflexive nurse manager might approach a conflict:

• Think of the conflict not as an obstacle, but as an opportunity for problem-solving.

• Reframe the issue from emotional reaction to substantive issues.

• Turn the situation into an opportunity for building respect.

• Present or generate a variety of options for resolution.

• Shift attention from positions to interests and then to mutual interests (such as
patient-centered, high-quality, safe care).

208 Chapter 13

Case study 13-1 | Conflict Management
Mai Tran is the nurse manager of a 20-bed medical– surgical
unit in a large university hospital. Her nursing staff is diverse
in experience and educational background. Working in a
teaching hospital, Mai believes that nurses should be open
to new methods and work processes, with an emphasis on
evidence-based practice.

Ken Robertson, RN, has worked for 2 years on the
unit and is in his final semester of a master’s program
focusing on geriatric care. Eileen Holcomb, RN, has worked
on the same unit for the past 28 years and is a graduate of
the hospital’s former diploma program. Ken recently com-
pleted a clinical rotation in dermatology and has worked
with the skin care team at the hospital to develop new pro-
tocols for preventing skin breakdown. During a recent staff
meeting, Ken presents the new protocols to the staff. Dur-
ing the presentation Eileen comments that simply getting
patients out of bed and making sure they have adequate
nutrition is easier and less time-consuming than the new
protocol. “All these new protocols are just a way to justify all
those credentials behind a name,” Eileen says, gathering a
chorus of chuckles from some of the older nurses on the

staff. Ken frowns at Eileen and responds, “As nurses
become educated, we need to reflect a professional
practice.” Mai notices that several staff members are
uncomfortable as the meeting ends.

Ken and Eileen continue to exchange sarcastic com-
ments and glares over the next two shifts they work
together. The obvious disagreement is affecting their cow-
orkers, and gossiping is decreasing productivity on the unit.
Mai schedules individual meetings with Ken and Eileen to
discuss their perspectives. After reviewing the situation and
determining that the issue is simply one of personality con-
flict, Mai brings Ken and Eileen together for a meeting in her
office. Mai reviews the facts of the situation with them and
shares her opinion that both have acted inappropriately.
She states that their actions have affected not only their
work but also that of the unit as a whole. She informs Ken
and Eileen that they must act in a professional and respect-
ful manner with each other or disciplinary action will be
taken. She then works to facilitate a conversation during
which both parties can express their concerns, with the
goal of finding common ground.

While these steps may seem straightforward, they can constitute an engaging, time-
consuming process. However, the outcomes are potentially transformative for future
interactions.

Alternative Dispute Strategies
Conflicts that have the potential to lead to legal action are often negotiated using alter-
native dispute resolution (ADR) (Sander, 2009). mediation is a form of ADR that
involves a third-party mediator to help settle disputes. Mediation agreements can sat-
isfy all parties, cost less and take less time than legal remedies, and lead to improved
interprofessional relationships (Gardner, 2010). Mediation has been used successfully
in settling disputes in long-term care facilities (Rosenblatt, 2008).

ADR efforts have resulted in the creation of the International Institute of Conflict
Prevention and Resolution, expanded state and federal legislation encouraging media-
tion, a dispute resolution division in the American Bar Association, and development
of ADR courses in law schools. The use of ADR in public policy promises to increase in
the coming years (Susskind, 2009).

See how one nurse manager handled a conflict between two members of her staff
in Case Study 13-1.

Managing conflict is an essential skill for the manager and, indeed, all nurses.
Avoiding unnecessary conflict or allowing conflict to fester and remain unresolved
undermines the manager’s effectiveness, can result in dissatisfied staff and turnover,
and potentially harms patients. Resolving conflict, on the other hand, can lead to better

Handling Conflict 209

outcomes, both with immediate and future situations, and encourages the manager to
resolve conflict in the future.

More strategies for handling conflict can be found in Chapter 10, “Dealing with
Difficult People and Situations,” in Becoming Influential: A Guide for Nurses ( Sullivan,
2013).

What You Know Now
• Conflict is a dynamic communication process and

the consequence of real or perceived differences
between individuals or groups.

• Conflict can be positive and the first step in initiat-
ing change, or it may be negative and disruptive.

• Antecedent conditions that cause conflict include
incompatible goals, role conflicts, structural

conflict, competition for scarce resources, and dif-
ferences in values and beliefs.

• A number of strategies exist to handle conflict;
choosing the best one to use is based on the situa-
tion and the people involved.

• Learning to manage conflict is a key to success for
all nurses and managers.

Tools for Handling Conflict
1. Evaluate conflict situations to decide if and when

to intervene.
2. Understand the antecedent conditions for the

conflict and the positions of those involved.
3. Enlist others to help solve conflicts when appro-

priate.

4. Be aware of your preference for a conflict manage-
ment strategy, then consider a style appropriate
to the situation and the other people involved.

5. Practice the conflict management strategies dis-
cussed in the chapter and evaluate the outcomes.

Questions to Challenge You
1. How are conflicts handled at work or school? Do

leaders need to be good conflict managers? Give
an example to explain your answer.

2. Briefly describe a conflict in which you were
involved. How did you handle yourself? How
did the others involved handle it? Did it turn out
well? Explain.

3. What have you found to be the most difficult part
of handling conflicts? What strategies from this
chapter are you planning to try when you encoun-
ter your next conflict?

Resources
Patterson, K., Grenny, J., McMillan, R., & Switzler,

A. (2005). Crucial confrontations: Tools for resolving
broken promises, violated expectations, and bad
behavior. New York, NY: McGraw-Hill.

Sullivan, E. J. (2013). Becoming influential: A guide
for nurses (2nd ed.). Upper Saddle River, NJ:
Pearson.

210 Chapter 13

References
Agency for Healthcare Research and Quality. (2015).

Pocket Guide: TeamSTEPPS: Team strategies and tools
to enhance performance and patient safety. Retrieved
September 11, 2015, from http://www.ahrq.
gov/professionals/education/curriculum-tools/
teamstepps/instructor/essentials/pocketguide.html

Filley, A. C. (1975). Interpersonal conflict resolution.
Glenview, IL: Scott Foresman.

Gardner, D. (2010). Expanding scope of practice:
Inter-professional collaboration or conflict?
Nursing Economics, 28(4), 264–266.

Goleman, D. (2006). Emotional intelligence: Why it can
matter more than IQ. New York, NY: Bantam.

Leever, A. M., Hulst, M. V. D., Berendsen, A. J.,
Boendemaker, P. M., & Roodenburg, J. L. N.
(2010). Conflicts and conflict management in the
collaboration between nurses and physicians: A
qualitative study. Journal of Interprofessional Care,
24(6), 612–624.

Littlejohn, S. W., & Domenici, K. (2007). Communication,
conflict, and the management of difference. Long Grove,
IL: Waveland Press, Inc.

Oetzel, J. G., & Ting-Toomey, S. (2013). The SAGE
handbook of conflict communication (2nd ed.). Los
Angeles, CA: Sage.

Pondy, L. R. (1967). Organizational conflict: Concepts
and models. Administrative Science Quarterly, 12,
296–320.

Rosenblatt, C. L. (2008). Using mediation to manage
conflict in care facilities. Nursing Management,
39(2), 16, 17.

Runde, C., & Flanagan, T. (2013). Becoming a conf lict
competent leader: How you and your organization
can manage conf lict effectively (2nd ed.). San
Francisco, CA: John Wiley & Sons, Inc.

Sander, F. E. A. (2009). Ways of handling conflict:
What we have learned, what problems remain.
Negotiation Journal, 25(4), 533–537.

Sullivan, E. J. (2013). Becoming influential: A guide for
nurses (2nd ed.). Upper Saddle River, NJ: Pearson.

Susskind, L. (2009). Twenty-five years ago and
twenty-five years from now: The future of public
dispute resolution. Negotiation Journal, 25(4),
549–556.

Thomas, K. W., & Kilmann, R. H. (1974). Thomas-
Kilmann Conflict Mode Instrument. Tuxedo, NY:
Xicom.

http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.html

http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.html

Chapter 14

Managing Time

Learning Outcomes

After completing this chapter, you will be able to:

1. Critique time-wasters.

2. Examine goals and determine priorities.

3. Develop ways to control interruptions.

4. Incorporate time management strategies into meeting activities.

5. Summarize methods to respect time for yourself and others.

Key Terms
goal setting

interruption log

time logs

time-waster

to-do list

Introduction
Time management is a misnomer. No one manages time: What is managed is how time
is used. In today’s downsized healthcare organization, the pressure to do more in less
time has increased. Job enlargement occurs when a flatter organizational structure
causes positions to be combined and results in managers having more employees to
supervise, a situation common today.

Time-wasters

Setting Goals
Determining Priorities

Daily Planning and Scheduling

Grouping Activities and Minimizing
Routine Work

Personal Organization and Self-discipline

Controlling Interruptions
Phone Calls, Voice Mail, Email, and Text Messages

Email

In-person Interruptions

Paperwork

Controlling Time in Meetings

Respecting Time

211

212 Chapter 14

The managerial skills needed today are different from those in the past. The flatter
organizational structures result in more responsibilities shared throughout the organi-
zation and a greater use of electronic communications. Technology has changed how
managers and staff interact. Geographic location is less important than it was before
the widespread utilization of the internet, as is time away from work. Being always
connected can be both a time-saver and a time-stealer. Nonetheless, instant communi-
cation is here to stay.

Teams often do what managers formerly dictated, with the best decisions coming
out of the team’s cooperative efforts. Time management is equally important in team-
work as it is for individuals. Teams must plan and organize their work to meet dead-
lines. Efficiency is paramount.

Time can be used proactively or reactively. If you focus your energy on people
and events over which you have some direct or indirect control, you are using a
proactive approach. If, on the other hand, you spend most of your time on what
concerns you most about other people and events, your efforts are less apt to be
effective. For example, you can set and follow your goals and priorities, or you can
spend your time worrying, blaming, or making excuses about what you do not
accomplish.

Time-wasters
Why do we waste time? It is one of our most valuable resources, and yet everyone
admits to wasting it. Box 14-1 answers this question by showing some of the con-
straints on an individual’s ability to manage time effectively. These patterns of behav-
ior must be understood and dealt with to be effective in managing time.

Box 14-1 Why We Fail to Manage Time Effectively
• We do what we like to do before we do what we do

not like to do.
• We do things we know how to do faster than things

we do not know how to do.
• We do things that are easiest before things that are

difficult.
• We do things that require a little time before things that

require a lot of time.
• We do things for which resources are available.
• We do things that are scheduled (e.g., meetings)

before unscheduled things.
• We sometimes do things that are planned before

things that are unplanned.
• We respond to demands from others before demands

from ourselves.
• We do things that are urgent before things that are

important.

• We readily respond to crises and emergencies.
• We do interesting things before uninteresting things.
• We do things that advance our personal objectives or

that are politically expedient.
• We wait until a deadline approaches before we really

get moving.
• We do things that provide the most immediate

closure.
• We respond on the basis of who wants it.
• We respond on the basis of the consequences of our

doing or not doing something.
• We tackle small jobs before large jobs.
• We work on things in the order of their arrival.
• We work on the basis of the squeaky-wheel principle

(“The squeaky wheel gets the grease”).
• We work on the basis of consequences to the group.

Managing Time 213

In addition to these patterns of behavior, certain time-wasters prevent us from
effectively managing time. A time-waster is something that prevents a person from
accomplishing the job or achieving the goal. Common time-wasters include the fol-
lowing:

• Interruptions, in person or by phone calls, text messages, and email alerts

• Meetings, both scheduled and unscheduled

• Lack of clear-cut goals, objectives, and priorities

• Lack of daily and/or weekly plans

• Lack of personal organization and self-discipline

• Lack of knowledge about how one spends one’s time

• Failure to delegate

• Working on routine tasks

• Ineffective communication

• Waiting for others and thus not using transition time effectively

• Inability to say no

The first step in time management is to analyze how time is being used. The
second is to determine whether time use is appropriate to your role. You may find
much of your time is taken up doing busywork rather than activities that contrib-
ute to a particular outcome. Job redesign places emphasis on ensuring that time is
spent wisely, and that the right individual is correctly assigned the responsibility
for tasks.

Time logs are written or digital records of what you do every minute of the
day and are useful in analyzing your time. See an example of a nurse manager’s
time log in Table 14-1. Start by selecting a typical week and keeping a log of activi-
ties in 15- to 60-minute increments. You can use your smartphone’s calendar, a
planner, or a separate log. Keep it simple. List columns for the time period and the
activity. Review your log for what activities are essential and what can be dele-
gated or eliminated.

Table 14-1 Nurse Manager’s Time Analysis Log

Time Activity Purpose Value

7:00–7:30 Review emails received
overnight; list work to
accomplish during shift

To respond to people who
have emailed and to plan
what work must be done

Sets the plan for the day so
as much work as possible
can be accomplished

7:30–8:30 Be available for any night
shift staff who need to talk
with manager before leaving

Manager is accountable to
all staff that work on unit.
During this time, manager
can have face-to-face inter-
action with night shift staff
and follow up on any issues
that present

Provides time for night shift
staff to see and talk to man-
ager and develop relation-
ships and strong lines of
communication

8:30–10:00 Budget planning meeting Meet with VP of patient care
and other managers to work
on planning next fiscal year
budget

Manager has input into the
budget that he/she will work
to meet during next fiscal
year

214 Chapter 14

Setting Goals
Nurses are accustomed to setting both long- and short-range goals, although typically
such goals are stated in terms of what patients will accomplish rather than what the
nurse will achieve. A critical component of time management is establishing one’s
own goals and time frames.

Goals are specific statements of outcomes that are to be achieved. They provide
direction and vision for actions as well as a timeline for activities to be accomplished.
Defining goals and time frames helps reduce stress by preventing the panic people often
feel when confronted with multiple demands. Although time frames may not be as short
as the nurse manager would like (the tendency is to expect completion yesterday), nec-
essary actions have been identified and time frames can be adjusted as a task unfolds.

Individual or organizational goals encourage thinking about the future and what
might happen, what one wants to happen, and what is likely to happen (Sullivan,
2013). Goal setting helps relate current behavior, activities, or operations to the long-
range goals of an organization or individual. Without this future orientation, activities
may not lead to the outcomes that will help achieve the goals and meet the ideals of
the individual or organization. The focus should be to develop measurable, realistic,
and achievable goals.

It is useful to think of individual or personal goals in categories, such as the fol-
lowing:

• Department or unit

• Interpersonal (at work)

• Professional

• Financial

• Family and friends (outside of work)

• Vacation and travel

• Physical

• Lifestyle

• Community

• Spiritual

This partial listing is a guide to stimulate thinking about goals. Think about long-
term goals, lifetime goals, and short-term goals. These should be divided into job-related
goals and personal goals. Job-related goals may revolve around the clinic, unit, or depart-
ment, whereas personal goals may include family life and community involvement.

Short-term goals should be set for the next 6 to 12 months, but they should be
related to long-term goals. To manage time effectively, answer five major questions
about these goals:

1. What specific objectives are to be achieved?

2. What specific activities are necessary to achieve these objectives?

3. How much time is required for each activity?

4. Which activities can be planned and scheduled for concurrent action, and which
must be planned and scheduled sequentially?

5. Which activities can be delegated to others?

Managing Time 215

Delegating tasks to others can be an efficient time-management tool. Delega-
tion is the process by which responsibility and authority are transferred to another
individual. It involves assigning tasks, determining expected results, and grant-
ing authority to the individual expected to accomplish these tasks. Delegation is
perhaps the most difficult leadership skill for a nurse or a manager to acquire
(Murray, 2010). Today, when more assistive personnel are being used to carry out
the nurse’s work and when the manager’s span of control has expanded, appro-
priate delegation skills are essential for both nurses and nurse managers to be
successful.

Determining Priorities
To establish priorities, take into consideration both short- and long-term goals. Cate-
gorize them according to the following:

• What you must do

• What you should do if possible

• What you could do if you have time to spare (Jones & Loftus, 2009)

Next, determine the importance and urgency of each activity as shown in Table 14-2.
Activities can be identified according to the following:

• Urgent and important

• Important but not urgent

• Urgent but not important

• Busywork

• Wasted time

Activities that are both urgent and important must be completed. Activities that
are important but not urgent may make the difference between career progression and
maintaining the status quo. Urgent but not important activities must be completed
immediately but are not considered important or significant. Busywork and wasted
time are self-explanatory.

In addition, others’ emergencies or crises can intrude on your priorities. Again,
determine if these are truly urgent and important or if the person is overreacting to an
immediate situation.

Table 14-2 Importance–Urgency Chart

Category of Time Use Examples

Important and urgent Replacing two call-offs and ensuring sufficient staffing for the
upcoming shift

Important, not urgent Drafting an educational program for nurses on the changes in Medicare
reimbursement

Urgent, not important Completing and submitting the “Beds Available List” for a disaster drill

Busywork Compiling new charts for future patient admissions

Wasted time Sitting by the phone waiting for return calls

216 Chapter 14

Daily Planning and Scheduling
Once goals and priorities have been established, you can concentrate on schedul-
ing activities. Prepare a to-do list of the tasks to be completed each day, either after
work hours the previous day or early before work on the same day. The list is typi-
cally planned by workday or workweek. If you have a combination of many
responsibilities, a weekly to-do list may be more effective. Flexibility must be a
major consideration in this plan; some time should remain uncommitted to allow
you to deal with emergencies and crises that are sure to happen. The focus is not
on activities and events but, rather, on the outcomes that can be achieved in the
time available.

A system to keep track of regularly scheduled meetings (e.g., staff meetings), reg-
ular events (e.g., annual or quarterly report due dates), and appointments is also nec-
essary. This system should be used when establishing the to-do list; it should include
both a calendar and files.

The calendar might include information on the purpose of the meeting, who will
be attending, and the time and place. Several commercial planning systems are avail-
able, including software for computers, tablets, and smartphones. Any such system
includes a daily, weekly, or monthly calendar; a to-do section; a memo or note section;
and an address book with phone numbers. Separate files for projects, committees, or
reports should be kept arranged by date.

Grouping Activities and Minimizing Routine Work
Work items that are similar in nature and require similar environmental surround-
ings and resources should be grouped within divisions of the work shift. Set aside
blocks of uninterrupted time for the really important tasks, such as preparing the
budget.

Group routine tasks, especially those that are not important or urgent, during
your least productive time. For example, list what you can do in 5 minutes, such as
scan your email, check text messages, confirm a meeting, or set up an appointment, or
in 10 minutes, such as return a phone call, scan a website, or compose an email. This
helps you spend the small allotments of time productively.

Much time spent in transition or waiting can be turned into productive use. Com-
muting time can be used for self-development or planning work activities. We all have
to wait sometimes: waiting for a meeting to start or to talk to someone are just two
examples. Keep up with texts, voice mails, and emails on your phone, or use the time
to read blogs or scan websites. View waiting or transition time as an opportunity, espe-
cially to think.

If you are having difficulty completing important tasks and are highly stressed,
especially as the day winds down, doing routine tasks for a while often helps reduce
stress. Pick a task that can be successfully completed, then save it for the end of the
day. Reaching closure on even a routine task at the end of the day can reduce your
sense of overload and stress.

Implementing the daily plan and daily follow-up is essential to managing your
time. You should also repeat your time analysis at least semiannually to see how well
you are managing your time, whether the job or the environment has changed, and if
changes in planning activities are required. This can help prevent reverting to poor
time-management habits.

Managing Time 217

Personal Organization and Self-discipline
Some other time-wasters are lack of personal organization and self-discipline, includ-
ing the inability to say no, having to wait for others, multitasking, and excessive or
ineffective paperwork. Effective personal organization results from clearly defined
priorities based on well-defined, measurable, and achievable objectives. Priorities and
objectives are often related to those of many professionals as well as to objectives of
patients and their families.

How time is used is often a matter of resolving conflicts among competing needs.
It is easy to become overloaded with responsibilities and with more tasks to do than
can be accomplished in the time available. This is typical. There is never enough time
for all the activities, situations, and events in which one might like to become involved.

To be effective, nurses and nurse managers must be personally well organized and
possess self-discipline. Trying to do several tasks at once is known as multitasking
and, while such production sounds good if possible, the reality is that such behavior
usually results in none of the tasks completed appropriately. It is better to concentrate
on one task at a time, then move on to the next one.

Self-discipline also includes being able to say no. Taking on too much work can
lead to overload and stress. Being realistic about the amount of work to which you
commit is an indication of effective time management. If a superior is overloading
you, make sure that person understands the consequences of additional assignments.
Be assertive in communicating your own needs to others.

One manager who felt overwhelmed by all of her responsibilities used the strate-
gies shown in Case Study 14-1 to help her solve her problems.

Controlling Interruptions
An interruption occurs any time you must stop in the middle of one activity to give
attention to something else. Interruptions can be an essential part of your job, or they
can be a time-waster. An interruption that is more important and urgent than the activ-
ity in which you are involved is a positive interruption: It deserves immediate atten-
tion. An emergency or crisis, for instance, may cause you to interrupt daily rounds.

Some interruptions interfere with achieving the job and are less important and
urgent than current activities. Because the manager’s role has expanded to a broader
span of responsibility, more decision making is placed on teams and staff. When a

Leading at the Bedside: Managing Time
As a staff nurse, you may have little, if any, free or uncom-
mitted time. No planning is required because every minute
is taken. However, you may have more discretionary time
than you think.

Ask yourself the following:

• Do you chart as you complete a task? Or do you wait
until end of shift and end up staying beyond your shift
to do so?

• Do you make or take personal calls during your shift?

• Do you search online during work time?

• What about text messages? Or emails?

• Do you gather the necessary supplies before beginning
a task?

• Finally, are you able to delegate to others appropriately?

Follow up your answers with changes as you see fit,
and you’re likely to find some minutes or more that will help
you manage your time (Murray, 2010).

218 Chapter 14

manager is interrupted to solve problems within the staff nurse’s scope of accountability,
the manager should not become responsible for solving the problem. Gently but firmly
directing the individual to search for solutions will begin to break old patterns of behav-
ior and help develop individual responsibility. Although it is time-consuming in the
beginning, this practice eventually reduces the number of unnecessary interruptions.

Keeping an interruption log on an occasional basis may help. The log should show
who interrupted, the nature of the interruption, when it occurred, how long it lasted,
what topics were discussed, the importance of the topics, and time-saving actions to be
taken. An example of a nurse manager’s interruption log is shown in Table 14-3.

Analysis of these data may identify patterns for you to plan ways to reduce the
frequency and duration of interruptions. They may also indicate that certain staff
members are the most frequent interrupters and require individual attention to
develop problem-solving skills.

Phone Calls, Voice Mail, Email, and Text Messages
Phone calls, voice mail, email, and text messages are a major source of interruption.
A ringing phone or beep from an incoming text is highly compelling; few people can
allow it to go unanswered. All of us receive numerous phone calls and texts, and some
of them are time-wasters. Handling them effectively is a must.

PHONE CALL STRATEGIES Employing a few simple methods to manage phone
calls can increase efficiency and decrease time wasted:

• Minimize socializing and small talk. If you answer the phone with “Hello, what
can I do for you?” rather than “Hello, how are you?” the caller is encouraged to

CASE STUDY 14-1 | Time Management
For the past 6 years, Jane Schumann has been the man-
ager of staff development for three hospitals in a Catholic
healthcare system. After the healthcare system suffered
record operating losses last fiscal year, many middle man-
agement positions were eliminated. Jane was retained but
had several additional departments assigned to her. Now
Jane is responsible for staff development, utilization review
staff, in-house float pool, night nursing supervisors, agency
staffing, coordination of student nurse clinical rotations,
and training of all nursing staff for the new hospital informa-
tion system at four different hospitals.

Jane has been overwhelmed with her new responsi-
bilities. Wanting to establish trust and learn more about
her staff, Jane has adopted an open-door policy, resulting
in many drop-in visits each day. She has been working
much longer hours and most weekends. She has fre-
quently had to fill in for night supervisors, stretching her
workday to 18 hours. Her desk is stacked with paper-
work, and her voice mailbox is full of messages to be
returned. On average, she returns 40 of the 60 emails
received each day.

When Jane comes across information about a time-
management seminar, she quickly signs up. At the seminar,
Jane learns a number of strategies that she can use.

Back at work, she makes a plan. First, she makes a list
of priorities for each of her departments and a time frame
for completing each project. Then she completes daily
plans for the next two weeks as well as a three-month plan
for the upcoming quarter. Jane also determines who among
her new staff members can assume additional responsibili-
ties and notes which tasks can be delegated. She sorts
through paperwork and establishes a filing system for each
department. Jane decides that she will train her administra-
tive assistant to file routine paperwork and route other
paperwork to Jane or delegated personnel. Jane also
decides that at each departmental meeting, she will estab-
lish specific times that she will be available for drop-in visi-
tors. She schedules a meeting with the senior nursing
executive to discuss the staffing implications for training
nurses at the four hospitals to use the new hospital informa-
tion system. Finally, she takes advantage of an upcoming
four-day weekend to catch up on some well-deserved rest.

Managing Time 219

Table 14-3 Nurse Manager’s Interruption Log

Name Purpose Time Topics Importance Actions

Joan, RN Stopped in manager’s
office to talk

10 minutes Kids’ baseball games,
husband’s new job

Not related to work
activities, but helps build
relationship with staff

Proactively plan time for
occasional personal con-
versations with staff to
build relationships; plan to
eat lunch with staff in break
room 1 day per week in
order to have informal con-
versations

Bill, janitor Ask manager if he/she
has seen any furniture
in hallways because a
chair was missing
from a patient room

5 minutes Patient’s room furniture
was missing

Patient rooms need a
chair so the patient can
get out of bed and have
a place to sit. There is
an issue with furniture
that is sent for repair
being misplaced when
returned to the unit.

Ask the unit clerk to keep a
log of all furniture sent off
the unit for repair. When
the furniture is returned,
rather than putting it in the
hallway until someone says
a chair is needed in a
room, the unit clerk proac-
tively finds out where the
chair belongs and takes it
to that location.

Jason, nurse
aide

Tells the manager that
he has tried four dif-
ferent machines, but
no one machine can
measure blood pres-
sure, temperature,
and oxygen saturation

15 minutes When equipment fails,
manager works with
employee to call bio med
department to get equip-
ment in for repairs; four
rental machines are
brought to unit while
others are being fixed

Staff need functioning
equipment to do their
jobs efficiently

Partner with bio med
department to have unit
equipment checked once
per week to ensure each
component of the
machines is functioning
properly

get to business first. Be warm, friendly, and courteous, but do not allow others to
waste time with inappropriate or extensive small talk. Calls placed and returned
just prior to lunchtime, at the end of the day, and on Friday afternoons tend to
result in more business and less socializing.

• Plan calls. The person who plans phone calls does not waste anyone’s time,
including that of the person called. Note the topics you want to discuss before you
make the call. That way, you will not need to call back to give additional informa-
tion or ask a forgotten question.

• Set a time for calls. You may have a number of calls to return and make. It is best
to set aside a time for routine phone calls, especially during your downtime. Try
not to interrupt what is being done at the moment. If an answer is necessary before
your work can be continued, phone immediately; if not, phone for the information
at a later time.

• State the reason for the call and ask for preferred call times. If a party is not avail-
able, explain why you are calling and provide several time frames when you will
be available for a return call. Find out when the person you are calling is available.
This makes it easier for him or her to be prepared for the call and helps prevent
phone tag.

Voice mail is an excellent way to send and receive messages when a real-time
interaction is not essential. For example, one person or a large group of people can
learn about an upcoming meeting in one voice mail message. They can phone in their
responses at their convenience (with no need to reach each other directly). Like other
forms of communication, voice mail must be used appropriately. Long messages or

220 Chapter 14

sensitive information is better conveyed one-on-one. Moreover, another person (e.g.,
unit clerk) may be responsible for taking voice mail messages off the system, so it is
important to state the message in a professional manner, omitting personal or confi-
dential information.

TEXT MESSAGES Text messages demand attention unless the phone’s notification
feature is turned off. Even then, frequently glancing at the phone’s screen alerts you to
new messages. Few of us can resist checking “just this one” message. Text messages
are a combination of voice messages and email, so establish a time to return them.

EMAIL Email can enhance time management or be a further time-waster. Email min-
imizes the time you waste trying to contact individuals, enables you to contact many
people simultaneously, and allows you to code the urgency of the message. Tone, how-
ever, is difficult to convey by email. Therefore, it is better to use more personal forms
of communication, such as the phone or in-person contact, for potentially sensitive or
troublesome issues.

Incoming Messages. Checking email too often can waste time. Each time you read a
message, you are forced to think about it and you lose your focus on the task at hand.
Turn off your email alert and set specific times of day to check your in-box.

Also discourage people who forward you unwanted messages. Set your email fil-
ter to direct these messages to your spam folder or tell the sender that you cannot
receive personal messages at work (Merritt, 2009).

Outgoing Messages. Writing clear messages helps increase prompt and useful
responses. Here are some tips:

• Direct messages only to the people involved (e.g., committee members) and copy
others (e.g., the department chair).

• Title the subject line appropriately. For example, write “Meeting Friday morning”
rather than “Information.”

• Avoid salutations, if possible. “Dear” and “Hi” are often not needed on routine
messages.

• Craft your message succinctly but politely: “The division meeting will be held in
conference room C at 9:00 a.m.”

In-person Interruptions
Although often friendly and seemingly harmless, the typical “Got a minute?” inter-
ruption is rarely as short as that. Of course, some interruptions are important, urgent,
or both. You must attend to those. For others, however, you can control the duration of
the in-person interruption (Jones & Loftus, 2009). Take charge of the visit by identify-
ing the issue or question, arranging an alternative meeting, referring the visitor to
someone else, or redirecting the visitor’s problem-solving efforts.

Paperwork
Healthcare organizations cannot function effectively without good information sys-
tems. In addition to phone calls and face-to-face conversations, nurses and managers
spend considerable time writing and reading communications. Implementing aspects
of the Affordable Care Act, increasing regulations, measures to avoid legal action,

Managing Time 221

stronger privacy requirements, new treatments and medications, data processing,
work processing, and electronics place pressure on everyone to cope with increasing
paperwork (including electronic “paperwork”).

1. Plan and schedule paperwork. Writing and reading reports, forms, email, letters,
and memos are essential elements of a job. They will, however, become a major
source of frustration if their processing is not planned and scheduled as an inte-
gral part of daily activities. Learn the organization’s information system and
requirements, analyze the paperwork requirements of the position, and make sig-
nificant progress on that part of the job daily.

2. Sort paperwork for effective processing. A system of file folders for paper mail,
document files, or email can be very helpful (Raso, 2010). Here is a system to
handle it:

• Place all paperwork (or email) requiring personal action in an “action” folder
on your tablet, computer, or phone. Handle that according to its relative impor-
tance and urgency.

• Place work that can be delegated in a separate file, and distribute it appropriately.
• Place all work that is informational and related to present work in an “informa-

tional” folder on your tablet, computer, or phone.
• Place other reading material, such as professional journals, technical reports, and

other items that do not relate directly to the immediate work, in a “read” file.

The informational file contains materials that must be read immediately,
whereas the reading file materials are not as urgent and can be read later.

Do not be afraid to throw things away or delete them from your tablet or com-
puter. Do not let them become clutter when they no longer have value. Use recycle
receptacles for paper. Delete electronic files.

3. Send every communication electronically. Unless a paper memo, report, or letter
is required, send your work electronically.

4. Analyze paperwork frequently. Review filing policies and rules regularly and
purge files at least once each year. All standard forms, reports, and memos should
be reviewed annually. Each should justify its continued existence and its present
format. Do not be afraid to recommend changes and, when possible, initiate those
changes.

5. Do not be a paper shuffler. “Handle a piece of paper only once” is a common
adage, but impossible to follow if taken literally. Rather, each time you handle a
document (paper or online) or an email message, take action to further process it.
Paper shufflers are those who continually move documents around or accumulate
unread emails. They delay action unreasonably, and the problem mounts.

Controlling Time in Meetings
Meetings consume much time for nurses and managers, and much of that time is
wasted. To manage meetings follow these rules (Merritt, 2009):

• Do not meet simply because you always meet on Monday morning. If no meeting
is needed, cancel it.

• Invite only key people to initial meetings. Others can be sent the minutes or
invited to future meetings.

222 Chapter 14

• Establish the meeting’s goal and outcomes expected at the outset.

• Send information before the meeting so time is not spent reading it.

• Set a time limit for all meetings. Routine meetings should last no more than
1 hour. If more time is needed, schedule another meeting.

• Determine the agenda and keep to the topic.

• Follow up with actions assigned.

Respecting Time
The key to using time-management techniques is to respect one’s own time as well as
that of others. Using the preceding suggestions for time management communicates
to those who interact with you that you expect them to respect your time. You, how-
ever, must reciprocate by respecting their time, too. If you need to talk to someone,
make an appointment, particularly for routine matters.

You should continually ask, “What is the best use of my time right now?” Then
you should answer in three ways:

• For myself and my goals

• For my staff and their goals

• For the organization and its goals

Efforts to manage time may seem to take more time, but the reverse is true. Any
activity that helps set goals, determine priorities, organize activities, and minimize
interruptions will pay off in increased efficiency and effectiveness.

What You Know Now
• The first step in time management is to analyze

how you use your time by keeping a time log.

• Daily planning and scheduling help determine
priorities and set goals.

• Personal organization strategies help use time
productively.

• An interruption log helps identify patterns
that can be used to reduce unnecessary interrup-
tions.

• Phone calls can be controlled by minimizing
small talk and planning calls; voice mail and
email should be used efficiently.

• Written communication can also cause interrup-
tions that can be minimized by planning and
scheduling paperwork and emails and using an
effective filing system.

• People who respect their own time are likely to
find others respecting it, too.

Tools for Managing Time
1. Recognize that there will never be enough time to

accomplish everything you want.
2. Use a time log to identify and reduce time-

wasters.

3. Use a planning system to list goals, determine
priorities, and schedule activities.

4. Monitor interruptions and decide on ways to
minimize them.

Managing Time 223

Questions to Challenge You
1. What are your major time-wasters? Keep a time

log for 1 week. Compare how you thought you
wasted time with what your time log revealed.

2. Write down your goals for the next week. What
action steps can you take to realize your goals? At
the end of the week, evaluate your progress. Then
write down the next week’s goals.

3. What is keeping you from accomplishing your
goals? Think about how you can change the cir-
cumstances to better reflect your priorities.

4. Do you use a planner or other scheduling device?
If not, investigate the choices and select the one
that will work best for you. Then use it!

5. Think about how you handle interruptions. Dur-
ing the next week, try various strategies to mini-
mize the effect of interruptions.

References
Jones, L., & Loftus, P. (2009). Time well spent: Getting

things done through effective time management.
Philadelphia, PA: Kogan Page.

Merritt, C. (2009). Too busy for your own good.
New York, NY: McGraw-Hill.

Murray, K. (2010). Mentoring time management
skills. Nursing Management, 41(5), 56.

Raso, R. (2010). Tackling time management and
performance evaluation. Nursing Management
41(10), 56.

Sullivan, E. J. (2013). Becoming influential: A guide for
nurses (2nd ed.). Upper Saddle River, NJ: Pearson.

224 Chapter 15

Learning Outcomes

After completing this chapter, you will be able to:

1. Describe how the budgeting process works.

2. Differentiate among different approaches to budgeting.

3. Describe components of an operational budget.

4. Demonstrate how to plan a salary and nonsalary budget.

5. Explain the nurse manager’s role with capital budgeting.

6. Demonstrate how to monitor and control budgetary performance.

7. Describe how staff affects budgetary performance.

The Budgeting Process
Timetable for the Budgeting Process

Approaches to Budgeting
Incremental Budget

Zero-based Budget

Fixed or Variable Budgets

The Operating Budget
The Revenue Budget

The Expense Budget

Determining the Salary and Nonsalary
Budget

The Salary Budget

The Supply and Nonsalary Expense Budget

The Capital Budget

Monitoring and Controlling Budgetary
Performance During the Year

Variance Analysis

Position Control

Staff Impact on Budget
Improving Performance

224

Chapter 15

Budgeting and
Managing Fiscal
Resources

Budgeting and Managing Fiscal Resources 225

Key Terms
benefit time

budget

budgeting

capital budget

cost center

direct costs

efficiency variance

expense budget

fiscal year

fixed budget

fixed costs

incremental (line-by-line) budget

indirect costs

nonsalary expenditure variance

operating budget

position control

profit

rate variances

revenue budget

salary (personnel) budget

variable budget

variable costs

variance

volume variances

zero-based budget

Introduction
Budgeting is the process of planning and working to meet or exceed the goals of the
plan (Finkler, Jones, & Kovner, 2012). A budget is a detailed, quantitative plan that
communicates these expectations and serves as the basis for comparing them to actual
results. The budget shows how resources will be acquired and used over some spe-
cific time interval; its purpose is to allow management to project activities into the
future so that the objectives of the organization are coordinated and met. It also helps
ensure that the resources necessary to achieve these objectives are available at the
appropriate time. In addition, a budget helps management control the organization.

Budgeting is performed by businesses, governments, and individuals. In fact,
nearly everyone budgets, even though he or she may not identify the process as such.
Even if a budget exists only in an individual’s mind, it is nonetheless a budget. Any-
one who has planned how to pay a particular bill at some time in the future—say,
6 months—has a budget. Although it is very simple, that plan accomplishes the essen-
tial budget functions. One now knows how much of a resource (money) is needed and
when (in 6 months) it is needed. Note that the “when” is just as important as the “how
much”—the money has to be available at the right time.

Demands for patient safety, reimbursement changes with healthcare reform, techno-
logical advances, and the changing roles of healthcare providers require that budgets be
constructed as accurately as possible and for nurse managers to understand financial
implications (Dunham-Taylor & Pinczuk, 2015). This is no small task. Attention to the bud-
geting process is the first step in understanding how to use resources most effectively.

The Budgeting Process
A budget is a quantitative statement, usually in monetary terms, of the plans and
expectations of a defined area over a specified period of time. Budgets provide a foun-
dation for managing and evaluating financial performance. Budgets detail how

226 Chapter 15

resources (money, time, people) will be acquired and used to support planned services
within the defined time period.

The budget process also helps ensure that the resources needed to achieve these
objectives are available at the appropriate time, and that operations are carried out
within the resources available. The budgeting process increases the awareness of costs
and also helps employees understand the relationships among goals, expenses, and
revenues. Open dialogue between a nurse manager and staff nurse about the budget
can help raise awareness for nurses about where money comes from or how money
functions in an organization. As a result, employees are committed to the goals and
objectives of the organization, and various departments are able to coordinate activi-
ties and collaborate to achieve the organization’s objectives. Budgets also help man-
agement control the resources expended through an organizational awareness of costs.
Finally, budget performance provides management with feedback about management
of resources and the impact on the budget.

Budgeting involves planning and controlling future operations by comparing
actual results with planned expectations. Planning first involves reviewing established
goals and objectives of both nursing and the organization. Goals and objectives help
identify the organization’s priorities and direct the organization’s efforts. To plan, the
organization must know the following:

• Demographics of the population served, community influences, societal trends,
and competitors

• Sources of revenue, especially with changes in reimbursement due to enactment
of healthcare reform

• Statistical data, including:

○ Number of admissions or patient appointments
○ Average daily census
○ Average length of stay
○ Patient acuity
○ Projected volume base for ambulatory or procedure-based units or home

care visits

• Wage increases of market adjustments

• Price increases, including inflation rate, for supplies and other costs

• Costs for new equipment or technologies (e.g., communication devices, IV pumps,
monitoring equipment)

• Staff mix (e.g., RNs, LPNs, UAPs)

• Regulatory changes (e.g., legislation mandating nurse-to-patient ratios, state
board of health regulations) for the budgetary period

• Organizational changes (e.g., decentralization of pharmacy or respiratory ther-
apy services) that result in salary and benefit dollars being charged in portion to
the unit

Management normally uses the past as the common starting point for projecting
the future, but in today’s evolving payment environment, the past may be a poor pre-
dictor of the future. This is one of the major drawbacks of the budgeting process. In a
rapidly changing industry, basing budgets on historical data often requires readjust-
ment during the actual budget period.

Budgeting and Managing Fiscal Resources 227

Controlling is the process of comparing actual results with the results projected in
the budget. (See Monitoring and Controlling Budgetary Performance During the Year
later in this chapter.) Two techniques for controlling budgetary performance are vari-
ance analysis and position control. By measuring the differences between the projected
and the actual results, management is better able to make modifications and correc-
tions. Therefore, controlling depends on planning.

Timetable for the Budgeting Process
Depending on the size and complexity of the organization, the budgeting process
takes between 3 and 6 months. The process begins with the first-level manager. The
individual at this level of management may or may not have formalized budget
responsibilities but is nevertheless key to identifying needed resources for the upcom-
ing budget period.

The manager seeks information from staff about areas of needed improvement
or change and reviews unit productivity and the need for updated technology or
supplies. The manager uses this information to prepare the first draft of the budget
proposal.

Depending on the levels of organizational management, this proposal ascends
through the managerial hierarchy. Each subsequent manager evaluates the budget pro-
posal, making adjustments as needed. By the time the budget is approved by executive
management, significant changes to the original proposal usually have been made so
the budget fits into the grand scheme of the budget for the whole organization.

The final step in the process is approval by a governing board, such as a board of
directors or designated shareholders. Typically, the budget process timetable is struc-
tured so that the budget is approved a few months before the beginning of the new
fiscal year.

Clearly articulating budgetary needs is essential for the manager to be successful
in budget negotiations. Senior management must prioritize budget requests for the
entire organization, and they base those decisions on strong supporting documenta-
tion. Nurse managers should not expect to receive all of their budget requests, but they
need to be prepared to defend their priorities.

Approaches to Budgeting
Budgets may be developed in various formats depending on how the organization is
structured. They may be considered as:

• Cost centers. Managers are responsible for predicting, documenting, and manag-
ing the costs (staffing, supplies) of the area of responsibility.

• Revenue centers. Managers are responsible for generating revenues.

• Profit centers. Managers are responsible for generating revenues and managing
costs so that the department shows a profit, which means that revenues exceed
costs.

• Investment centers. Managers are responsible for generating revenues and man-
aging costs and capital equipment and assets.

Nursing units are typically considered to be cost centers, but they may also be
viewed as revenue centers, profit centers, or investment centers. How the unit is

228 Chapter 15

viewed is crucial in determining the manager’s understanding of responsibility and
approach to budgeting.

Also, some nursing managers are responsible for service lines, and their staff are
from multiple disciplines and departments. Other nurse managers are responsible for
a single unit, such as a telemetry unit or the staff in a multiple-physician office.

The organization may choose various approaches, or combinations of approaches,
for requesting departmental managers to prepare their budget requests. These
approaches are incremental (line-by-line), zero-based, fixed, and variable.

Incremental Budget
With an incremental (line-by-line) budget, the finance department distributes a bud-
get worksheet listing each expense item or category on a separate expense line. The
expense line is usually divided into salary and nonsalary items. A budget worksheet is
commonly used for mathematical calculations to be submitted for the next year. It may
include several columns for the amount budgeted for the current year, the amount
actually spent year-to-date, the projected total for the year based on the actual amount
spent, increases and decreases in the expense amount for the new budget, and the
request for the next year with an explanation attached.

The base or starting point for calculating next year’s budget request may be either
the previous year’s actual results or projected expenditures for the current year. For
salary expenses, the adjustment might be the average salary increase projected for next
year. For nonsalary expenses, the finance department may provide an estimate of the
average increase for supplies or opt to use a standard measure of cost increases, per-
haps the consumer or medical price index projected for the next year.

To complete budget worksheets accurately, managers must be familiar with
expense account categories and what type of expenses, such as instruments and minor
equipment, are included under each line item. In addition, the manager must keep
abreast of different factors that have affected the expenditure level for each expense
line during the current year. The projected impact of next year’s activities will be trans-
lated into increases or decreases in expense levels of the nursing unit’s expenditures
for the coming year.

The advantage of the line-by-line budget method is its simplicity of preparation.
The disadvantage of this method is that it discourages cost efficiency. To avoid bud-
get cuts for the next year, an astute manager learns to spend the entire budget
amount established for the current year, because this amount becomes the base for
the next year.

Zero-based Budget
The zero-based budget approach assumes the base for projecting next year’s budget is
zero. Managers are required to justify all activities and programs as if they were being
initiated for the first time. Regardless of the level of expenditure in previous years,
every proposed expenditure for the new year must be justified under the current envi-
ronment and its fit with the organization’s objectives.

The advantage of zero-based budgeting is that every expense is justified. The disad-
vantage is that the process is time-consuming and may not be necessary. For that reason,
organizations may not use this process every year. An adaptation of the zero-based bud-
get is to start the budget with a lower base—for example, 80%—of the current expenses.
Managers then have to justify any budgetary expenses requested above the 80% base.

Budgeting and Managing Fiscal Resources 229

Fixed or Variable Budgets
Budgets can also be categorized as fixed or variable. In a fixed budget, the bud-
geted amounts are set without regard to changes that may occur during the year,
such as patient volume or program activities, that have an impact on the cost
assumptions originally used for the coming year. In contrast, the variable budget is
developed with the understanding that adjustments to the budget may be made
during the year based on changes in revenues, patient census, utilization of sup-
plies, and other expenses.

The Operating Budget
The operating budget, also known as the annual budget, is the organization’s state-
ment of expected revenues and expenses for the coming year. It coincides with the
fiscal year of the organization, a specified 12-month period during which the opera-
tional and financial performance of the organization is measured. The fiscal year may
correspond with the calendar year—January to December—or another time frame.
Many organizations use July 1 to June 30; the federal government begins its fiscal year
on October 1. The operating budget may be further divided into smaller periods of
6 months or into four quarters (3 months each); each quarter may be further separated
into three 1-month periods. The revenues and expenses are organized separately, with
a bottom-line net profit or loss calculated.

The Revenue Budget
The revenue budget represents the patient care income expected for the budget
period. Most commonly, healthcare payers pay a predetermined rate based on dis-
counts or allowances. In many cases, actual payment generated by a given service
or procedure will not equal the charges that appear on the patient bill. Instead, the
healthcare provider will be reimbursed based on a variety of methods, including
the following:

• Reimbursement of a predetermined amount, such as fixed costs per case (Medi-
care recipients)

• Bundled payments (e.g., total knee replacement paid with predetermined fee to
cover the operation, hospital stay, and outpatient therapy)

• Negotiated rates, such as per diems (a specified reimbursement amount per
patient, per day)

• Negotiated discounts

• Capitation (one rate per member, per month, regardless of the service provided).

Revenue projections for the next year are based on the volume and mix of
patients, rates, and discounts that will prevail during the budget period. Projections
are developed from historic volume data, impact of new or modified clinical pro-
grams, shifts from inpatient to outpatient procedures, market changes, and other
influences. Today, however, these projections may not be viable, especially in the light
of healthcare reform.

Medicare is changing the way hospitals are paid (Medicare.gov, 2016). Payment is
no longer based solely on services provided by a hospital. It is based on the quality of

230 Chapter 15

service that is provided. Quality metrics such as readmission rates and hospital-
acquired infections are factored into payments rendered for services.

The Expense Budget
The expense budget consists of salary and nonsalary items. Expenses should reflect
patient care objectives and activity parameters established for the nursing unit. The
expense budget should be comprehensive and thorough; it should also take into con-
sideration all available information regarding expectations for the next year. Described
in the next sections are several concepts and definitions related to the budgetary pro-
cess in a healthcare setting.

COST CENTERS In healthcare organizations, nursing units are typically considered
cost centers. A cost center is the smallest area of activity within an organization for
which costs are accumulated. Cost centers may be revenue producing, such as labora-
tory and radiology, or non–revenue producing, such as environmental services and
administration. Nursing managers are commonly given the responsibility for costs
incurred by their department, but they have no revenue responsibilities.

In contrast, if managers are responsible for controlling both costs and revenues
and if their financial performance is measured in terms of profit (the difference
between revenues and expenses), then the manager is responsible for a profit center.
Customarily, nursing is not directly reimbursed for its services. Nursing costs today
are included in the room charge, although that may change as methods to match
nurses’ skills to patient needs improve.

CLASSIFICATION OF COSTS Costs are commonly classified as fixed or variable.
Fixed costs are costs that will remain the same for the budget period regardless of the
activity level of the organization, such as rental payments and insurance premiums.
Variable costs depend on and change in direct proportion to patient volume and
patient acuity, such as patient care supply expenses. If more patients are admitted to a
nursing unit, more supplies are used, causing higher supply expenses.

Expenditures may also be direct or indirect. Direct costs are expenses that directly
affect patient care. For example, salaries for nursing personnel who provide hands-on
patient care are considered direct costs. Indirect costs are expenditures that are neces-
sary but do not affect patient care directly. Salaries for security or maintenance person-
nel, for example, are classified as indirect costs.

Determining the Salary
and Nonsalary Budget
Budgets include expenses for both salary and nonsalary costs. Salary costs include
expenses related to personnel. Nonsalary costs include supplies and other opera-
tions expenses.

The Salary Budget
The salary (personnel) budget projects the salary costs that will be paid and charged to
the cost center in the budget period. Managing the salary budget is directly related to the
manager’s ability to supervise and lead the staff. Strong managers tend to have more

Budgeting and Managing Fiscal Resources 231

stable staff with fewer resources spent on supplementary staff, turnover, or absenteeism.
In addition to anticipated salary expenses, factors such as benefits, shift differentials,
overtime, on-call expenses, and bonuses and premiums may affect the salary budget.

BENEFITS A full-time equivalent (FTE) is a full-time position that can be equated to
40 hours of work per week for 52 weeks, or 2,080 hours per year. After the number of
required FTEs is determined for an organization, it is also necessary to determine how
many FTEs are necessary to replace personnel for benefit time (e.g., vacations, holi-
days, personal days). This factor can be calculated by determining the average number
of vacation days, paid holidays, personal days, bereavement days, sick days, or other
days off with pay that the organization provides to employees.

To determine FTEs required for replacement, calculate the following:

1. Determine hours of replacement time per individual.

2. Then determine FTE requirement.

Benefit Time Hours/shift Replacement Hours

15 vacation days × 8 hours = 120

8 holidays × 8 hours = 64

4 personal days × 8 hours = 32

5 sick days × 8 hours = 40

Total = 256

Divide replacement time by annual FTE base

256
2,080

= 0.12

An FTE budget is calculated from the FTE calculations (see Table 15-1). This budget
provides the base for the salary budget. However, shift differentials, overtime, and
bonuses or premiums may also affect budget performance and need to be considered.

Table 15-1 Monthly Salary Budget and Year-to-Date Budget Comparison Report
Fiscal Year Ending June 30

Position
June
Actual
Salary

June
Budgeted
Salary

June
Variance

Year-to-
Date
Actual
Salary

Year-to-
Date
Budgeted
Salary

Year-to-
Date
Variance

Nurse Manager $6,250 $6,250 $0 $68,750 $75,000 $6,250

Registered
Nurses 95,722 93,825 (1,897) 1,048,813 1,125,878 77,065

Licensed
Practical Nurses 19,025 20,800 1,775 231,426 249,600 18,174

Nursing
Assistants 14,886 13,200 (1,686) 159,500 158,400 (1,100)

Unit Clerks 5,483 5,495 12 60,391 65,273 4,882

Float Pool RNs 1,426 1,000 (426) 16,800 12,500 (4,300)

TOTAL SALARY: $142,792 $140,570 ($2,222) $1,585,680 $1,686,651 $100,971

232 Chapter 15

SHIFT DIFFERENTIALS Some facilities use a set percentage to determine shift dif-
ferential: 10% for evenings, 15% for nights, and 20% for weekends and holidays, for
example. If the hourly rate is $22.00, for instance, then the cost for a nurse working
evenings would be $22.00 plus $2.20 for each hour worked. On an 8-hour shift, the
total cost would be $193.60, and for the year, $50,336. Other facilities use a set dollar
amount per hour as the shift differential. For instance, evenings adds $2.50 per hour to
base pay, night shift $4.00 per hour, and weekends $2.50 per hour additional pay.

OVERTIME Fluctuations in workload, patient volume, variability in admission pat-
terns, and temporary replacement of staff due to illness or time off all create overtime
in the nursing unit. A projection of overtime for the next year can be calculated by
determining staff classification (RN, LPN, nursing assistant, and other employee clas-
sifications), then the historical or typical number of hours of overtime worked and
multiplying that number by 1.5 times the hourly rate. For example, if the average
number of overtime hours paid in a unit for RNs is 35 hours per two-week pay
period, and the average hourly rate is $22.00, the projected overtime cost for the year
would be $30,030 for the RN category.

To determine overtime costs:

1. Multiply average salary for classification $22.00

by factor × 1.50

to obtain overtime rate $33.00

2. Multiply average overtime hours 35

by overtime rate × $33.00

to obtain expenditure per pay period $1,155.00

3. Multiply number of pay periods 26

by overtime expenditure × $1,155.00

to obtain annual overtime costs $30,030.00

Clearly, overtime can rapidly deplete finite budget dollars allocated to a nursing
unit. The nurse manager should explore options to overtime, such as using part-time
or PRN (staff scheduled on an as-needed basis) workers in order to keep the cost per
hour more in line with the regular hourly rates. A competent manager certainly would
also evaluate unit productivity to decrease overtime.

ON-CALL HOURS If the nursing unit uses a paid on-call system, the approximate
number of hours that employees are put on call for the year should be estimated and
that cost added to the budget. Typically under the on-call system, staff members are
requested to be available to be called back to work if patient need arises, and the num-
ber of hours on call are paid at a flat rate per hour.

PREMIUMS Some organizations offer premiums for certifications or clinical ladder
steps. In this situation, a fixed dollar amount may be added to the base hourly rate of
eligible personnel; for example, an additional $1.00 per hour paid for professional cer-
tifications. This would result in the hourly rate of the employee being adjusted from a
base of $22.00 to $23.00. In this case, if the employee is full time and works 2,080 hours
a year (40 hours a week multiplied by 52 weeks a year), the annual new salary would
be $47,840, or $23.00 multiplied by 2,080.

Budgeting and Managing Fiscal Resources 233

SALARY INCREASES Merit increases and cost-of-living raises also need to be fac-
tored into budget projections. These increases are usually calculated on base pay. For
example, if a 3% cost-of-living raise is projected and the base salary for an RN is
$45,000, then the new base becomes $46,350.

ADDITIONAL CONSIDERATIONS Other important factors to consider when
developing the salary budget are changes in technology, clinical supports, delivery
systems, clinical programs or procedures, and regulatory requirements. Changes in
patient care technology or the introduction of new equipment may influence the
number, skill, or time that unit personnel may spend in becoming trained to use the
new equipment and, later, operating and maintaining it. If significant, the projected
number of additional labor hours for the new budgetary period should be incorpo-
rated into the request.

Departments such as environmental services, dietary, transport, or laboratory
may provide the nursing unit with support in performing certain tasks, such as trans-
porting patients or specimens. Any change in the level of support they provide should
be reviewed, and the effect of such change on the unit’s staffing levels should be quan-
tified for the next year’s budget request. Changes in staffing can place new demands
on the unit. Therefore, orientation and additional workload needs should also be
considered.

In addition, changes might be made to the way the organization charges costs. For
example, some direct or indirect costs formerly charged under other divisions might
now be allocated to the various units. You might find your unit charged for its fair
share of the heating or security budget. Major changes, of course, are planned ahead of
time, but some changes occur during the budget year, and the unit might be expected
to absorb those additional costs within its original budget.

The Supply and Nonsalary Expense Budget
The supply and nonsalary expense budget identifies patient-related supplies needed
to operate the nursing unit. In addition to supplies, other operating expenses—such as
office supplies, rental fees, maintenance costs, and equipment service contracts—may
also be paid out of the nursing unit’s nonsalary budget.

An analysis of the current expense pattern and a determination of its applicability
for the next budget period should be performed first. Any projected changes in patient
volume, acuity, and patient mix should also be considered because they will affect next
year’s supply use and other nonsalary expenses. For example, if a new surgery is being
performed at your hospital and a special expensive type of dressing is used on the
patients, you would plan this cost into the next year’s budget.

Increases due to an inflation rate index, or at a rate estimated by the finance or
purchasing department, are included as part of the budget request. A simple way of
calculating the effect of a price increase is to take the estimated total ending expense
for the year and multiply it by the inflationary factor.

To determine projected price increases, perform the following calculation:

Multiply current total line item

expense $12,758

by inflation factor plus 1.0 × 1.05

$13,396

234 Chapter 15

Increases in expenses, such as maintenance agreements and rental fees, should
also be incorporated as part of the budget request. The introduction of new technology
and changes in programs and regulatory requirements may require additional
resources for supplies as well as increased salaries.

The Capital Budget
The capital budget is an important component of the plan to meet the organization’s
long-term goals. This budget identifies physical renovations, new construction, and
new or replacement equipment planned within a specified time period. Organizations
define capital items based on certain conditions or criteria. Usually, capital items must
have an expected performance of 1 year or more and exceed a certain dollar value.

The capital budget is limited to a specified amount, and decisions must be made
regarding how best to allocate available funds. The capital budget fund is determined
by profit that the organization has had and the amount it can afford to reinvest in itself.
Some organizations also gain additional capital budget dollars through philanthropy
support. Priority is given to those items needed most. Not all items that fall under the
capital budget will necessarily get funding in a given year.

The role of a nurse manager in the capital budget process is often to identify capi-
tal needs that exist in his or her areas of responsibility. Many healthcare organizations
have departments that coordinate bringing in selected vendors and items and limit
choices to that equipment. The nurse manager would then be responsible for reporting
what needs exist and helping to select and determine the amount of equipment
needed. The capital pool is expensed out across all units that use the equipment.

The nurse manager is also asked to play a role in the prioritization process. A
nurse manager might request new televisions for her unit because the old televisions
are breaking down often and patients complain that the picture is blurry. At the same
time, the nurse manager could request a new piece of lift equipment that will improve
staff safety when moving patients. The manager is allowed a set amount from the capi-
tal budget and has to decide between buying televisions and improving patient satis-
factions or the new lift and potentially improving staff safety.

The impact of the new equipment on the unit’s expenses, such as the number of
staff needed to run the equipment, use of supplies, and maintenance costs, must be
considered as part of the operating budget, not the capital budget. Likewise, the need
for additional nursing and nonnursing personnel to operate the new equipment,
additional workload, and training of personnel should be quantified for the next
year’s budget.

Monitoring and Controlling Budgetary
Performance During the Year
The difference between the amount that was budgeted for a specific revenue or cost
and the actual revenue or cost that resulted during the course of activities is known as
the variance. Variance might occur in the actual cost of delivering patient care for a
certain expense line item in a specified period of time. Nurse managers are commonly
asked to justify the reason for variances and present an action plan to reduce or elimi-
nate these variances.

Budgeting and Managing Fiscal Resources 235

Managers receive reports summarizing the expenses for the department (see
Table 15-1). In the past, monthly reports on paper were sent to managers. Today
these reports are most often generated in electronic form, allowing them to be com-
piled and communicated rapidly and for managers to adjust more quickly than with
paper reports.

Monthly reports show expense line items with the budgeted amount, actual
expenditure, variance from budget, and percentage from the budgeted amount that
such variance represents. Often, they also show the comparison between actual year-
to-date results and the year-to-date budget.

To assess variance, follow these steps:

• Identify items that are over or under budgeted amounts.

• Find out why the variance occurred (e.g., a one-time event or an ongoing
occurrence).

• Keep notes on what you have learned in preparation for next year’s budget.

• Examine the payroll and note overtime or use of agency personnel.

• Validate the use of overtime or additional personnel and keep a note for your files.

Keeping notes throughout the year will help prevent the annual budget process
from becoming an overwhelming challenge. Trying to reconstruct what happened and
why during the past 12 months is unlikely to present a complete and accurate picture
of events and makes creating a future budget more difficult.

Variance Analysis
In the daily course of events, it is unlikely that projected budget items will be com-
pletely on target in all situations. One of the manager’s most important jobs is to man-
age the financial resources for the department and to be able to respond to variances in
a timely fashion.

When expenses occur that differ from the budgeted amounts, organizations usu-
ally have an established level at which a variance must be investigated and explained
or justified by the manager of the department. This level may be a certain dollar
amount, such as $500, or it may be a percentage, such as a 5% or 10% increase from the
budgeted amount.

In determining causes for variance, the nurse manager must review the activity
level of the unit for the same period. There may have been increases in census or
patient acuity that generated additional expense in salary and supplies.

Also, in many situations, variances might not be independent of one another.
Variances can result from expenses that follow a seasonal pattern and occur only at
determined times in the year (renewal of a maintenance agreement is one example).
Expenses can also follow a tendency or trend either to increase or to decrease during
the year. Even if the situation is outside the manager’s usual responsibility or
control, the manager needs to understand and be able to identify the cause or reason
for the variance.

To determine when a variance is favorable or unfavorable, it is important to relate
the variance to its impact on the organization in terms of revenues and expenses. If
more earnings came in than expected, the variance is favorable; if less, the variance is
negative. Likewise, if less was spent than expected, the variance is favorable; if more
was spent, the variance is negative.

236 Chapter 15

For instance, the nurse manager might receive the following expense report:

Budgeted
Expenditures

Actual
Expenditures

Variance (in $) Percent (in %)

$34,560 $36,958 (2,398) (6.9)

This expense variance is considered unfavorable because the actual expense was
greater than the budget. In this example, more money was spent on medical/surgical
supplies than was projected in the budget.

If the variance percentage of the actual budgeted amount is not presented in the
reports, it can be calculated as follows:

$2,398
$34,560

= 0.069

Divide the dollar variance by the budget amount, then multiply by 100:

0.069 × 100 = 6.9% over budget

SALARY VARIANCES With salary expenditures, variances may occur in volume,
efficiency, or rate. Typically these factors are related and have an impact on each other.
Volume variances result when there is a difference in the budgeted and actual work-
load requirements, as would occur with increases in patient days. An increase in the
actual number of patient days will increase the salary expense, resulting in an unfa-
vorable volume variance. Although the variance is unfavorable, concomitant increases
in revenues for the organization should be apparent. Thus, the impact to the organi-
zation should be welcomed, even though it generated higher salary costs at the nurs-
ing unit level.

Efficiency variance, also called quantity or use variance, reflects the difference
between budgeted and actual nursing care hours provided. Patient acuity, nursing
skill, unit management, technology, and productivity all affect the number of
patient care hours actually provided versus the original number planned or
required. At the same time, if the census had been higher than expected, it would be
understandable if more hours of nursing care were provided and paid. A favorable
efficiency, or fewer nursing care hours paid, could suggest that patient acuity was
lower than projected, that staff was more efficient, or that higher-skilled employees
were used. An unfavorable efficiency may be due to greater patient acuity than
allowed for in the budget, overstaffing of the unit, or the use of less experienced or
less efficient employees.

Rate variances, also known as price or spending variances, reflect the difference in
budgeted and actual hourly rates paid. A favorable rate variance may reflect the use of
new employees who were paid lower salaries. Unfavorable rate variance may reflect
unanticipated salary increases or increased use of personnel paid at higher wages,
such as agency personnel.

NONSALARY EXPENDITURE VARIANCES A nonsalary expenditure variance may
be due to changes in patient volume, patient mix, supply quantities, or prices paid.
New, additional, or more expensive supplies used at the nursing unit because of tech-
nology changes or new regulations could also influence expenditure totals.

Budgeting and Managing Fiscal Resources 237

Position Control
Another monitoring tool used by nurse managers is the position control. The position
control is used to compare actual numbers of employees to the number of budgeted
FTEs for the nursing unit. The position control is a working tool that is a list of
approved, budgeted FTE positions for the nursing cost center. The positions are dis-
played by category or job classification, such as nurse manager, RNs, LPNs, and so on.
The nurse manager updates the position control with employee names and FTE fac-
tors for each individual with respect to personnel changes, new hires, and resignations
that take place during the year.

The position control is often color coded for easy viewing and interpretation. For
example, the nurse manager may designate blue as the color code for medical leave.
She would highlight in blue the two nurses who are on maternity leave. This cues the
manager that while all positions are filled, two nurses will not be working shifts for
12 weeks. The manager knows to plan for a PRN or overtime shift to cover these open
positions until the nurses return to work.

Staff Impact on Budget
Staff can acutely affect the organization’s finances, making accurate patient care docu-
mentation very important. Misuse of sick time, excessive overtime or turnover, and
wasteful use of resources can result in negative variance. (See Leading at the Bedside:
Managing Resources.) The manager plays a key role in explaining the unit’s goals, the
organization’s financial goals, and how each individual is responsible for helping the
organization meet those goals.

Leading at the Bedside: Managing Resources
You have been managing resources your whole life. From
the time you received your first allowance to being paid for
lawn mowing or babysitting to managing your money in col-
lege, you know that resources are finite. Healthcare organi-
zations, too, must conserve precious resources. You have a
key role in helping your organization use its resources wisely.

Your time is your organization’s most valuable resource.
How you use it affects your patients and your colleagues.

How you use (or misuse) supplies and equipment also
affects your organization’s financial situation. In addition,
you have a responsibility to inform management about
needed equipment, supply shortages, or protocols that
waste staff time. You are the front line of budget control.
Manage it wisely.

Improving Performance
It is important for the nurse manager to raise the awareness of staff about how critical
accurate, thorough documentation is for reimbursement. For example, a nurse man-
ager may get a call from a billing coder who asks why a patient has not been dis-
charged. When reviewing the documentation, the coder notes normal vital signs and
that the patient is ambulating and has showered. After discussion with the nurse about
the patient, the nurse manager learns that the patient had been vomiting, did not eat
breakfast or lunch, and has not urinated today. This information was not documented

238 Chapter 15

in the patient’s chart by the nurse. By documenting accurate care activities, the nurse
can demonstrate the rationale for why the patient is still in need of hospital care.

Organizations can implement a number of different programs and incentives for
increasing employee awareness and minimizing costs. Techniques to decrease absen-
teeism and turnover can be instituted. Displaying equipment costs on supply stickers
or requisitions and indicating medication costs on medication sheets increase staff
awareness of costs. Participation in quality improvement and action teams serves to
inform staff of cost factors. Bonuses based on net gains can be shared with employees,
in addition to cost-of-living raises.

When one staff member wants to take time off, the shift still must be covered. Nurse
managers must hire enough staff to cover the unit when people are on vacation without
using excessive overtime. Float pool or PRN staff (staff scheduled on an as-needed basis)
are often used to cover staff time off. Managers must plan how to cover each employee’s
nonproductive time (e.g., vacation, sick days, education) in the least expensive way.

Magnet Hospital perforMance In Magnet-certified hospitals, staff are
taught about budgeting and how the unit’s money “works.” Bedside staff make excel-
lent, informed decisions about what resources should be used, and understand the
give-and-take of budget management. Bedside staff are empowered to make decisions
that impact how they work. For example, the charge nurse on the unit takes phone

Case study 15-1 | Budget Management
Jeff Tate is a nurse manager for the surgical recovery
department of a private orthopedic hospital. Jeff has
received notice from the vice president of clinical services
that next year’s budget is due to her for review at the end of
the month. Jeff has kept careful records during the previous
12 months for use in preparing the department budget.

Each month, Jeff has received and reviewed monthly
reports of revenues and expenses for his department. He
validated each month’s budget targets, carefully noting
areas that did not meet budget projections. For example,
when pharmacy charges for the month of April were 15%
above budget projections, Jeff noted that surgery volume
was up 30% over the previous year, accounting for the
increase in postoperative drug charges. Nursing salaries
were also over budget for the year, but again, increased
surgery volume had resulted in the addition of two full-
time recovery nurses to the department. When summer
vacations resulted in agency staffing in the OR, Jeff saved
copies of the approval from the vice president and the
human resources department and noted the total cost to
his department.

Jeff will use the budget information for the past
12 months to project the next fiscal year’s budget for his
department. Information from the human resources

department provides data for cost-of-living and merit
increases in salary, while materials management has pro-
jected a 10% across-the-board increase in surgical sup-
plies and pharmaceutical charges. Jeff will also request an
additional ice-and-water machine and three gurneys as
part of the capital budget. These items were requested by
staff during the last department meeting when Jeff asked
for changes and improvements in the budget. He learned
that the staff were walking to the unit down the hall for ice
and water for their patients because the machine on the
unit currently was not large enough to keep up with
the demand. He also learned that staff spent excess time
searching for additional gurneys. Both of these issues led
to staff spending time doing tasks that did not add value to
patient care.

Budget discussion is part of each staff meeting, and
Jeff provides copies of actual budget numbers to the staff
each month. He has found that showing revenue and
expense reports to staff increases compliance with over-
time expenses and supply usage; it also generates good
discussion on how to be most productive in patient care.

With monthly preparation, good record keeping, and
accurate analysis, Jeff is confident that his budget presen-
tation will be on time and on target.

Budgeting and Managing Fiscal Resources 239

What You Know Now
• A budget is a quantitative statement, usually

written in monetary terms, of plans and expecta-
tions over a specified period of time.

• The operating or annual budget is the organiza-
tion’s statement of expected revenues and expenses
for the coming year.

• The revenue budget represents the patient care
revenues expected for the budget period based
on volume and mix of patients, rates, and dis-
counts that will prevail during the same period
of time.

• Nursing units are typically considered cost cen-
ters but may be considered revenue centers, profit
centers, or investment centers.

• Nurse managers may be responsible for service
lines and staff from multiple disciplines and
departments.

• Nurse managers have input into capital expenses
and are responsible for salary and operating costs
related to new equipment.

• A full-time equivalent (FTE) is a full-time posi-
tion that can be equated to 40 hours of work per
week for 52 weeks, or 2,080 hours per year.

• The position control is a list of approved, bud-
geted FTEs that compares the budgeted number
of FTEs by classification (RN, LPN), shift, and sta-
tus to the actual available employees of the unit.

• Variance is the difference between the amount
that was budgeted for a specific revenue or cost,
and the actual revenue or cost that resulted dur-
ing the course of activities.

• Monitoring the budget throughout the year
requires attention to variances and the reasons
they occurred.

calls about unit staffing. The float pool might have an additional aide coming in to
work who is not assigned yet. The charge nurse takes the call from the staffing office to
ask if the unit needs another aide and makes the decision.

Another example includes flexing staff for needs on the unit. The charge nurse,
along with the coworkers, decides whether someone can be sent home on a slow day
or another staff member should be called in if the unit is excessively busy.

NursiNg relatioNship iN patieNt Care Nursing care is one of the largest
expenditures in healthcare organizations (Welton & Harper, 2015). Being in tune to the
patient population the nursing staff serves is as important as planning the budget for
the nurse manager. Many aspects of nursing care are not captured in the hours per
patient day (HPPD). Caring, empathy, trust, and building a relationship with patients
are all important pieces of the nursing relationship. As well, the intensity of care for
one patient on the unit may be higher than the intensity of care for another patient
with the same diagnosis (Jenkins & Welton, 2014). Understanding these complexities
of nursing care can help a manager perform better.

Managing fiscal resources is a challenge for all nurse managers. This is even truer
today as healthcare payment reform continues to evolve. Close attention to costs, bal-
anced by awareness of quality and patient safety, is essential.

Case Study 15-1 illustrates how one nurse manager handled his budget.

240 Chapter 15

Tools for Budgeting and Managing Resources
1. Understand the budgeting process in your orga-

nization.
2. Determine the number of full-time equivalents

necessary to staff the unit.
3. Compute the salary and nonsalary budget, includ-

ing salary increases and various additional factors.
4. Monitor variances over the budget period and

identify negative variances, keeping notes in
your files.

5. Understand that factors out of your control, such
as changes in technology or indirect or direct
costs that may be assigned to your budget, affect
your budget and its performance.

6. Encourage staff to monitor resource use, includ-
ing time and supplies.

Questions to Challenge You
1. Do you have a budget for your personal and pro-

fessional income and expenses? If so, how well
do you manage it? If not, begin next month to
track your income and expenses for one month.
See if you are surprised at the results.

2. How well does your organization manage its
resources? Can you make suggestions for impro-
vement?

3. Are there tasks or functions in your work that you
believe are redundant, unnecessary, or repetitive
or that could be done by a lesser-paid employee?
Explain.

4. Does your organization waste salary or nonsalary
resources? If not, think of ways that organizations
could waste resources. Describe them.

References
Dunham-Taylor, J., & Pinczuk, J. Z. (2015). Financial

management for nurse managers: Merging the heart
with the dollar (3rd ed.). Burlington, MA: Jones &
Bartlett.

Finkler, S. A., Jones, C., & Kovner, C. T. (2012).
Financial management for nurse managers and
executives (4th ed.). St. Louis, MO: Saunders.

Jenkins, P., & Welton, J. (2014). Measuring direct
nursing cost per patient in acute care settings.
Journal of Nursing Administration, 44(5), 257–262.

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Retrieved January 14, 2016, from http://www.
medicare.gov/hospitalcompare/linking-quality-
to-payment.html

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value-based financial models. Nursing Economics,
33(1), 14–25.

http://www.medicare.gov/hospitalcompare/linking-qualityto-payment.html

http://www.medicare.gov/hospitalcompare/linking-qualityto-payment.html

Chapter 16

Recruiting and
Selecting Staff

Learning Outcomes

After completing this chapter, you will be able to:

1. Identify the important elements of the recruitment and selection
process.

2. Describe how to recruit applicants.

3. Delineate how to select candidates.

4. Explain how to interview prospective candidates.

5. Determine how to make a hiring decision.

6. Examine the legal issues involved in hiring.

The Recruitment and Selection
Process

Recruiting Applicants
Where to Look

How to Look

When to Look

How to Promote the Organization

Cross-training as a Recruitment Strategy

Selecting Candidates

Interviewing Candidates
Principles for Effective Interviewing

Involving Staff in the Interview Process

Interview Reliability and Validity

Making a Hire Decision
Education, Experience, and Licensure

Integrating the Information

Making an Offer

Legality in Hiring

241

242 Chapter 16

Key Terms
Age Discrimination Act

Americans with Disabilities Act

behavioral interviewing

bona fide occupational qualification
(BFOQ)

business necessity

four Ps of marketing

interrater reliability

interview guide

intrarater reliability

negligent hiring

position description

validity

work sample questions

Introduction
Recruiting and selecting staff who will contribute positively to the organization is cru-
cial in the fast-paced world of healthcare and in the face of ever-increasing nursing
shortages (U.S. Department of Labor, 2015). The direct costs of recruiting, selecting,
and training an employee who must later be terminated because of unsatisfactory per-
formance are expensive and unnecessary. The hidden costs may be even more expen-
sive and include poor quality of work, disruption of morale, and patients’ ill will and
dissatisfaction, which may contribute to later liability.

The Recruitment and
Selection Process
The purpose of the recruitment and selection process is to match people to jobs.
Responsibility for selecting nursing personnel in healthcare organizations is usually
shared by the human resources (HR) department, which may include a nurse recruiter,
and nursing management. First-line nursing managers are the most knowledgeable
about job requirements and can best describe the job to applicants. HR performs the
initial screening and monitors hiring practices to be sure they adhere to legal
stipulations.

Before recruiting or selecting new staff, those responsible for hiring must be
familiar with the position description. The position description describes the
skills, abilities, and knowledge required to perform the job. (See Box 16-1 for
an example.)

The position description should reflect current practice guidelines and include the
following:

• Principal duties and responsibilities involved in a particular job

• Tasks required to carry out those duties

• Personal qualifications (skills, abilities, knowledge, and traits) needed for the
position

• Competency-based behaviors (perhaps).

Recruiting and Selecting Staff 243

Recruiting Applicants
The purpose of recruitment is to locate and attract enough qualified applicants to pro-
vide a pool from which the required number of individuals can be selected. Even
though recruiting is primarily carried out by HR staff and nurse recruiters, nurse man-
agers and nursing staff play an important role in the process. Recruiting is easier when
current employees spread the recruiting message, reducing the need for expensive
advertising and reward methods.

The best recruitment strategy is the organization’s reputation among its nurses.
Aiken and colleagues (Kutney Lee et al., 2015) found that a positive hospital care envi-
ronment not only reduced patient mortality but also improved nurses’ perception of
the work setting. Kelly, McHugh, and Aiken (2011) found that nurses in Magnet hospi-
tals demonstrated higher levels of job satisfaction than those in non-Magnet hospitals.
It follows that satisfied nurses are more likely to speak highly of the organization.

Individual nurse managers also affect how well the unit is able to attract and
retain staff. A nurse manager who is able to create a positive work environment
through leadership style and clinical expertise will have a positive impact on recruit-
ment efforts, because potential staff members will hear about and be attracted to that
area (e.g., hospital unit, home health team), as described in Leading at the Bedside:
Recruiting Is Your Job, Too. In contrast, an autocratic manager is more likely to have a
higher turnover rate and less likely to attract sufficient numbers of high-quality nurses.

Box 16-1 Position Description: Registered Nurse Adult
Medical Intensive Care Unit (MICU)

Job Overview
The medical intensive care unit registered nurse is respon-
sible for direct patient care of adults admitted to the MICU
for management of complex life-threatening illness. The RN
reports directly to the MICU nurse manager.

Qualifications
• Current licensure in good standing in the state of

practice
• Minimum of 1 year previous adult ICU experience

within the past 3 years or 2 years telemetry experience
within the past 3 years

• Current BLS mandatory, ACLS or TNCC preferred.
ACLS must be obtained with 6 months of employment.

Responsibilities
• Performs complete, individualized patient assessment

within unit time frames and determines patient care
priorities based on assessment findings

• Completes additional patient assessments as
required, based on patient status, protocols, and/or
physician orders

• Administers medications and appropriate treatments
as ordered by the physician accurately and within
specified time frames

• Initiates and maintains an individualized patient plan of
care for each patient, using nursing interventions as
appropriate

• Provides ongoing education to the patient and the
patient’s family

• Documents patient assessments, medication and ther-
apy administration, patient response to treatments,
and interventions in an accurate and timely manner

• Initiates emergency resuscitation procedures accord-
ing to ACLS protocols

• Maintains strict confidentiality of all information related
to the patient and the patient’s family

• Provides nursing care in a manner that is respectful
and sensitive to the needs of the patient and the
patient’s family and protects their dignity and rights

• Communicates changes in patient condition to appro-
priate staff during the shift

• Maintains (or obtains within 6 months of initial hire)
certification in ACLS

• Completes unit-based training modules for critical
care competency on an annual basis

244 Chapter 16

Any recruiting strategy includes essentially four elements:

1. Where to look

2. How to look

3. When to look

4. How to sell the organization to potential recruits

Each of these elements may be affected by market competition, nursing shortages,
reputation, visibility, and location.

Where to Look
Today many organizations use social media for recruitment. Using the organization’s
social media platforms (e.g., Facebook, Twitter), a recruitment plan may be designed
to reach qualified nurses (Holland, 2015). If one platform or strategy has been success-
ful in the past, it indicates a likely source of applicants.

Because proximity to home is a key factor in choosing a job, recruitment efforts
should focus on nurses living nearby (Mooneyham et al., 2011). The state board of
nursing can provide the names of registered nurses by zip code to allow organizations
to target recruitment efforts to surrounding areas. Also, personnel officers in large
companies or other organizations in the area can be asked to assist in recruiting nurse
spouses of newly hired employees.

Collaborative arrangements with local schools of nursing offer opportunities for
recruitment. Providing preceptors or mentors for students during their clinical rota-
tion or offering externships or residencies encourages post-graduation students to
consider employment in the organization. Nurses who work with students play a key
role in recruitment. Students are more likely to be attracted to the organization if they
see nurses’ work valued and appreciated and perceive a positive impression of the
work group.

Employing students as aides may provide another recruitment tool because it
allows students to learn firsthand about the organization and what it has to offer. In
turn, the organization can evaluate the student as a potential employee post-
graduation. Some organizations provide assistance with student loan payments if
the student continues to work after graduation. Of major importance to new gradu-
ates is the orientation program. Graduates look for an orientation that provides
successful transition into professional practice. Other top factors they consider are
the reputation of the agency, benefits, promotional opportunities, specialty area,
and nurse–patient ratio.

Leading at the Bedside: Recruiting Is Your Job, Too
You may think you have little to do with recruitment. You’re
not a manager; nor are you involved in hiring. But you
would be wrong. You are a walking, talking, caring repre-
sentative of the healthcare organization for which you work.
Think about it. You tell your friends and neighbors where

you work. They know someone who’s looking for a nursing
position; they think of you. What do they see? A competent
professional? A nurse who knows the profession is a
career, not just a job?

Don’t fool yourself. You are a recruiter.

Recruiting and Selecting Staff 245

How to Look
Posting online on general job search sites or on nurse-specific job referral sites is a
common practice. Professional associations such as Sigma Theta Tau International and
the American Nurses Association offer job search services. Specialty organizations
such as the American Organization of periOperative Registered Nurses could be used
for a surgical nurse position.

Employee referrals, advertising in professional journals, attendance at profes-
sional conventions, job fairs, career days, visits to educational institutions, employ-
ment agencies (both private and public), and temporary help agencies are all recruiting
sources. Advertising in professional journals, in newspapers, or on websites or public
access TV can be an effective recruiting tool as well.

During extreme nursing shortages, some organizations offer bonuses to staff
members who refer candidates and to the recruits themselves. Direct applications and
employee referrals are quick and relatively inexpensive ways of recruiting people, but
these methods also tend to perpetuate the current cultural or social mix of the work-
force. It is both legally and ethically necessary to recruit individuals without regard to
their race, ethnicity, gender, or disability. In addition, organizations can benefit from
the diversity of a staff composed of people from a wide variety of social, experiential,
cultural, generational, and educational backgrounds.

On the other hand, nurses referred by current employees are likely to have
more realistic information about the job and the organization and, therefore, their
expectations more closely fit reality. Those who come to the job with unrealistic
expectations may experience dissatisfaction. In an open labor market, these indi-
viduals may leave the organization, creating high turnover. When nursing jobs are
less plentiful or the economy is in a recession, dissatisfied staff members tend to
stay in the organization because they need the job, but they are not likely to perform
as well as other employees.

When to Look
The time lag in recruiting is a concern to nursing because of the shortage. Positions in
certain locations (e.g., rural areas) or specialty areas (e.g., critical care) may be espe-
cially difficult to fill. Careful planning is necessary to ensure that recruitment begins
well in advance of anticipated needs.

How to Promote the Organization
A critical component of any recruiting effort is marketing the organization and avail-
able positions to potential employees. The nursing division and/or HR should develop
a comprehensive marketing plan. Generally, four strategies are included in marketing
plans and are called the four Ps of marketing:

• Product

• Place

• Price

• Promotion

The consumer is the key figure toward which the four concepts are oriented, and
in the recruiting process, the consumer is the potential employee.

246 Chapter 16

Product is the available position(s) within the organization. Consider several
aspects of the position and organization, such as these:

• Professionalism

• Standards of care

• Quality

• Service

• Respect

• Reputation

• Organizational culture

Place refers to the physical qualities and location, such as these:

• Accessibility

• Scheduling

• Parking

Price includes the following:

• Pay and differentials

• Benefits

• Sign-on bonuses

• Insurance

• Retirement plans

Promotion includes the following:

• Advertising

• Public relations

• Direct word of mouth

• Personal selling (e.g., job fairs, professional meetings)

Developing an effective marketing message is important. Sometimes the tendency
is to use a “scatter-gun” approach (recruit everywhere), sugarcoat the message, or
make it very slick. A more balanced message, which includes honest communication
and personal contact, is preferable. Overselling the organization creates unrealistic
expectations that may lead to later dissatisfaction and turnover.

Realistically presenting the job requirements and rewards improves job satisfaction,
in that the new recruit learns what the job is actually like. Promising a nurse every other
weekend off and only a 25% rotation to nights on a severely understaffed unit, then sched-
uling the nurse off only every third weekend with 75% night rotations is an example of
unrealistic job information. It is important to represent the situation honestly and describe
the steps that management is taking to improve situations that the applicant might find
undesirable. The applicant can then make an informed decision about the job offer.

Cross-training as a Recruitment Strategy
In today’s rapidly changing healthcare environment, the patient census fluctuates rap-
idly, and staffing requirements must be adjusted appropriately. These conditions may
bring about layoffs and daily cancellations and contribute to low morale. Offering

Recruiting and Selecting Staff 247

cross-training so potential employees can be oriented to more than one unit may
increase the applicant pool.

Cross-training can provide a number of benefits: increased morale and job satis-
faction, improved efficiency, increased flexibility of the staff, and a means to manage
fluctuations in the census. It gives nurses, such as those in obstetrics and neonatal
areas, an opportunity to provide more holistic care. On the other hand, some nurses do
not want to be cross-trained, and thus requiring cross-training could reduce retention.

If cross-training is used, care should be taken to provide a didactic knowledge base in
addition to clinical training. How broadly to cross-train is an important decision, because
training in too many areas may overload the nurse and reduce the quality of care.

Selecting Candidates
Once an applicant makes contact with the organization, HR reviews the application
and may conduct a preliminary interview (see Box 16-2). If the applicant does not meet
the basic needs of the open position or positions, he or she should be so informed.
Rejected applicants may be qualified for other positions or may refer friends to the
organization and thus should be treated with utmost courtesy.

Reference checks and managerial interviews are next. In most cases, the interview is
last, but practices may vary. Even if an applicant receives poor references, it is prudent to
carry out the interview so the applicant is not aware that the reference checking led to
the negative decision. In addition, applicants may feel they have a right to “tell their
story” and may spontaneously provide information that explains poor references.

The nurse manager should participate in the interview process for two reasons:

• He or she is best able to assess applicants’ technical competence, potential, and
overall suitability

• He or she is able to answer applicants’ technical, work-related questions more
realistically.

In some organizations, the candidate’s future coworkers also participate in the
interview process to assess compatibility.

The nurse manager must keep others involved in the selection process informed.
The manager is usually the first to be aware of potential resignations, requests for trans-
fer, and maternity or family medical leaves that require replacement staff. The manager
is also aware of changes in the work area that might necessitate a redistribution of staff,
such as the need for a night rather than a day nurse. Communicating these needs to HR
promptly and accurately helps ensure effective coordination of the selection process.

Box 16-2 Selection Process
1. Review application (nurse manager and HR).
2. Conduct screening interview (HR).
3. Contact references (HR).
4. Conduct second interview (nurse manager).
5. Compare applicants (nurse manager/nursing

department).

6. Make hire/no hire decision (nurse manager/nursing
department).

7. Perform background check (HR).
8. Make phone offer, conditional on clean drug test within

24 hours (nurse manager).
9. With clean drug test, offer is official.

248 Chapter 16

Interviewing Candidates
The most common selection method, the interview, is an information-seeking mecha-
nism between an individual applying for a position and a member of an organization
doing the hiring. After the applicant’s initial screening with HR, the nurse manager
usually conducts an interview.

The interview is used to clarify information gathered from the application form,
evaluate the applicant’s responses to questions, and determine the fit of the applicant
to the position, unit, and organization. In addition, the interviewer should provide
information about the job and the organization. Finally, the interview should create
goodwill toward the employing organization through good customer relations.

An effective interviewer must learn to solicit information efficiently and to gather
relevant data. Interviews typically last between 60 and 90 minutes and include an
opening, an information-gathering and information-giving phase, and a closing. The
opening is important because it is an attempt to establish rapport with the applicant so
she or he will provide relevant information.

Gathering information, however, is the core of the interview. Giving information
is also important because it allows the interviewer to create realistic expectations in the
applicant and sell the organization, if that is needed. However, this portion of the
interview should take place after the information has been gathered so that the appli-
cant’s answers will be as candid as possible. The interviewer should answer any direct
questions the candidate poses. Finally, the closing is intended to provide information
to the candidate on the mechanics of possible employment.

Principles for Effective Interviewing
Interviewing is the opportunity for candidates to learn about the organization and for
managers to get to know the candidate. It is an especially important time to determine
if the candidate would fit within the organization.

DEVELOPING STRUCTURED INTERVIEW GUIDES Unstructured interviews
present problems: if interviewers fail to ask the same questions of every candidate, it
is often difficult to compare them. The interview is most effective when the informa-
tion on the pool of interviewees is as comparable as possible. Comparability is maxi-
mized via a structured interview supported by an interview guide. An interview
guide is a written document containing questions, interviewer directions, and other
pertinent information so that the same process is followed and the same basic infor-
mation is gathered from each applicant. The guide should be specific to the job, or
job category.

Instead of the traditional interview questions, such as “Tell me about yourself,”
“What are your strengths and weaknesses?” and “Why do you want to work for us?”
specific questions that target job-related behaviors are more common today. Behav-
ioral interviewing, also called competency-based interviewing, uses the candidate’s
past performance and behaviors to predict behavior on the job. The questions are
based on requirements of the position. Examples of specific behaviors expected of staff
nurses and related sample questions are found in Table 16-1.

In addition, you can develop questions based on the specific job. For example, you
may want to add questions on teamwork and collaboration as they relate to the posi-
tion. Box 16-3 lists job-related questions for a medical telemetry unit position that can-
didates could be asked.

Recruiting and Selecting Staff 249

Table 16-1 Examples of Behavioral Interview Questions

Behavior Sample Question

Decision making What was your most difficult decision in the last month, and why was it
difficult?

Communication What do you think is the most important skill in successful communication?

Adaptability Describe a major change that affected you and how you handled it.

Delegation How do you make the decision to delegate? Describe a specific situation.

Initiative What have you done in school or in a job that went beyond what was
required?

Motivation What is your most significant professional accomplishment?

Negotiation Give an example of a negotiation situation and your role in it.

Planning and organization How do you schedule your time? What do you do when unexpected
circumstances interfere with your schedule?

Critical thinking
Describe a situation in which you had to make a decision by analyzing
information, considering a range of alternatives, and selecting the best
choice for the circumstances.

Conflict resolution Describe a situation in which you had to help settle a conflict.

Box 16-3 Job-related Questions
for Medical Telemetry Unit

Describe your actions in the following situations.

1. You are documenting your patient’s heart rhythms in his
medical record for the shift. A peer is sitting near you
and doing the same. You see that RN document the
patient’s heart rhythm as sinus rhythm, when you know
the patient has had atrial fibrillation the entire shift.

2. The physician is rounding on your patient. The patient
has had an elevated blood pressure of 160/90 despite
already having received all of her antihypertensive
medications for the day. The patient has reported to
you that she is also experiencing a headache. You tell
the doctor about the blood pressure reading and the
patient’s headache. You request that the physician
order another medication to help lower the patient’s
blood pressure. The physician says to you, “Oh, she’ll
be fine,” and begins to walk away.

3. You are caring for an elderly woman. Her daughter is
at her bedside. The patient has been having recurrent
flare-ups of congestive heart failure and has been
readmitted to the hospital three times in the last
month. Each time she returns, the swelling in her
extremities and her difficulty breathing are worse than
the time before. The physician rounds on the patient
and her daughter and shares that the healthcare team
will work to help her, but it appears that her heart is

getting weaker again, and the congestive heart failure
is going to continue to get harder to manage. After the
doctor leaves, you enter the room. The patient is
sleeping, and the daughter is quietly crying.

4. You run to the room of a patient where the code blue
alarm has been activated. Your team is doing CPR and
attaching the code cart to the patient. You put on
gloves and step in to help. As you approach the bed of
the patient, you look at the patient’s wrist and see a
do-not-resuscitate bracelet on his arm.

5. You are caring for a patient with paranoid schizophre-
nia and a heart dysrhythmia. It is time to administer his
9:00 a.m. meds. When you enter the room with the
medications that the patient takes to prevent ventricu-
lar tachycardia, he begins screaming, “No, I won’t
take those medications, you’re trying to poison me!”

6. You are caring for a patient who is recovering from a
myocardial infarction. You have been talking to her
about her new cardiac diet and what she can do to be
healthy when she leaves the hospital. You discuss eat-
ing low amounts of salt, a well-rounded diet rich in
fruits and vegetables, and avoiding fried and sugary
foods. Later in the day, you pass the patient’s room
and see her eating fried chicken and French fries that
her family brought.

250 Chapter 16

Interview guides reduce interviewer bias, provide relevant and effective ques-
tions, minimize leading questions, and facilitate comparison among applicants. Space
left between the questions on the guide provides room for note taking, and the guide
also provides a written record of the interview. An example of an interview script is
shown in Box 16-4.

PreParing for the interview Most managers do not adequately prepare
for the interview, which should be planned just like any business undertaking. All
needed materials should be on hand, and the interview site should be quiet and
pleasant. If others are scheduled to see the applicant, their schedules should be
checked to make sure they are available at the proper time. If coffee or other
refreshments are to be offered, advance arrangements need to be made. Lack of
advance preparation may lead to insufficient interviewing time, interruptions, or
failure to gather important information. Other problems include losing focus in
the interview because of a desire to be courteous or because the interviewee is
particularly dominant. This typically keeps the interviewer from obtaining the
needed information.

In general, when time is limited, it is better to use part of it for planning rather
than spend it all on the interview itself. Before the interview, the interviewer
should review job requirements, the application and résumé, and note specific
questions to be asked. Planning should be done on the morning of the interview
or the evening before for an early morning interview. If you are sure that time will
be available, planning is best done immediately before an interview or between
interviews. Unfortunately, a busy manager may have to deal with unexpected
crises between interviews and may not be able to use the time to plan the next
interview.

A cardinal rule is to review the application or résumé before beginning the
interview.

Box 16-4 Interview Script for Hiring
1. Why did you choose to become a nurse?
2. Why would you like to work at this hospital?
3. What about this patient specialty interests you?
4. Tell me about your previous work experiences.
5. How do your previous work experiences prepare you

for this job?
6. How would your previous coworkers describe you?
7. What does teamwork mean to you?
8. Tell me about a time when you were successful

because of great teamwork.
9. Tell me about a time you experienced a lack of team-

work. Describe what happened.
10. Describe a situation in which you had a conflict with a

patient or family member. What happened?
11. Tell me about a time you had a conflict with a coworker

or teacher. Explain what happened.

12. Tell me about a time you were working with someone
who was not putting his or her full effort forward, and it
was impacting patient care. What did you do?

13. What makes you most nervous about coming to
this job?

14. What do you find exciting about coming to this job?
15. What are you most proud of professionally?
16. What is something about you that makes you better

than any other candidate for this job?
17. What are you looking for from your manager?
18. What do you plan to do in the next five and ten years

of nursing and beyond? What are your goals?
19. What questions do you have about this job?

Recruiting and Selecting Staff 251

If the interviewee arrives with the résumé or application in hand, ask him or her to
wait for a few minutes while you review the material. In doing a quick review, look for
the following four things:

• Clear discrepancies between the applicant’s qualifications and the job specifica-
tions. If you find them, then only a brief interview may be necessary to explain
why the applicant will not be considered. (If a preliminary screening is performed
by HR, such applicants should not be referred to nurse managers.)

• Specific questions to ask the applicant during the interview.

• A rapport builder (something you have in common with the applicant) to break
the ice at the beginning of the interview.

• Areas where you need more information. Remember that the résumé is prepared
by the applicant and is intended to market an applicant’s assets to the organiza-
tion. It does not give a balanced view of strengths and weaknesses. So, examine
the résumé critically for gaps.

The setting of the interview is important in order to provide a relaxed, informal
atmosphere. Both you and the applicant should be in comfortable chairs, as close
together as comfortably possible. No table or desk should separate you. If you are using
an office, arrange the chairs so that the applicant is at the side of the desk. There should
be complete freedom from distracting phone calls and other interruptions. If the view is
distracting, seat the applicant so that she or he cannot look out a window.

Opening the interview Begin the interview on time. Give a warm, friendly
greeting, introduce yourself, and ask the applicant for her or his preferred name. Try to
minimize your status; do not patronize or dominate. The objective is to establish an
open atmosphere so applicants reveal as much as possible about themselves. Establish
and maintain rapport throughout the interview by talking about yourself, discussing
mutual interests such as hobbies or similar experiences, and using nonverbal cues,
such as maintaining eye contact. Finally, start the interview by outlining what will be
discussed and setting a limit on the meeting time.

Be careful not to form hasty first impressions. Interviewers tend to be influenced
by first impressions of a candidate, and such judgments often lead to poor decisions.
First impressions may degrade the quality of the interview; interviewers may search
for information to justify their first impressions, good or bad. If you have gotten a
negative first impression and thus decide not to hire a potentially successful candi-
date, you have wasted an hour or so and possibly lost a good recruit. If you hire an
unsuccessful candidate based on a positive first impression, problems may continue
for months. Conversely, your personal characteristics may influence the applicant’s
decisions. You create first impressions with your tone of voice, eye contact, personal
appearance, grooming, posture, and gestures.

Take notes, using the structured interview guide. Explain that you are doing this
in order to remember more about what is discussed in the interview, and tell the can-
didate that you hope he or she does not mind. There are various ways to ask ques-
tions, but ask only one at a time. When possible, ask open-ended questions, such as
those listed in Table 16-1. Open-ended questions cannot be answered with a yes, no,
or one-word answer and usually elicit more information about the applicant. Closed
questions (e.g., what, where, why, when, how many) should only be used to elicit
specific information.

252 Chapter 16

Work sample questions are used to determine an applicant’s knowledge about
work tasks and his or her ability to perform the job. It is easy to ask a nurse whether
she or he knows how to care for a patient who has a central intravenous line in place.
A yes answer does not necessarily prove the candidate’s ability, so you might ask some
very specific questions about central lines. Avoid leading questions, in which the
answer is implied by the question (e.g., “We have lots of overtime. Do you mind over-
time?”). You may also want to summarize what has been said, use silence to elicit more
information, repeat the applicant’s statements to clarify an issue, or indicate accep-
tance by urging the applicant to continue.

GIVING INFORMATION Before reaching the information-giving part of the inter-
view, consider whether the candidate is promising enough to warrant spending a lot
of time on this. Unless the candidate is clearly unacceptable, be careful not to commu-
nicate a negative impression, because your evaluation of the candidate may change
when the entire packet of material is reviewed or if more promising candidates decline
the job offer. You must also know what information you should give, and what is being
provided by others. Detailed benefit or compensation questions are usually answered
by HR. If you cannot answer a promising candidate’s questions, arrange for someone
to contact the candidate later with that information.

CLOSING THE INTERVIEW You may want to summarize the applicant’s strengths
at the end of the interview. Make sure to ask the applicant whether she or he has
anything to add or ask about the job and the organization. You may also want to
mention the candidate’s weaknesses, particularly if they are objective and clearly
related to the job (such as lack of experience in a particular field). Mentioning a per-
ception of a subjective weakness, such as poor supervisory skills, may lead to legal
problems. Wrap up by thanking the applicant and completing any notes that you
have been taking.

Involving Staff in the Interview Process
Today’s trend toward decentralization of decision making may lead to sharing inter-
view responsibilities with staff. Involving staff in interviews helps strengthen team-
work, improves work-group effectiveness, increases staff involvement in other unit
activities, and increases the likelihood of selecting the best candidate for the position.

If staff are involved in interviews, several steps must be taken to protect the integ-
rity of the interview process. An organized orientation to interviewing should be given
that includes the following:

• Federal, state, and local laws and regulations governing interviewing, as well as
any collective-bargaining agreements that may affect the process

• Tips on handling awkward interviewing situations

• Time for rehearsing interviewing skills; like the manager, staff should follow a
structured interview guide to help standardize the process

Graham Nelson is nurse manager of a dialysis center. Training a new renal dialysis
nurse is an expensive process. To reduce turnover among nursing staff, Graham includes
peer interviews as part of the overall interview process. Peer interviews can help ensure
that potential employees will interact well with existing staff and ensure a cultural fit
with the dialysis team. In addition, an interviewee can gain a better understanding of the
day-to-day workflow of the center.

Recruiting and Selecting Staff 253

Interview Reliability and Validity
Numerous research studies have been performed on the reliability and validity of
employment interviews. In general, agreement between two interviews of the same
measure by the same interviewer (intrarater reliability) is fairly high, agreement
between two interviews of the same measure by several interviewers (interrater reli-
ability) is rather low, and the ability to predict job performance (validity) of the typical
interview is very low. Research has also shown the following:

• Structured interviews are more reliable and valid.

• Interviewers who are under pressure to hire in a short time or meet a recruitment
quota are less accurate than other interviewers.

• Interviewers who have detailed information about the job for which they are
interviewing exhibit higher interrater reliability and validity.

• The interviewer’s experience does not seem to be related to reliability and validity.

• There is a decided tendency for interviewers to make quick decisions and there-
fore be less accurate.

• Interviewers develop stereotypes of ideal applicants against which interviewees
are evaluated. Individual interviewers may hold different stereotypes, which
decreases interrater reliability and validity.

• Race and gender may influence interviewers’ evaluations.

The greatest weakness in the selection interview may be the tendency for the
interviewer to try to assess an applicant’s personality characteristics. Although it is
difficult to eliminate such subjectivity, evaluations of applicants are often more subjec-
tive than they need to be. Information collected during an interview should answer
three fundamental questions:

• Can the applicant perform the job?

• Will the applicant perform the job?

• Will the candidate fit into the culture of the unit and the organization?

The best predictor of the applicant’s future behavior in these respects is past per-
formance. Previous work and other experience, past education and training, and cur-
rent job performance should be considered rather than personality characteristics,
which even psychologists cannot measure very accurately.

Making a Hire Decision
A number of criteria are involved in making the hiring decision. These include the
candidate’s education and experience and validating that the person is licensed. Refer-
ences, on the other hand, are not as useful as most people think.

Education, Experience, and Licensure
Education and experience requirements for nurses have long been important screen-
ing factors and bear a close relationship to work sample tests. Educational require-
ments are a type of job knowledge sample because they tend to ensure that applicants
have at least a minimal amount of knowledge necessary for the job.

254 Chapter 16

Educational preparation is particularly important for nurses. For example, nurses
who are graduates of associate degree and diploma programs are prepared to care for
individuals in structured settings and use the nursing process, the decision-making
process, and their management skills in the care of those individuals. Baccalaureate
graduates can provide nursing care for individuals, families, groups, and communities
using the nursing and decision-making processes. Baccalaureate graduates are also
prepared for beginning community health positions and possess the leadership and
management skills needed for entry-level management positions.

Avoid making assumptions about the type of experience and number of years of
experience that an applicant has. Factors such as job requirements, patient acuity, clinic
populations, autonomy, and degree of specialization vary from organization to organi-
zation. Therefore, careful interviewing is needed to determine the applicant’s knowl-
edge and skill level.

References and letters of recommendation are also used to assess the applicant’s
past job experience, but there is little evidence that these have any validity. Because
few people write unfavorable letters of recommendation, such letters do not really
predict job performance. Criticisms are likely to be mild and may be reflected by the
lack of positive language. Letters with any criticism should be verified with a tele-
phone call, if possible, to avoid overreacting to an unusually honest author.

To avoid legal problems, many organizations only include employment dates, sal-
ary, and whether the applicant is eligible for rehire in letters of recommendation. Many
organizations do not allow supervisors to write letters of recommendation. Negative
references may be viewed as a potential for slander or other legal recourse. Almost
every organization will at least verify position title and dates of employment, which
helps detect the occasional applicant who falsifies an entire work history. Unfortu-
nately, leaving out a position from a work history is more common than including a
position not actually held. The only way to detect such omissions is to ask that candi-
dates list the year and month of all their educational and work experiences. Caution is
necessary when asking about time between jobs; be careful not to inquire about mari-
tal or family status.

In almost every selection situation, an applicant fills out an application form that
requests information about previous experience, education, and references. As appli-
cation forms are reviewed, the critical question to be asked is whether the applicant
has distorted responses, either intentionally or unintentionally. Studies indicate that
there is usually little distortion, at least not on the easily verifiable information. Appli-
cants may stretch the truth a bit, but rarely are there complete falsehoods. Relative to
other predictors, the application form may be one of the more valid predictors in a
selection process.

Licensure status can be verified online with the state board of nursing. Because
results of the computerized NCLEX-RN examination are available within 7 to 10 days,
most organizations wait for new graduates to obtain a license before starting
employment.

Integrating the Information
When comparing candidates, first weigh the qualities required for the job in order of
importance, placing more emphasis on the most important elements. Second, weigh
the qualities desired on the basis of the reliability of the data. The more consistent the
observation of behavior from different elements in the selection system, the more

Recruiting and Selecting Staff 255

weight that dimension should be given. Third, weigh job dimensions by trainability—
consider the amount of education, experience, and additional training the applicant
can reasonably be expected to receive, and consider the likelihood that the behavior in
that dimension can be improved with training. Dimensions most likely to be learned
in training (e.g., using new equipment) should be given the least weight so that
more weight is placed on dimensions less likely to be learned in training (e.g., being
emotionally able to care for terminally ill children).

Attempt to compare data across individuals in making a decision. It is more accu-
rate to make decisions based on a comparison of several persons than to make a decision
for each individual after each interview. Analysis of the entire applicant pool requires
good interview records but lessens the impact of early impressions on the hiring deci-
sion because the interviewer must consider each job element across the entire pool.

Making an Offer
Before an offer is made, most organizations obtain permission to do criminal back-
ground checks. After the interview, if the nurse manager wants to offer a position to a
candidate, HR is notified. HR then does a thorough background check on the candidate
to confirm reported criminal history, licensure, and employment history. After that
clears, the candidate is called and offered the position, with the condition that a drug
screen completed within 24 hours of the phone offer is clean. If so, the offer is official.

Organizations are liable for the character and actions of the employees they hire.
To satisfy this requirement, the employer must check applicants’ backgrounds before
hiring in regard to licensure, credentials, and references. Failure to do so constitutes
negligent hiring if that employee harms a patient, visitor, or another employee.

Legality in Hiring
As a result of Title VII of the Civil Rights Act of 1964 as amended in 1991, the Equal
Pay Act of 1963, the Age Discrimination in Employment Act of 1967, and Title I of the
Americans with Disabilities Act of 1990 and its amendments of 2009, recruitment and
selection activities are subject to considerable scrutiny regarding discrimination and
equal employment opportunity. Title VII of the Civil Rights Act specifically prohibits
discrimination in any personnel decision on the basis of race, color, sex, religion, or
national origin. “Any personnel decision” includes not only selection but also entrance
into training programs, performance appraisal results, termination, promotions, com-
pensation, benefits, and other terms, conditions, and privileges of employment.

The Act applies to most employers with more than 15 employees, although there
are several exemptions—among them, a bona fide occupational qualification (BFOQ),
a business necessity, and the validity of the procedure used to make the personnel
decision. These exemptions allow discrimination on the basis of national origin (citi-
zenship or immigration status), religion, sex, and age if that discrimination can be
shown to be a “bona fide occupational qualification reasonably necessary for the nor-
mal operation of a business.” Examples include a woman playing a female part in a
play, a Sunday school teacher of a certain religion, or a female correctional counselor at
a women’s prison. Claims of “customer preference” for female flight attendants or
gross gender characteristics such as “women cannot lift over 30 pounds” have not been
supported as BFOQs.

256 Chapter 16

A BFOQ allows an organization to exclude members of certain groups (such as all
men or all women) if the organization can demonstrate that a selection method is a
business necessity. A business necessity is likely to withstand a legal challenge only in
the unusual instances when a selection method that discriminates against a protected
group is necessary to ensure the safety of workers or customers.

The Equal Employment Opportunity Commission (EEOC) is charged with enforc-
ing and interpreting the Civil Rights Act and has issued Uniform Guidelines on
Employee Selection Procedures (43 Fed. Reg., 1978). The guidelines specify the kinds
of methods and information required to justify the job relatedness of selection proce-
dures. These guidelines are not described in detail here; however, the methods of
selection discussed in this chapter do follow their specifications. Remember that the
law does not say one cannot hire the best person for the job. What it says is that race,
color, sex, religion, disability, national origin, or any other protected factor must not be
used as selection criteria. As long as the decision is not made on the basis of protected
status, one is complying with the Equal Employment Opportunity (EEO) law.

EEO law and successive court decisions have had three major impacts on selection
procedures. First, organizations are more careful to use predictors and techniques that
can be shown not to discriminate against protected classes. Second, organizations are
reducing the use of tests, which may be difficult to defend if they screen out a large num-
ber of minority applicants. Third, organizations are relying heavily on the interview pro-
cess as a selection device. Interviews are also subject to EEO and other regulations.

Table 16-2 presents appropriate questions to ask in an interview. The basic rule of
thumb for interviewing is when you are in doubt about a question’s legality, ask “How
is this question related to job performance?” If it can be proved that only job-related
questions are asked, EEO law will not be violated.

The Age Discrimination Act prohibits discrimination against applicants and
employees over the age of 40. Questions in recruitment and selection that are appro-
priate with respect to age are also presented in Table 16-2.

The Americans with Disabilities Act that took effect in July 1990 prohibits dis-
crimination based on an individual’s disability. A disability is defined as a physical or
mental impairment that substantially limits one or more of the major life activities, or
has a record of such impairment (e.g., attended a school for the deaf), or is regarded as
having such an impairment (e.g., uses a cane to walk). A qualified individual is one
who, with or without reasonable accommodation, can perform the essential functions
of the position under consideration.

The Act was amended in 2009 (U.S. Department of Justice, 2009). The definition of
a disability was broadened in several ways beneficial to employees: The amended Act
includes disabilities not previously covered (e.g., epilepsy, diabetes, bipolar disorder).
The amendments expand the definition of major life activities to include major bodily
functions (e.g., immune system, brain functions) and eliminate the ameliorative effects
of mitigating measures from consideration (e.g., medication, prosthetics).

Employers with 15 or more employees are required to make accommodations to
the known disability of a qualified applicant if it will not impose “undue hardship”
on the operation of the business. Reasonable accommodations may include making
existing facilities used by employees readily accessible to and usable by individuals
with disabilities; job restructuring; part-time or modified work schedules; reassign-
ment to a vacant position; acquiring or modifying equipment or devices; adjusting or
modifying examinations, training materials, or policies; and providing qualified read-
ers and interpreters.

Recruiting and Selecting Staff 257

Table 16-2 Preemployment Questions

Appropriate to Ask Inappropriate to Ask

Name Applicant’s name. Whether applicant has school or work
records under a different name.

Questions about any name or title that indicate race, color,
religion, sex, national origin, or ancestry.

Questions about father’s surname or mother’s maiden name.

Address Questions concerning place and length of current and
previous addresses.

Any specific probes into foreign addresses that would indicate
national origin.

Age Requiring proof of age by birth certificate after hiring.
Can ask if applicant is over 18.

Requiring birth certificate or baptismal record before hiring.

Birthplace or
national origin

Any question about place of birth of applicant or place of birth
of parents, grandparents, or spouse.

Any other question (direct or indirect) about applicant’s national
origin.

Race or color Can request after employment as affirmative action data. Any inquiry that would indicate race or color.

Sex Any question on an application blank that would indicate sex.

Religion Any questions to indicate applicant’s religious denomination or
beliefs.

A recommendation or reference from the applicant’s religious
denomination.

Citizenship Questions about whether the applicant is a U.S. citizen;
if not, whether the applicant intends to become one.

Questions of whether the applicant, parents, or spouse are
native born or naturalized.

Questions regarding whether applicant’s U.S. residence
is legal; requiring proof of citizenship after hiring.

Requiring proof of citizenship before hiring.

Appropriate to Ask Inappropriate to Ask

Photographs May require after hiring for identification purposes only. Requesting a photograph before hiring.

Education Questions concerning any academic, professional, or
vocational schools attended.

Questions specifically asking the nationality, racial, or religious
affiliation of any school attended.

Inquiry into language skills, such as reading and writing
of foreign languages.

Inquiries as to the applicant’s mother tongue or how any foreign
language ability was acquired (unless it is necessary for the job).

Relatives Name, relationship, and address of a person to be
notified in case of an emergency.

Any unlawful inquiry about a relative or residence mate(s) as
specified in this list.

Children Questions about the number and ages of the applicant’s
children or information on child-care arrangements.

Transportation Inquiries about transportation to or from work (unless a car is
necessary for the job).

Organization Questions about organization memberships and any
offices that might be held.

Questions about any organization an applicant belongs to that
may indicate the race, age, disabilities, color, religion, sex,
national origin, or ancestry of its members.

Physical condition/
disabilities

Questions about being able to meet the job
requirements, with or without some accommodation.

Questions about general medical condition, state of health,
specific diseases, or nature/severity of disability.

Military service Questions about services rendered in armed forces, the
rank attained, and which branch of service.

Questions about military service in any armed forces other than
the United States.

Requiring military discharge certificate after being hired. Requesting military service records before hiring.

Work schedule Questions about the applicant’s willingness to work the
required work schedule.

Questions about applicant’s willingness to work any particular
religious holiday.

References General and work references not relating to race, color,
religion, sex, national origin or ancestry, age, or
disability.

References specifically from clergy (as specified above) or any
other persons who might reflect race, age, disability, color, sex,
national origin, or ancestry of applicant.

Financial Questions about banking, credit rating, outstanding loans,
bankruptcy, or having wages garnished.

Other
qualifications

Any question that has direct reflection on the job to be
applied for.

Any non–job-related inquiry that may present information
permitting unlawful discrimination. Questions about arrests or
convictions (unless necessary for job, such as security clearance).

258 Chapter 16

The 2009 amendments included some employer-friendly provisions as well.
Although the pool of individuals covered in the amendments is expanded, the reason-
able accommodation features remain the same, as do existing exclusions for criminal
behavior and current drug use.

Recruiting and selecting the most appropriate staff is one of the most important
jobs in an organization. Candidates whose qualifications fit the job requirements are
more likely to be productive and to remain on the job. The tendency, especially during
times of shortages, is to shortcut the process, but this is ill-advised. The effort to attract
and select the best candidates pays off over time for the organization.

One nurse manager used the recommendations in this chapter to hire a nurse as
shown in Case Study 16-1.

CASE STUDY 16-1 | Selecting Staff
Jack Turner is nurse manager of the emergency department
(ED) in a large metropolitan area hospital. He has four full-time
RN positions open in his department. Three nursing programs
are located in the city: a state university program, a community
college program, and an RN-to-BSN completion program.

Jack recently participated in a nursing job fair hosted
by his hospital. The event was well attended by nursing stu-
dents, and he received several promising résumés of soon-
to-be graduate nurses. Jack notes that one of the applicants,
Sabrina Ashworth, will graduate next month with a BSN.
She has been working for the past year as a nursing assis-
tant in the ED of another local hospital. In addition to her ED
work, Sabrina has a high grade point average and indicates
a strong interest in trauma and critical care. Jack contacts
the HR department to set up an interview with Sabrina.

Sabrina agrees to an interview for an RN position in
the ED. Jack schedules a conference room adjacent to the
ED for the interview. Prior to Sabrina’s arrival, he reviews
her résumé and application, noting her educational

background, previous work history, and recent volunteer
trip to Mexico to assist with a vaccination program. Jack
has assembled a packet for Sabrina, including a job
description and materials from human resources that out-
line the application process.

The interview begins promptly. Jack warmly greets Sab-
rina and establishes rapport. He follows the interview guide
provided by HR. Jack informs Sabrina that he will be taking
notes during the interview process. After reviewing her educa-
tional and work history, Jack asks Sabrina several situational
questions related to work in the ED. He also allows time for
Sabrina to ask questions about the RN position. Jack also has
two RN staff members give Sabrina a tour of the ED. Finally,
Jack outlines the next steps in the application process and
indicates that he will follow up with Sabrina in 7 to 10 days.

Following the interview, Jack works with HR and asks
for transcript and reference checks for Sabrina. After verify-
ing her transcript and receiving positive references, Jack
extends an offer to Sabrina, which she accepts.

What You Know Now
• The selection of staff is a critical function that

requires matching people to jobs, and responsi-
bility for hiring is often shared by HR and nurse
managers.

• Position description is fundamental to all selec-
tion efforts because it defines the job.

• Recruitment is the process of locating and attract-
ing enough qualified applicants to provide a pool

from which the required number of new staff
members can be chosen.

• Selection processes should be job related and
most often include screening application forms,
résumés, medical examinations, reference and
background checks, and interviews.

• Interviewing is a complex skill that is intended
to  obtain information about the applicant and

Recruiting and Selecting Staff 259

to  give the applicant information about the
organization.

• Successful interviews require planning, imple-
mentation, and follow-up in order for them to
lead to making the best decisions.

• Developing a structured interview guide is a crit-
ical element in interviewing.

• Selection decisions are subject to provisions in the
Civil Rights Act of 1964 as amended in 1991, the
Equal Pay Act of 1963, the Age Discrimination
Act of 1967, and the Americans with Disabilities
Act of 1990 as amended in 2009.

Tools for Recruiting and Selecting Staff
1. Conduct or modify a job description as needed.
2. Coordinate recruitment efforts with HR as well as

technical support for social media platforms.
3. Ensure that your area of responsibility sends the

message you want (see Box 16-1).
4. Prepare adequately for interviews.

5. Conduct interviews following recommendations
presented in this chapter.

6. Process the information obtained in interviews
and reference and background checks to make a
final decision.

Questions to Challenge You
1. What approach does your organization use to

recruit employees? Is it effective? How could the
process be improved?

2. Imagine that a potential candidate asks you to
describe your present workplace. What would
you say?

3. Have you ever participated in a staff interview,
either as a candidate or as a member of the staff?

Describe your experience. Would you do anything
differently now that you have read this chapter?

4. Cross-training has been used as a recruitment
strategy. What are the pros and cons of using this
strategy?

5. Consider the last interview you had for a job or
school. Did the interviewer follow the principles
discussed in this chapter? Explain.

References
Age Discrimination in Employment Act of 1967

(Pub. L. 90-202).
Americans With Disabilities Act of 1990, Pub. L. No.

101-336, §2, 104 Stat. 328 (1991).
Civil Rights Act of 1991, 29 Code of Federal

Regulations, Sections 1604 et seq.
Equal Pay Act of 1963, 29 U.S. Code Chapter 8 § 206(d).
Holland, C. (2015). Investing in our nursing

workforce. Nursing Management, 46(9), 8–10.
Kelly, L. A., McHugh, M. D., & Aiken, L. H. (2011).

Nurse outcomes in Magnet and non-Magnet
hospitals. Journal of Nursing Administration, 41(10),
428–433.

Kutney Lee, A., Stimpfel, A., Sloane, D. M., Cimiotti, J.,
Quinn, L. W., & Aiken, L. H. (2015). Changes in

patient and nurse outcomes associated with Magnet
hospital designation. Medical Care, 53, 550–557.

Mooneyham, J. W., Goss, T., Burwell, L., Kostmayer,
J., & Humphrey, S. (2011). Employment incentives
for new grads. Nursing Management, 42(3), 39–44.

Uniform Guidelines on Employee Selection
Procedures, 4 Fed. Reg. (1978).

U.S. Department of Labor, Bureau of Labor Statistics.
(2015). Quick facts on registered nurses. Retrieved
October 27, 2015, from http://www.dol.gov/wb/
factsheets/Qf-nursing-05.htm

U.S. Department of Justice. (2009). Americans with
disabilities act of 1990, as amended. Retrieved
October 27, 2015 from http://www.ada.gov/
pubs/ada.htm

http://www.dol.gov/wb/factsheets/Qf-nursing-05.htm

http://www.ada.gov/pubs/ada.htm

http://www.dol.gov/wb/factsheets/Qf-nursing-05.htm

http://www.ada.gov/pubs/ada.htm

260 Chapter 17

Learning Outcomes

After completing this chapter, you will be able to:

1. Determine staffing needs using evidence-based tools.

2. Plan workforce full-time equivalents (FTEs).

3. Describe the various ways to schedule staff.

4. Explain how to supplement staff when needed.

Key Terms
block staffing

demand management

full-time equivalent (FTE)

nursing care hours (NCHs)

patient classification systems (PCSs)

pools

self-scheduling

staffing

staffing mix

Staffing
Patient Classification Systems

Determining Nursing Care Hours

Planning FTE Workforce
Determining Staffing Mix

Determining Distribution of Staff

Scheduling
Self-staffing and Scheduling

Shared Schedule

Open Shift Management

Weekend Staffing Plan

Automated Scheduling

Supplementing Staff
Internal Pools

External Pools

Chapter 17

Staffing and
Scheduling

260

Staffing and Scheduling 261

Introduction
Staffing and scheduling are important responsibilities of the nurse manager and criti-
cal aspects of providing nursing care for several reasons. Decreasing nurse-to-patient
ratios are associated with higher patient survival rates (McHugh et al., 2016). Further-
more, failing to match patient needs to nurses’ skills also increases patient mortality
(Needleman et al., 2011).

Staffing and scheduling are also important factors in job satisfaction for nurses.
(See Leading at the Bedside: Staffing and Scheduling.) Nurses’ perceptions of work-
load and feelings of burnout have been tied to job dissatisfaction, increased turnover,
and nurse-reported quality of care (Van Bogaert et al., 2014). Not only have higher
nurse staffing levels translated into lower mortality, but hospitals reported better nurse
retention rates as a result (Aiken et al., 2010). In addition, Magnet hospitals report
higher nurse staffing levels (Hickey, Gauvreau, Connor, Sporing, & Jenkins, 2010) and
improved teamwork (Kalisch & Lee, 2011).

Leading at the Bedside: Staffing and Scheduling
Being responsible for staffing and scheduling is incredibly
difficult in healthcare because the number of patients and
their needs are so variable. Nonetheless, organizations try to
schedule nurses so patients are adequately cared for with-
out having more nurses than needed’not an easy task.

You can help. How you respond to staffing and sched-
uling decisions affects the use of the valuable nursing

resources of your unit and your organization. You can
offer suggestions when the inevitable scheduling prob-
lems occur. You can be sensitive to an individual nurse’s
needs as well as help your colleagues understand the
whole unit’s needs. Working together with management,
you can ensure that your organization uses its human
resources wisely.

Staffing
The goal of staffing is to provide the appropriate number and mix of nursing staff
(nursing care hours) to match actual or projected patient care needs (patient care
hours) to provide effective and efficient nursing care. There is no single or perfect
method to achieve this. In addition, variability in patient census requires continuous
fine-tuning.

A hospital unit may experience a steady census during the 7 days of the week or a
higher census from Monday to Friday. Its patient days may be distributed evenly dur-
ing the year, or it may consistently experience peaks in occupancy in certain months
(seasonality pattern) such as during an outbreak of influenza. Outpatient clinics may
be busier on days when specialists are available or vaccines are offered. Staffing is a
challenge in all healthcare settings.

To determine the number of staff needed, managers must examine workload pat-
terns for the designated unit, department, or clinic. For a hospital, this means deter-
mining the level of care, average daily census, and hours of care provided 24 hours a
day, 7 days a week.

The Joint Commission, a hospital accrediting body, identifies staffing expectations
and requires that the right number of competent staff be provided to meet patients’
needs based on organization-selected criteria (Joint Commission, 2016). Nurse leaders

262 Chapter 17

have worked to develop evidence-based data-driven staffing plans that can be bud-
geted for and communicated to nursing staff (Dent, 2015). Midland Memorial Hospital
in Midland, Texas, created “Nine Principles for Improved Nurse Staffing” to guide its
staffing, and the document is flexible and geared at achieving optimal patient satisfac-
tion and patient quality outcomes, as shown in Box 17-1 (Dent, 2015).

Box 17-1 Nine Principles of Nurse Staffing at Midland
Memorial Hospital

1. The Nurse Staffing Advisory Council (NSAC) will meet
at least quarterly and review nurse staffing along with
nurse-sensitive outcomes including any patient griev-
ances associated with nurse staffing.

2. Budget nursing resources and reconcile the position
control or hiring plan created on a National Database
of Nursing Quality Indicators (NDNQI) 50th percentile
for registered nurse hours per patient day (RNHPPD).

3. Forecast turnover at a predetermined rate and pre-
hiring into on-boarding positions.

4. Maintain an internal resource team.
5. Budget the use of temporary traveler nurses during

an identified peak census time period, December
through April.

6. Nurses self-schedule within an electronic staffing
and scheduling system using predictive volume
patterns.

7. Assignments are acuity-based using a patient classifi-
cation system mapped from the electronic health
record with Nursing Outcomes Classification.

8. Minimum staffing identified to be the NDNQI 25th per-
centile for RNHPPD and maximum staffing identified
at the NDNQI 75th percentile for RNHPPD.

9. Assure nursing staff practice within a fatigue manage-
ment guideline.

Source: Dent, B. (2015). Nine principles for improved nurse staffing. Nursing Economics, 33(1), 41–66.

Patient Classification Systems
Patient classification systems (PCSs), sometimes referred to as patient acuity systems,
use patient needs to objectively determine workload requirements and staffing needs.
To be most effective, patient classification data are collected midpoint for every shift
by the unit nursing staff and analyzed before the next shift to ensure appropriate num-
bers and mix of nursing staff.

Ideally, this system would accurately predict the number and skill level of
nurses needed for the next shift. However, other factors impact staffing needs.
Some nurses may call in sick; the nurses scheduled may not have the skill set
necessary for a specific surgery; or, most important, the patient’s condition may
change.

Welton and Harper (2015) suggest that information from electronic health records
(EHRs) now allows us the opportunity to measure for nursing care needs in a way
not possible in the past. Using this data to inform better operational and clinical deci-
sion making could improve cost and quality (Welton & Harper, 2015). This topic has
long been discussed. (Picard and Warner [2007] suggested fine-tuning PCS systems
to predict the demand for nursing expertise several days in advance. Their system,
called demand management, uses best-practices staffing protocols to predict and
control the demand for nurses based on patient outcomes. Based on historical data, a

Staffing and Scheduling 263

patient progress pattern typifies expected patient outcomes throughout a stay. Devia-
tions are tracked and staffing adjusted accordingly. This system allowed the manager
to staff into the next few days with more assurance than predicting from one shift to
the next.) Whatever system is used, the next step is to determine the necessary nursing
care hours.

Determining Nursing Care Hours
Patient workload trends are analyzed for each day of the week (each hour in critical
care) or for a specific patient diagnosis to determine staffing needs, known as nursing
care hours (NCHs). For example, if 26 patients with the following acuities required
161 nursing care hours, then an average of 6.19 nursing hours per patient per day
(NHPPD) are required. NHPPD are calculated by dividing the total nursing care hours
by the total census (number of patients).

Number of
Patients

Acuity Level
Associated Hours

of Care
Total Hours of

Care

3 I 2 6

10 II 6 60

11 III 7 77

2 IV 9 18

Total 26 161

There are no specific standards for NCHs for any type of patient or patient care
unit. NCHs may vary on the average from 5 to 7 hours of care for patients on medical
and surgical units, to 10 to 24 hours of care for patients in critical care units, to 24 to
48 hours of care for selected patients, such as new patients suffering from severe burns.

Planning FTE Workforce
Positions are defined in terms of a full-time equivalent (FTE). One FTE equals
40 hours of work per week for 52 weeks, or 2,080 hours per year. In a 2-week pay period,
one FTE would equal 80 hours. For computational purposes, one FTE can be filled by
one person or a combination of staff with comparable expertise. For example, one
nurse may work 24 hours per week, and two other nurses may each work 8 hours per
week. Together, the three nurses fill one FTE (24 + 8 + 8 = 40).

Several methods are available for determining the number of FTEs required to
staff a unit 24 hours a day, 7 days a week. One technique incorporates information
regarding the hours of work for the staff for 2 weeks, average daily census, and
hours of care. The average daily census can be determined by dividing the total
patient days (obtained from daily census counts for the year) by the number of days
in the year.

• ExamplE

Total patient days =
9490
365

= 26 patients per day

264 Chapter 17

Data
Number of hours worked per FTE in 2 weeks = 80
Number of days of coverage in 2 weeks = 14
Average daily census = 26
Average nursing care hours (from PCS) = 6.15

Formula

A second technique uses nursing care hours and annual hours of work provided
by 1 FTE:

Data
Number of hours worked per FTE in 1 year = 2,080
Total nursing care hours (from PCS) = 161

Formula

x =
Total nursing care hours × days in a year

Total annual hours per 1 FTE

x =
161 × 365

2080
=

58,765
2080

= 28.25, or 28 FTEs

One person working full-time usually works 80 hours (ten 8-hour shifts) in a
2-week period. However, to staff an 8-hour shift takes 1.4 FTEs, one person working ten
8-hour shifts (1.0 FTE) and another person working four 8-hour shifts (0.4 FTE) in order
to provide for the full-time person’s 2 days off every week. For 12-hour shifts, it takes
2.1 FTEs to staff one 12-hour shift each day, each week; two people each working three
12-hour shifts and one person working one 12-hour shift each week (0.9 FTE + 0.9 FTE
+ 0.3 FTE = 2.1 FTEs). Therefore, the same number of FTEs is required to staff a unit for
24 hours a day for 2 weeks, regardless of whether or not the staff are all on 8-hour shifts
(1.4 FTEs × 3 shifts = 4.2 FTEs) or 12-hour shifts (2.1 FTEs × 2 shifts = 4.2 FTEs).

Determining Staffing Mix
The same data used to determine FTEs are used to identify staffing mix. For example,
for patient care needs involving general hygiene care, feeding, ambulating, or turning
patients, licensed practical nurses (LPNs) or unlicensed assistive personnel (UAPs)
can be used. For patient care needs involving frequent assessments, patient education,
or discharge planning, RNs will be needed because of the skills required. A high RN-
skill mix allows for greater staffing flexibility. Again, information on typical or usual
patient needs is obtained by using trends from the patient classification system.

Determining Distribution of Staff
For many patient care units, the distribution of staff varies from shift to shift
and by days of the week. Patient census on a surgical unit will probably fluctuate

average nursing care hours × days in staffing period × average patient census
hours of work per FTE in 2 weeks

x =

x =
6.15 × 14 × 26

80
= 27.98, or 28 FTEs

2238.6
80

=

Staffing and Scheduling 265

throughout the week, with a higher census Monday through Thursday and a lower
census over the weekend. In addition, some surgical units may have more complex
cases earlier in the week and short-stay surgical cases later in the week. Surgical
patients may have a shorter length of stay (LOS) than many medical patients. The
patient census on a medical unit rarely fluctuates Monday through Friday, but it may
be less on weekends when diagnostic tests are less commonly performed.

The workload on many units also varies within the 24-hour period. The care
demands on a surgical unit will be heaviest early in the morning hours prior to the
start of the surgical schedule; midmorning, when the unit receives patients from
critical care units; late in the afternoon, when patients return from the postanes-
thesia recovery unit; and in the evening hours, when same-day surgical patients
are discharged.

Critical care units may have greater care needs in the mornings when transfer-
ring patients to medical or surgical units and in the early afternoon hours when
admitting new complex surgical cases. Medical units usually have the heaviest
care needs in the morning hours, when patients’ daily care needs are being met
and physicians are making rounds. On skilled nursing and rehabilitation units,
care needs are greatest before and immediately after mealtimes and in the evening
hours; during other times of the day, patients are often involved in various thera-
peutic activities.

In contrast with the medical, surgical, critical care, and rehabilitation units, which
have definite patterns of patient care needs, labor-and-delivery and emergency depart-
ment areas cannot easily predict when patient care needs will be most intense. Thus,
labor-and-delivery and emergency department areas must rely on block staffing to
ensure that adequate nursing staff are available at all times.

Here is what a nurse manager told a new nurse candidate when asked about the
nurse-to-staff ratio:

On the surgical step-down f loor, we most typically staff at a one-RN-to-four-patient
ratio. We also plan to have a charge nurse who is not taking patients to assist staff
with extra tasks and needs. On occasion, a nurse may have three patients or five
patients. We always work to be f lexible, looking at the acuity of the patients and
the competencies of the staff who are working. During each shift, we reassess every
4 hours and as needed to ensure assignments are still appropriate and patient needs
haven’t significantly changed, necessitating a reassignment of patients. We also have
nurse aides on this f loor. They help with vital signs, bed changes, baths, and ambu-
lation. There is most typically one aide for every eight to twelve patients. Also, a
unit clerk answers the phones and greets guests. This team dynamic creates great
patient care.

BLOCK STAFFING Block staffing involves scheduling a set staff mix for every shift.
However, there may be trends in peak workload hours in emergency departments,
when additional staff (RN, UAP, or secretary) beyond the block staff are necessary. Exam-
ples of peak workload hours within the emergency department may be from 6:00 p.m.
to 10:00 a.m. to accommodate patient needs after physicians’ offices close, or from
12:00 a.m. to 3:00 a.m. to accommodate alcohol-related injuries. All these needs in pat-
terns of care must be known when staffing requirements and work schedules are
established. Data reflecting peak workload times must be continuously monitored to
maintain the appropriate levels and mix of staff.

266 Chapter 17

Scheduling
Nurse shortages and current restrictions in salary budgets have made creative and
flexible staffing patterns necessary and probably everlasting. Combinations of 4-, 6-,
8-, 10-, and 12-hour shifts and schedules that have nurses working 6 consecutive days
of 12-hour shifts with 9 days off, and staffing strategies, such as weekend programs
and split shifts, are common.

Flexible staffing patterns can be a major challenge and, in some cases, a mathemat-
ical challenge. However, once a schedule is established and agreed to by the nurse
manager and the staff, it can become a cyclic schedule for an extended period of time,
such as 6 to 12 months. This allows staff members to know their work schedule many
months ahead of time.

The use of 8-hour and 12-hour shifts is fairly straightforward. Problems with com-
bined staffing patterns may include the following:

• The perception that nurses do not work full-time when they work several days in
a row, then are off for several days in a row

• Disruption in continuity of care if split shifts are used (7:00 to 11:00 a.m.; 11:00 a.m.
to 3:00 p.m.; 3:00 p.m. to 7:00 p.m.; 7:00 p.m. to 1:00 a.m.; 1:00 a.m. to 7:00 a.m. shifts)

• Immense challenges for nurse managers to communicate with all staff in a
timely manner

Advantages of using combined staffing patterns are that it achieves the
following:

• Better meets patient care needs during peak workload times

• Improves staff satisfaction

• Maximizes the availability of nurses

Ten-hour shifts provide greater overlap between shifts to permit extra time for nurses
to complete their work; for this reason, they may increase salary expenditures. There are
a few specialty units in which 10-hour shifts would be cost-efficient—for example, post-
anesthesia recovery areas, operating departments, and emergency departments.

Self-staffing and Scheduling
Some hospitals have instituted self-staffing. This is an empowerment strategy that
allows unit staff the authority to use their backup staffing options if the patient work-
load increases or if unscheduled staff absences occur. Likewise, staff can and must go
home early if the patient workload decreases.

SELF-SCHEDULING Self-scheduling allows the staff to create and manage the
schedule by indicating their preferred shifts to work and noting what shifts they are
not available (Russell, Hawkins, & Arnold, 2012). Self-scheduling allows staff to feel
satisfied because they play a large role in choosing their schedules. The manager’s role
with self-scheduling is to pay close attention to the proposed schedule and balance
staffing if the proposed self-schedule draft is not balanced to meet patient care needs.
After a schedule is completed and balanced, it is posted for staff to see, well in advance
of when the schedule starts. Posting of the schedule may be done on paper on the unit
and also online in electronic format.

Staffing and Scheduling 267

Shared Schedule
Another tool currently in use is a shared schedule: Two people share one full-time
schedule by splitting the day of 12 hours into half days of 6.5 hours each, alternating
morning and afternoon shifts. This allows nurses who might not be able to work the
full 12 hours to share the shift. This option might be attractive to parents of young
children who want to work but do not want to be away from home long hours. It can
also be helpful to nurses who are close to retiring from their nursing career but still
want to work some hours.

Open Shift Management
Open shift management is a technique that allows staff to schedule additional shifts
beyond their expected shifts. With the schedule posted online, staff members can select
assignments and shifts that fit their expertise and accommodate their personal sched-
ules. Healthcare systems, with multiple hospitals, might use open shift management
so staff can select assignments at multiple care locations within the system.

Case Study 17-1 shows how one hospital used open scheduling to decrease its use
of agency staff and improve staff morale.

CASE STUDY 17-1 | Scheduling
Tori Abraham and Jillian Moore are both nurse managers of
general med/surg units at separate hospitals that are part
of a large metropolitan healthcare system. Staffing among
the med/surg units has been problematic due to increased
patient volume and cost control measures enacted by the
healthcare corporation. Staff members have complained
numerous times that extra shifts are only offered to part-
time employees, and that premium pay shifts are given to
those with more seniority. As the holidays approach, staff
tension increases as a lottery system has traditionally been
used to assign shifts for major holidays. In addition, since
employees are free to transfer within any of the eight metro-
politan hospitals, there has been significant turnover on the
med/surg units as employees decide to transfer to ambula-
tory care and same-day surgery facilities.

Tori and Jillian have volunteered to be part of a new
scheduling system for their healthcare system. Nurses and
nursing assistants will be able to view open shifts on each
unit and e-mail Tori or Jillian with requests to staff shifts for
which they are qualified. By allowing staff to have greater

control over which additional shifts and at which facility they
prefer to work, the nurse managers hope to decrease
agency staffing and increase employee satisfaction. Addi-
tional units are expected to come online, which will also
allow staff to have experience on oncology, skilled nursing,
and orthopedic patients. The education department will
provide a database of employee certifications to managers
to ensure that staff wishing to work away from their home
units are qualified for the job.

After 90 days of using the new open shift scheduling
system, Tori and Jillian are pleased with the results. Agency
staff use has decreased by 60%, and staff members report
they are happier with the ability to schedule their own
additional shifts as well as work at a different facility with-
out having to transfer. Holiday staffing has been easier, as
those employees who prefer to work holidays for premium
pay are able to self-schedule. Tori and Jillian present their
findings to the chief nursing officer and will be part of
the team implementing systemwide use of open shift
scheduling.

Weekend Staffing Plan
Hospitals can no longer arbitrarily staff patient care units for weekends or nights with
marginal numbers or levels of qualified staff. The acuity of patients in hospitals,
including medical and surgical patients, mandates staffing units on the weekends by
the same principles used for weekdays. Thorough trend analysis of patient data can

268 Chapter 17

provide the justification necessary to appropriately decrease the number of RNs, at
least for some levels, because of differences in patient care needs throughout the day.

Automated Scheduling
Technology today makes automated scheduling feasible (Douglas, 2010). Matching
patient demand to nurse staffing is better done by automated systems than by indi-
viduals. To aid in scheduling decisions, data should include patient information, nurse
characteristics, and hospital data (Frith, Anderson, & Sewell, 2010). Automated sys-
tems improve patient care outcomes because nurses spend more time with the patients
who need the most nursing care. In addition, using nurses’ time appropriately
improves financial outcomes (Barton, 2011).

Data are often displayed on a dashboard. A dashboard is a computer display of real-
time data collected from various sources and categorized for use in decision making.

Supplementing Staff
When there is a need for additional staff because of scheduled or unscheduled
absences, increased workload demands, or existing staff vacancies, the nurse manager
must find additional staff. Options include using PRN staff (staff scheduled on an as-
needed basis), part-time staff, internal float pools, or outside agency nurses.

Supplemental staff are needed when workload increases beyond that which the
existing staff can manage, staff absences and resignations occur, and staff vacancies
exist. Chronic staffing problems must be addressed in a proactive manner involving
the nurse manager, the chief nurse executive, and the nursing personnel on the unit
with the problem.

Internal Pools
Acute staffing problems can be addressed by establishing internal float pools using
nursing staff and unlicensed assistive personnel (UAPs). Internal float pools of nurses
can provide supplemental staffing at a substantially lower cost than external agency
nurses. In addition, internal staff are familiar with the organization. All staff partici-
pating in the internal float pool must be adequately trained for the type of patient care
they will be giving.

Internal float pools can be centralized or decentralized. A centralized pool is the
most efficient. A pool of RNs, LPNs, UAPs, and unit clerks are available for placement
anywhere in the institution. However, it may be difficult to place the person with the
correct skills for a particular unit at the needed time.

In decentralized pools, a staff member usually works only for one nurse manager
or on only one unit. The advantages of decentralized pools include better accountabil-
ity, improved staffing response, and improved continuity of care. Critical care units,
operating rooms, maternal–child units, and other highly specialized or technical areas
tend to use a decentralized system.

In addition, staff can receive cross-training in preparation for assignment to
another unit. A critical-care nurse might be cross-trained for the step-down unit, for
example. Dual-unit positions could be established in the recruiting phase to give the
organization the maximum flexibility in scheduling and the employee an opportunity
to acquire additional skills.

Staffing and Scheduling 269

External Pools
For some institutions, agency nurses become part of the regular staff contracted to fill
vacancies for a specified period of time (e.g., a nurse on maternity leave). However,
most agency nurses are used as supplemental staff. All agency nurses require orienta-
tion to the facility and unit, and they must work under the supervision of an experi-
enced in-house nurse. Management must verify valid licensure, ensure that either the
agency or agency nurse has current malpractice insurance, and develop a mechanism
to evaluate the agency nurse’s performance. Although an agency nurse may meet an
urgent staffing need, continuity of care may be compromised, and there may be some
staff resentment because these nurses may earn two to three times the salary of in-
house nurses.

Concern about the quality of agency nurses appears to be unfounded, according
to a study analyzing mortality outcomes and failure to rescue (Aiken, Shang, Xue, &
Sloane, 2013). Rather, hospitals with poor work environments were found to have
higher numbers of agency nurses, and the work environment appeared to contribute
to the poor patient outcomes.

Ensuring that sufficient staff are available and appropriately scheduled is a
demanding task, one that is constantly in flux. Nevertheless, such activities are crit-
ical to achieving positive patient outcomes and providing safe, effective, and cost-
conscious staffing.

What You Know Now
• The goal of staffing and scheduling is to provide

an adequate mix of nursing staff to match patient
care needs.

• The Joint Commission requires that organizations
determine criteria for nurse staffing and provide
adequate numbers of competent staff to meet that
criteria.

• Patient classification systems use patient needs to
determine workload requirements and staffing
needs.

• Scheduling involves assigning available staff in a
way that patient care needs are met.

• Flexible and creative staffing and scheduling tech-
niques are increasingly necessary.

• Self-staffing and scheduling, including open shift
management, are options in which nursing staff
participate in designing the schedule and accept
responsibility for ensuring attendance.

• Automated scheduling improves patient outcomes
and uses fiscal resources appropriately.

Tools for Handling Staffing and Scheduling
1. Familiarize yourself with the current patient clas-

sification system, acuity system, or automated
system in use.

2. Determine the nursing care hours needed.
3. Determine the FTEs needed.

4. Create or modify a schedule that best meets your
patients’ needs.

5. Supplement staff as needed.
6. Consider self-staffing if appropriate.

270 Chapter 17

Questions to Challenge You
1. What has been your experience with staffing?

Use any work setting where you are or have been
an employee. How well did it work? Was there
adequate coverage to meet the needs of the orga-
nization? Explain.

2. Using the formulas for calculating FTEs in the
chapter, create your own examples and work
the problems from them. Were you able to com-
pute needed FTEs? Now calculate the hours

needed when nursing staff work 8-hour or
12-hour shifts.

3. On occasion, more staff are available than are
needed. As a nurse manager, how would you
handle this? How might the staff respond?

4. No one is ever completely satisfied with the
schedule. How would you handle a staff member
who repeatedly asks to have his schedule
changed?

References
Aiken, L. H., Shang, J., Xue, Y., & Sloane, D. M. (2013).

Hospital use of agency-employed supplemental
nurses and patient mortality and failure to rescue.
Health Services Research, 48(3), 931–948.

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke,
S. P., Flynn, L., Seago, J. A., . . . & Smith, H. L.
(2010). Implications of the California nurse staffing
mandate for other states. Health Services Research,
45(3), 904–921.

Barton, N. S. (2011). Matching nurse staffing to
demand. Nursing Management, 42(2), 37–39.

Dent, B. (2015). Nine principles for improved nurse
staffing. Nursing Economics, 33(1), 41–66.

Douglas, K. (2010). Digital dashboards and staffing:
A perfect match. American Nurse Today, 5(5), 52–53.

Frith, K. H., Anderson, F., & Sewell, J. P. (2010).
Assessing and selecting data for a nursing
services dashboard. Journal of Nursing
Administration, 40(1), 10–16.

Hickey, P., Gauvreau, K., Connor, J., Sporing, E.,
& Jenkins, K. (2010). The relationship of nurse
staffing, skill mix, and Magnet recognition to
institutional volume and mortality for congenital
heart surgery. Journal of Nursing Administration,
40(5), 226–232.

Kalisch, B. J., & Lee, K. H. (2011). Nurse staffing
levels and teamwork: A cross-sectional study of
patient care units in acute care hospitals. Journal of
Nursing Scholarship, 43(1), 82–88.

McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg,
R. A., Mancini, M. E., Nadkarni, V. M., Merchant,
R. M., . . . & American Heart Association’s Get

with Guidelines-Resuscitation Investigators.
(2016). Better nurse staffing and nurse work
environments associated with increased survival
of in-hospital cardiac arrest patients. Medical Care,
54(1), 74–80.

Needleman, J., Buerhaus, P., Pankratz, S., Leibson,
C. L., Stevens, S. R., & Harris, M. (2011). Nurse
staffing and inpatient hospital mortality. New
England Journal of Medicine, 364(11), 1037–1045.

Picard, B., & Warner, M. (2007). Demand
management: A methodology for outcomes-driven
staffing and patient flow management. Nurse
Leader, 5(2), 30–34.

Russell, E., Hawkins, J., & Arnold, K. A. (2012).
Guidelines for successful self-scheduling on
nursing units. Journal of Nursing Administration,
42(9), 408–409.

The Joint Commission. (2016). Comprehensive
accreditation manual for hospitals: The official
handbook. Retrieved April 4, 2016, from http://
www.jointcommission.org

Van Bogaert, P., Timmermans, O., Weeks, S. M., van
Hueusen, D., Wouters, K., & Franck, E. (2014).
Nursing unit teams matter: Impact of unit-
level nurse practice environment, nurse work
characteristics, and burnout on nurse reported job
outcomes, and quality of care, and patient adverse
events–A cross-sectional survey. International
Journal of Nursing Studies, 51(8), 1123–1134.

Welton, J. M., & Harper, E. M. (2015). Nursing care
value-based financial models. Nursing Economics,
33(1), 14–25.

http://www.jointcommission.org

http://www.jointcommission.org

Chapter 18

Motivating and
Developing Staff

Learning Outcomes

After completing this chapter, you will be able to:

1. Describe the factors that influence job performance.

2. Compare and contrast the use and effectiveness of various staff
development methods.

3. Discuss why succession planning is essential to the future.

Key Terms
content theories

equity theory

expectancy theory

extinction

goal-setting theory

horizontal promotion

motivation

on-the-job instruction

orientation

preceptors

process theories

punishment

reinforcement theory
(behavior modification)

shaping

A Model of Job Performance
Employee Motivation

Motivational Theories

Staff Development
Orientation

On-the-job Instruction

Preceptors

Mentoring

Coaching

Nurse Residency Programs

Career Advancement

Leadership Development

Succession Planning

271

272 Chapter 18

Introduction
A continual and troublesome question today is why some employees perform better
than others. Making decisions about who performs what tasks in a particular manner
without first considering individual behavior can lead to irreversible, long-term
problems.

Each employee is different in many respects, and those differences influence
behavior and performance on the job. Ideally, the manager assesses the new employee
when the person is hired. In reality, however, many employees are placed in positions
without the manager having adequate knowledge of their abilities and interests. This
often results in problems with employee performance as well as conflict between
employees and managers. Employee performance literature ultimately reveals two
major dimensions as determinants of job performance: motivation and ability (Hersey,
Blanchard, & Johnson, 2012).

A Model of Job Performance
Nurse managers spend considerable time making judgments about the fit among indi-
viduals, job tasks, and effectiveness. Such judgments are typically influenced by the
characteristics of both the manager and the employee. For example, ability, instinct,
and aspiration levels—as well as age, education, and family background—account for
why some employees perform well and others poorly. Based on these factors, a model
that considers motivation and ability as determinants of job performance is presented
in Table 18-1.

This performance model identifies six categories likely to be viewed as important:

• Daily job performance

• Attendance

• Punctuality

• Adherence to policies and procedures

• Absence of incidents, errors, and accidents

• Honesty and trustworthiness

Table 18-1 A Simplified Model of Job Performance

Motivation + Ability = Employee Performance

Compensation Responsibilities Daily job performance

Benefits Education—basic/advanced Attendance

Job design Continuing education Punctuality

Leadership style Skills/abilities Adherence to policies and procedures

Recruitment and
selection Absence of incidents/errors/accidents

Employee needs/
goals/abilities Honesty and trustworthiness

Motivating and Developing Staff 273

Although there is conceptual overlap in these categories, separate designation of
each helps emphasize their importance.

When using this model, carefully consider several factors. First, the healthcare
organization should establish and communicate clear descriptions of daily job perfor-
mance so that deviations from expected behaviors can be easily identified and docu-
mented. Second, behaviors considered troublesome on one unit may be acceptable on
another. Finally, some behaviors are viewed as serious only when repeated (e.g., being
late to work), whereas others are classified as troublesome following only one incident
(e.g., a medication error with severe consequences).

Employee Motivation
Motivation describes the factors that initiate and direct behavior. Because individuals
bring to the workplace different needs and goals, the type and intensity of motivators
vary among employees. Nurse managers prefer motivated employees because they
strive to find the best way to perform their jobs. Motivated employees are more likely
to be productive than are unmotivated workers. This is one reason that motivation is
an important aspect of enhancing employee performance.

Leading at the Bedside: Know Yourself
What motivates you? Motivation, you’ve learned, com-
bines with ability to predict how well you are able to do
your job. If you don’t have the skills for a job, no amount
of motivation will inspire you to do it. On the other hand,
you may have all the skills necessary to do the tasks
involved in your position, but you have little motivation to

do it. When considering a new position, remember these
two conditions: If the position meets both your ability
and your motivation, you are more likely to be satisfied in
your job.

Know yourself, and then find your place in nursing.
You and your profession will be the better for it.

Motivational Theories
The usefulness of motivational theories depends on their ability to explain motivation
adequately, to predict with some degree of accuracy what people will actually do, and,
finally, to suggest practical ways of influencing employees to accomplish organiza-
tional objectives. Motivational theories can be classified into at least two distinct
groups: content theories and process theories.

Content theories Content theories emphasize individual needs or the rewards
that may satisfy those needs. Content theories are less useful today because they spec-
ify neither what rewards would motivate an individual nor how people vary in per-
ceiving the importance of the reward.

ProCess theories Whereas content theories attempt to explain why a person
behaves in a particular manner, process theories emphasize how the motivation pro-
cess works to direct an individual’s effort into performance. These theories add
another dimension to the understanding of motivation and help predict employee
behavior in certain circumstances. Examples of process theories are reinforcement the-
ory, expectancy theory, equity theory, and goal-setting theory.

274 Chapter 18

Reinforcement theory (behavior modification) views motivation as learning
(Skinner, 1953). According to this theory, behavior is learned through a process called
operant conditioning, in which a behavior becomes associated with a particular conse-
quence. In operant conditioning, the response—consequence connection is strength-
ened over time—that is, it is learned.

Consequences may be positive, as with praise or recognition, or negative. Positive
reinforcers are used for the express purpose of increasing a desired behavior.

Kyle, a staff nurse, offered a creative idea to redesign work f low on the unit. His
manager supported the idea and helped Kyle implement the new process. In addition,
the manager praised Kyle for the extra effort and publicly recognized him for the idea.
Kyle was encouraged by the outcome and sought other solutions to work-f low
problems.

Negative reinforcers are used to inhibit an undesired behavior. Punishment is a
common technique.

To get Rose to chart adequately, the manager supervised Rose’s charting daily until
Rose achieved an acceptable level of charting. Rose found the task laborious and humiliat-
ing. As a result, Rose was soon charting appropriately.

Because punishment is negative in character, an employee may instead fail to
improve and also may avoid the job. Undesirable behavior will be suppressed only as
long as the employee is monitored and the threat of punishment is present. Conversely,
positive reinforcement is the best way to change behavior.

Extinction is another technique used to eliminate negative behavior. By removing
a positive reinforcer, undesired behavior is extinguished.

Jasmine was a chronic complainer. To curb this behavior, her manager chose to ignore
her many complaints and not try to resolve them. Initially, Jasmine complained more,
but eventually she realized her behavior was not getting the desired response and stopped
complaining.

A problem with behavior modification is that there is no sure way to elicit the
desired behavior so that it can be reinforced. In addition, staff and the manager may
view consequences differently.

As a new employee, Thad conscientiously completed critical paths for his assigned
patients. When the manager recognized Thad for his good work, his peers began to
exclude him from the group. Although the manager was attempting positive reinforce-
ment, Thad quit completing critical paths because he felt the manager had alienated him
from his coworkers.

Another procedure is shaping. Shaping involves selectively reinforcing behaviors
that are successively closer approximations to the desired behavior. When people
become clearly aware that desirable rewards are contingent on a specific behavior,
their behavior will eventually change.

Behavior modification works quite well, provided that rewards can be found
that employees, in fact, see as positive reinforcers, and provided that such rewards
are contingent on performance. This does not mean that all rewards work equally
well or that the same rewards will continue to function effectively over a long time.
If someone is praised four or five times a day every day, the praise would soon begin

Motivating and Developing Staff 275

to wear thin: It would cease to be a positive reinforcer. Care must be taken not to
overdo a good thing.

Like reinforcement theory, expectancy theory (Vroom, 1964) emphasizes the
role of rewards and their relationship to the performance of desired behaviors.
Expectancy theory regards people as reacting deliberately and actively to their
environment.

In an effort to improve the amount of delegation by the nurses on her unit, Andrea
approached the situation from an expectancy theory perspective. She identified that the
nurses wanted to assign more duties to assistive personnel but were reluctant because of
concerns about liability. Once Andrea was able to clarify liability issues, the nurses were
eager to delegate tasks that could be performed by nonlicensed staff in order to devote
more time to their professional responsibilities.

Expectancy theory also considers multiple outcomes. Consider the possibility of a
promotion to nurse manager. Even though a staff nurse believes such a promotion is
positive and is a desirable reward for competent performance in patient care, the nurse
also realizes there are possibly some negative outcomes (e.g., working longer hours,
losing the close camaraderie enjoyed with other staff members). These outcomes may
influence the staff nurse’s decision.

Similarly, equity theory suggests that a person perceives that one’s contribution to
the job is rewarded in the same proportion that another person’s contribution is
rewarded. Job contributions include such things as ability, education, experience, and
effort, whereas rewards include job satisfaction, pay, prestige, and any other outcomes
an employee regards as valuable (Adams, 1963, 1965).

Unlike expectancy theory and equity theory, goal-setting theory suggests that it is
not the rewards or outcomes of task performance per se that cause a person to expend
effort but, rather, the goal itself (Locke, 1968).

Timothy was new to a home care hospice program. An important skill in care with the
terminally ill is therapeutic communication. Timothy and his manager recognized that
he needed help to improve his skills in communicating with these patients and their fami-
lies. His manager asked him to write two goals related to communication. Timothy
expressed a desire to attend a communications workshop and also indicated he would try
at least one new communication technique each week. Within a month, Timothy’s thera-
peutic communication skills had already improved. As a result, Timothy was more satis-
fied with his position, his patients received more compassionate care, and Timothy found
his work more rewarding.

Each theory of work motivation contributes something to our understanding of,
and ultimately our ability to influence, employee motivation.

Staff Development
Developing staff begins as soon as employees are hired. Orientation begins the pro-
cess, followed by on-the-job-instruction and the use of preceptors. In addition, nurse
residency programs help nurse graduates transition into the nursing role, and mentors
and coaches can be helpful during the nurse’s career. Career progression and leader-
ship advancement are additional development approaches.

276 Chapter 18

Orientation
Getting an employee started in the right way is essential. Orientation is the training a
new employee undergoes on organizational structure and expectations as well as job-
specific tasks. A well-planned orientation reduces the anxiety that new employees feel
when beginning the job. In addition, socializing the employee into the workplace con-
tributes to unit effectiveness by reducing dissatisfaction, absenteeism, and turnover.

Orientation is a joint responsibility of both the organization’s staff development
personnel and the nurse manager. In most organizations, the new staff nurse com-
pletes the orientation program, whereupon the nurse manager (or someone appointed
to do this) provides an on-site orientation. Staff development personnel and unit staff
should have a clear understanding of their respective, specific responsibilities so that
nothing is left to chance. The development staff should provide information involving
matters that are organization-wide in nature and relevant to all new employees, such
as benefits, mission, governance, general policies and procedures, safety, quality
improvement, infection control, and common equipment. The nurse manager should
concentrate on those items unique to the employee’s specific job.

New employees often have unrealistically high expectations about the amount of
challenge and responsibility they will find in their first job. If they are assigned fairly
undemanding, entry-level tasks, they feel discouraged and disillusioned. The result is
job dissatisfaction, turnover, and low productivity.

So, one function of orientation is to correct any unrealistic expectations. Specifi-
cally what is expected of the new employee should be delineated. Such realistic job
previews help prevent early departures from the organization and, possibly, the nurs-
ing profession.

Socializing new employees can sometimes be difficult because of the anxiety peo-
ple feel when they first come on the job. They simply do not hear all of the information
they are given. They spend a lot of energy attempting to integrate and interpret the
information presented, and consequently they miss some of it. So repetition may be
necessary the first few days or weeks on the job. Ongoing follow-up is important.

Trina Prescott, RN, joined the pediatric oncology unit of a large university teaching
hospital. Her nurse manager, Lily Yuen, scheduled a lunch with Trina 30 days after she
started. Lily had a relaxed conversation with Trina about the first 30 days of her employ-
ment. Trina expressed how much she enjoyed her new job, but that she still felt uncom-
fortable accessing implanted vascular ports without assistance. Lily makes a note to
schedule one-on-one teaching for Trina with a nurse from the IV team. Scheduling a
lunch with new employees approximately 30 to 60 days into their employment has
improved new employee retention and increased open communication between Lily and
her staff.

On-the-job Instruction
The most widely used educational method is on-the-job instruction, which often
involves assigning new employees to experienced nurse peers, preceptors, or the
nurse manager to learn by observing the experienced employee and by performing the
actual tasks under supervision.

On-the-job instruction has several positive features, one of which is its cost-
effectiveness. New nurses learn effectively at the same time they are providing care.
Moreover, this method reduces the need for outside instructional facilities and reliance

Motivating and Developing Staff 277

on professional educators. Transfer of learning is not an issue because the learning
occurs on the actual job. However, on-the-job instruction often fails because there is no
assurance that accurate and complete information is presented, and the instructor may
not know learning principles. As a result, presentation, practice, or feedback may be
inadequate or omitted.

On-the-job instruction fulfills an important function; however, staff members
involved may not view it as having equal value to more standardized and formal
classroom instruction.

To implement effective on-the-job instruction, the following are suggested:

• Employees who function as educators must be convinced that educating new
employees in no way jeopardizes their own job security, pay level, seniority, or
status.

• Individuals serving as educators should realize that this added responsibility will
be instrumental in attaining other rewards for them.

• Teachers and learners should be paired to minimize any differences in back-
ground, language, personality, attitudes, or age that may inhibit communication
and understanding.

• Teachers should be selected on the basis of their ability to teach and their desire to
take on this added responsibility.

• Staff nurses chosen as teachers should be carefully educated in the proper meth-
ods of instruction.

• Assignments should be formalized so nurses do not view on-the-job instruction as
happenstance or second-class instruction.

• Learners should be rotated to expose each one to the specific know-how of various
staff nurses or education department teachers.

• Employees serving as teachers should understand that their new assignment is by
no means a chance to get away from their own jobs but that they must build
instructional time into their workload.

• The efficiency of the unit may be reduced when on-the-job instruction occurs.

• The learner must be closely supervised to prevent him or her from making any
major mistakes and carrying out procedures incorrectly.

Preceptors
One method of orientation is the preceptor model, which can be used to assist new
employees and to reward experienced staff nurses. Preceptors continue the new
nurse’s orientation by socializing the individual to the organization and the unit, being
available to answer questions, and helping the new nurse to problem solve. In addi-
tion, being selected as a preceptor is a way to recognize exceptionally competent staff
nurses. Staff nurses who serve as preceptors are selected based on their clinical compe-
tence, organizational skills, ability to guide and direct others, and concern for the effec-
tive orientation of new nurses.

The primary function of the preceptor is to orient the new nurse to the unit. This
includes proper socialization of the new nurse within the group as well as familiariz-
ing her or him with unit functions. The preceptor teaches any unfamiliar procedures
and helps the new nurse develop any necessary skills. The preceptor acts as a resource
person on matters of unit functions as well as policies and procedures. The

278 Chapter 18

preceptorship is for approximately 3 weeks, although the time may vary depending
on the nurse’s individual learning needs or the organization’s policies.

New graduates may need to use their preceptors as counselors as they make
their transition to the unit. If new graduates experience discrepancy between their
educational preparation or their expectations and the realities of working in the unit,
the preceptor’s role as counselor can prove invaluable in helping them cope with
“reality shock.”

The preceptor also serves as a staff nurse role model, demonstrating work-
related tasks, how to set priorities, solve problems and make decisions, manage time,
delegate tasks, and interact with others. In addition, the preceptor evaluates the new
nurse’s performance and provides both verbal and written feedback to encourage
development.

The staff development department’s function is to teach the experienced nurse the
role of a preceptor, principles of adult education applicable to learning needs, how to
teach necessary skills, how to plan teaching, how to evaluate teaching and learning
objectives, and how to provide both formal and informal feedback.

Mentoring
Mentoring is another strategy to help nurses flourish in their careers (Patten, 2012).
Mentors play a greater role than preceptors in developing staff. Precepting usually is
associated with orientation of staff, whereas mentoring occurs over a much longer
period and involves a bigger investment of personal energy.

A mentor is a wiser and more experienced person who guides, supports, and nur-
tures a less experienced person. Mentors are usually the same sex as the protégé, 8 to
15 years older, highly placed in the organization, powerful, and willing to share their
experiences. They are not threatened by the mentee’s potential for equaling or exceed-
ing them. Mentees are selected by mentors for several reasons: good performance, loy-
alty to people and the organization, a similar social background or a social acquaintance
with each other, appropriate appearance, an opportunity to demonstrate the extraordi-
nary, and high visibility.

Mentor–mentee relationships typically advance through several stages. The initia-
tion stage usually lasts 6 months to a year, during which the relationship gets started.
During the mentee stage, the mentee’s work is not yet recognized for its own merit
but, rather, as a by-product of the mentor’s instruction, support, and encouragement.
The mentor thus buffers the mentee from criticism.

A breakup stage may occur between 6 months and 2 years after a significant
change in the relationship, usually resulting from the mentee taking a job in another
department or organization so that a physical separation of the two individuals occurs.
It also can occur if the mentor refuses to accept the mentee as a peer or when the rela-
tionship becomes dysfunctional for some reason. The lasting friendship stage is the
final phase and will occur if the mentor accepts the mentee as a peer or if the relation-
ship is reestablished after a significant separation. The complete mentoring process
usually includes the last stage.

Coaching
Coaching is a strategy that helps the recipient focus on solving a specific problem or
conflict (Thorn & Raj, 2012). Coaches are often nurses or human resources staff within
the organization prepared to help resolve conflicts. Conflicts could be occurring

Motivating and Developing Staff 279

between two nurses, between a nurse and a patient, or between a nurse and a physi-
cian. In a confidential environment, the coach helps the staff member explore the exact
nature of the problem, consider various alternatives (e.g., transfer, quit, do nothing),
delve into embedded issues (e.g., values conflict with organization, unmatched expec-
tations), discover links (e.g., working with friends), and identify the disadvantages of
leaving (e.g., start over with vacation time, benefits, leave friends). The goal is to
reduce turnover from issues that can be resolved.

Nurse Residency Programs
Residency programs, typically 12 or 18 months in length, are designed to acclimate
new graduates to the work environment (Little, Ditmer, & Bashaw, 2013). Residency
programs appear to be beneficial to both the nurse and the organization (Fiedler, Read,
Lane, Hicks, & Jegler, 2014). Surveying members of the American Organization of
Nurse Executives, Pittman and colleagues (2013) found that approximately one third
of reporting hospitals offered nurse residency programs for new graduates. Chappell
(2014) found that residency fellowship programs supported an institution’s goal
toward Magnet certification. Furthermore, residencies may encourage nurses to stay
with the organization (Rosenfeld, Glassman, & Capobianco, 2015).

Career Advancement
One example of a career advancement development strategy is the clinical ladder pro-
gram. It uses a system of performance indicators to advance an employee within the
organization. The following are the key components:

• Horizontal promotion

• Clinical ladder

• Clinical mentee

Horizontal promotion rewards the excellent clinical nurse without promoting the
nurse to management. A clinical ladder, based on Benner’s (2000) novice-to-expert
concepts, includes the following:

• Clinical apprentice—new nurse or nurse new to the area

• Clinical colleague—a full partner in care

• Clinical mentee—demonstrates preceptor ability

• Clinical leader—demonstrates leadership in practice

• Clinical expert—combines teaching and research with practice

The strength of the system is that superb, clinical nurses can remain at the bed-
side, clinical excellence can be rewarded, and nurses can move back and forth among
the levels based on their personal and professional goals and needs.

Another example of a clinical advancement program was used at a Magnet-
certified institution, Cincinnati Children’s Hospital Medical Center (Allen, Fiorini, &
Dickey, 2010). The program’s goal was to improve the quality of patient care, provide
career opportunities for participating nurses, and enhance job satisfaction and nurse
retention. Evaluation of the program illustrated that goals were met. An additional
finding revealed that the program had a substantial positive fiscal impact on the orga-
nization as well.

280 Chapter 18

Leadership Development
Developing internal staff is a cost-effective way to build leaders within the organization.
The advantages include knowledge of the skills and strengths of the candidates, the cost
saving in retaining high-performing staff, and the ability to design a program that fits
the organization’s specific needs. In fact, many nurse leaders fail not because they do not
want to do the job, but because they do not have the leadership tools required.

Built around Benner’s novice-to-expert concepts (Benner, 2000), one hospital
designed a leadership curriculum that targeted the learning needs of staff at different
developmental levels—for example, 200 level for charge nurses, 300 level for assistant
nurse managers, 400 level for nurse managers (Swearingen, 2009). As a result, the
organization developed a pool of candidates available for promotion to higher-level
positions. In addition, they found nurse retention rates improved.

CASE STUDY 18-1 | Motivating Staff
Jamie Edgar is nurse manager of the mental health outpa-
tient clinic for a large county health department. Her staff
includes nurses, licensed clinical social workers, licensed
mental health technicians, and clerical support staff. State
funding for mental health services has been drastically cut.
Jamie had a difficult decision to make regarding who on the
staff would receive pay increases, and who would not.
Compounding her problem is the shortage of qualified psy-
chiatric nurses and two vacant nursing positions that she
has been unable to fill due to the low starting salary.

Jamie decides that the nursing staff will receive a 4%
raise and the licensed clinical social workers will receive a
3% raise. The mental health technicians and clerical staff
will not receive a wage increase this year. The mental health
technicians and clerical staff members are upset when
Jamie tells them there will not be any pay increases this
year. Kevin Adams, a licensed mental health technician,
and Charlotte DuBois, an administrative assistant, have
both expressed frustration about the disparity in pay
increases. Over the past two workweeks, Kevin has been
clocking in 10 minutes late each workday and taking longer
lunch periods than scheduled. The quality of Charlotte’s
work has decreased, and she is using more business time
for personal telephone calls and personal business.

Jamie is concerned that the negative attitudes exhib-
ited by Kevin and Charlotte will continue to affect their
work as well as the morale of the staff. Initially, she tried
more frequent praise of their work, but after 3 weeks she
noted no improvement in their attitude or performance.
She counseled each employee individually about perfor-
mance expectations; however, neither employee made an
effort to improve behavior. After receiving a final budget
for her clinic, Jamie allocated $800 for training of clerical
staff and mental health technicians. She met with Kevin,

Charlotte, and two other staff members. Jamie asked the
group to assist her in determining how to best spend
the $800 training budget. The group agreed that time-
management skills could be improved among many of the
staff. After reviewing the cost associated with several
time-management training programs, the group was sur-
prised at the expense. Jamie challenged her group to
think of alternative ideas other than sending staff mem-
bers to a seminar and offered a restaurant gift certificate
for the most creative ideas.

At their next meeting, Kevin produced reviews of sev-
eral interactive CD-ROM training programs. Kevin had
searched the Internet for the best price for the programs
and brought in several demonstration CDs of the top two
time-management programs. Charlotte proposed purchas-
ing planners for those staff members who did not already
have a planner or electronic calendar. Charlotte had spoken
to the supplier who had the contract for county office sup-
plies. They had agreed to a price of $12 per planner for a
complete year of time-planning supplies. The group agreed
that the ideas submitted by both Kevin and Charlotte were
excellent, in addition to them coming in under the $800 limit.

Kevin and Charlotte were responsible for implement-
ing their ideas with staff who requested training in time
management. Although neither employee received a raise
in base salary, Jamie was able to secure approval for both
to work extra hours to complete training for the clinic staff.
Jamie continued to praise both employees for their com-
mitment to the clinic and their coworkers. Kevin began to
arrive promptly for each work shift and kept his lunch peri-
ods to 30 minutes. Charlotte was eager to demonstrate to
coworkers how her new planner helped her prioritize work
and personal tasks. Her use of work time for personal busi-
ness greatly decreased.

Motivating and Developing Staff 281

What You Know Now
• Job performance is determined by motivation

and ability.

• Motivational theories (e.g., reinforcement, expec-
tancy, equity, and goal-setting theories) describe
the factors that initiate and direct behavior.

• Orientation methods include on-the-job instruc-
tion and the use of preceptors.

• Nurse residencies, career advancement opportu-
nities, and leadership development programs can
help motivate staff members.

• Succession planning is a strategic process to
develop future nurse leaders.

Tools for Motivating and Developing Staff
1. Recognize that an employee’s job performance

includes both ability to do the job and motivation.
2. Become familiar with various theories of motiva-

tion and use the information to help you moti-
vate others.

3. Be aware that you may be a role model to other
staff regardless of your formal position.

4. Identify core competencies involved in specific
positions and high performers with the potential
to fill those positions.

5. Encourage staff development at all levels, includ-
ing your own.

Succession Planning
Due to an aging nursing workforce, as well as the overall shortage of nurses, succes-
sion planning at all levels of nursing management is essential to ensure a smooth tran-
sition after a manager leaves or retires (Ponti, 2009). Succession planning is a strategic
process that is a natural outgrowth of leadership development. It involves identifying
core competencies required at each level of management, recognizing potential
recruits, and providing opportunities for development and growth.

One institution developed a nurse management internship program to prepare
first-line managers from an internal pool of interested nurses (Wendler, Olson-Sitki, &
Prater, 2009). The 1-year program successfully prepared several nurses for manage-
ment positions in its first year. Those costs were recouped when a long-term manage-
ment opening was filled b y one of the nurses who completed the internship.

There is no single way to motivate people. The organization and the manager
must use various tools to offer incentives and rewards that satisfy their staff. Increased
productivity, patient care quality, job satisfaction, and retention are all outcomes that
can result in appropriate motivational activities.

Case Study 18-1 illustrates how one nurse manager used her ingenuity to moti-
vate staff.

282 Chapter 18

Questions to Challenge You
1. What motivational theory appeals to your sense

of how you learn? Why?
2. You are a new nurse manager:

a. How would you discover what motivates the
individuals on your staff?

b. How could you utilize the organization’s
resources to motivate your staff?

c. What staff development programs are avail-
able in your organization or community?

d. How could you make those resources avail-
able to your staff?

3. What recommendations would you make to a
new nurse manager regarding motivating staff?
Have you seen any of these work? Explain.

References
Adams, J. S. (1963). Toward an understanding of

inequity. Journal of Abnormal and Social Psychology,
67, 422.

Adams, J. S. (1965). Injustice in social exchange. In
L. Berkowitz (Ed.), Advances in experimental social
psychology (Vol. 2, pp. 267–299). New York, NY:
Academic Press.

Allen, S. R., Fiorini, P., & Dickey, M. (2010). A
streamlined clinical advancement program
improves RN participation and retention. Journal
of Nursing Administration, 40(7/8), 316–322.

Benner, P. (2000). From novice to expert: Excellence and
power in clinical nursing practice. Upper Saddle
River, NJ: Prentice Hall.

Chappell, K. (2014). The value of RN residency and
fellowship programs for Magnet® hospitals.
Journal of Nursing Administration, 44(6), 313–314.

Fiedler, R., Read, E. S., Lane, K. A., Hicks, F.
D., & Jegler, B. J. (2014). Journal of Nursing
Administration, 44(7/8), 417–422.

Hersey, P., Blanchard, K. H., & Johnson, D. E. (2012).
Management of organizational behavior (10th ed.).
Upper Saddle River, NJ: Pearson.

Little, J. P., Ditmer, D., & Bashaw, M. A. (2013). New
graduate nurse residency: A network approach.
Journal of Nursing Administration, 41(6), 361–366.

Locke, E. A. (1968). Toward a theory of task motives
and incentives. Organizational Behavior and Human
Performance, 3, 157.

Patten, C. S. (2012). Mentor and protégé: A mutually
beneficial relationship. American Journal of Nursing,
112(1), 17, 18.

Pittman, P., Herrera, C., Bass, E., & Thompson,
P. (2013). Residency programs for new nurse
graduates: How widespread are they and what
are the primary obstacles to further adoption?
Journal of Nursing Administration, 43(11),
597–602.

Ponti, M. D. (2009). Transition from leadership
development to succession management. Nursing
Administration Quarterly, 33(2), 125–141.

Rosenfeld, P., Glassman, K., & Capobianco, E. (2015).
Journal of Nursing Administration, 45(6), 331–338.

Skinner, B. F. (1953). Science and human behavior. New
York, NY: Free Press.

Swearingen, S. (2009). A journey to leadership:
Designing a nursing leadership development
program. Journal of Continuing Education in
Nursing, 40(3), 107–112.

Thorn, P. M., & Raj, J. M. (2012). A culture of
coaching: Achieving peak performance of
individuals and teams in academic health centers.
Academic Medicine, 87(11), 1482–1483.

Vroom, V. H. (1964). Work and motivation. New York,
NY: Wiley.

Wendler, M. C., Olson-Sitki, K., & Prater, M. (2009).
Succession planning for RNs. Journal of Nursing
Administration, 39(7/8), 326–333.

Chapter 19

Evaluating Staff
Performance

Learning Outcomes

After completing this chapter, the learner will be able to:

1. Describe the manager’s role in performance management.

2. Explain the components of a successful performance evaluation
process.

3. Examine a variety of methods for collecting performance data.

4. Anticipate and address the challenges of performance review.

5. Set the stage for a successful performance review that clearly identifies
performance strengths and weaknesses within a trusting environment.

Key Terms
behavior-oriented performance

evaluation

developmental plan

performance evaluation

performance management

peer review

self-evaluation

skill competency

Performance Management

The Performance Evaluation Process
Management Responsibilities

Components of the Annual Performance Evaluation

Developing Evaluation Tools

Methods for Collecting Performance
Data

Peer Review

Self-evaluation

Skill Competency

Manager’s Evaluation

Facing the Challenges of Performance
Review

Conducting the Annual Performance
Review

283

284 Chapter 19

Introduction
The evaluation process, both formative and summative, provides a pivotal opportu-
nity to grow and develop staff, enhance workplace health, and improve patient satis-
faction, physician satisfaction, and patient care quality. A high-functioning unit, free of
performance issues, results in the most cost-effective healthcare. A unit burdened by
tardy staff, staff who abuse paid time off (PTO) or sick leave, or staff who bully and
produce turnover, is expensive to run.

Performance evaluation is one of the most important accountabilities of the nurse
manager. The nurse manager who gets into the rhythm of evaluation, considering it a
part of daily work, will be highly successful.

Organizations manage the formal evaluation process in many ways. Some have
transitioned the process to the same time of the year. To prepare for the formal review,
all meetings scheduled for the previous month are cancelled to allow the manager and
staff to focus on performance review. The manager should be rewarded for conscien-
tiousness and timely reviews. The manager, in addition, should be allowed to reward
high-performing staff members within the structure of organizational policy.

Performance Management
Performance management includes the systems, policies, procedures, positions des-
criptions, and evaluation components essential to providing consistent, high-quality
nursing practice. The key to successful performance management is setting up sys-
tems that create what Daniels and Daniels (2004) call the “ABC Model.” “A” is for
antecedents—those tangibles and intangibles that prompt behaviors, like position
descriptions, career ladders, journal clubs, and performance evaluations. “B” is for
behaviors—what a staff member says and does. Perhaps the most important is “C” for
consequences, which can be positive and negative—salary increases, feedback, being
able to attend a conference or work off-site, staying flat on the clinical ladder, being
passed over for a promotion, receiving a small or no salary increase, or denial of a spe-
cific vacation request due to performance. Performance management systems without
consequences are doomed to fail because behavior will never change.

At the unit level, a manager who does not use the ABC model will generally not
be successful in improving unit performance.

The Performance Evaluation Process
Performance evaluation, or appraisal, is one component of performance management.
As stated, it can be an antecedent, or a guide for behavior, and, in the ABC model, a
consequence. Therefore, it is a pivotal process. The goal of performance evaluation is
to support nursing practice development (Schoessler et al., 2008). Evaluating perfor-
mance by comparison to standardized behavioral expectations enables the manager to
identify developmental needs of the employee. Performance-related behaviors should
be directly associated with the role and must be accomplished to achieve a job’s objec-
tives (Topjian, Buck, & Kozlowski, 2009). Evaluating performance is both a daily and
annual role of the manager. Excellent performance assessment ensures patient safety,
addresses performance issues when they arise, and provides staff with a clear view of
management expectations for performance. Unit quality and workplace health will be
superior with consistent performance evaluation.

Evaluating Staff Performance 285

The best performance evaluations are based on transparent behavioral criteria
(see Table 19-1), provide an opportunity for input by not just management but by the
individual and team members, include positive and constructive feedback, and finally,
provide a developmental plan for performance improvement. Performance appraisals
serve as tools to grow staff as well as to provide vital information for salary increases
and career progression.

Table 19-1 Employee Performance Evaluation Form

Employee Name: _________________________

Position: Clinical Nurse I

Department: _________________________

Hire Date: _________________________

Evaluation Period: _________________________

Manager Reviewer: _________________________

This appraisal contains a five-point scale rating for each performance expectation. The description of the ranking on the five-point scale is as follows:

5 Significantly Exceeds Expectations: Staff member consistently goes above and beyond ordinary expectations. Mentors or coaches staff in
this category. Staff member is a role model of excellence—in the top 5% of nurses.

4 Exceeds Expectations: Staff member frequently does things that are beyond routine expectations. Peers, patients, colleagues (including
physicians) comment that staff member goes beyond what others do and exceeds routine expectations.

3 Meets Expectations: Staff member meets expectations of the position.

2 Usually Meets Expectations: Staff member meets performance expectations at times yet not consistently.

1 Does Not Consistently Meet Expectations: Performance is below the standard behaviors in the position description.

Core Performance Expectations

Does Not
Consistently
Meet
Expectations 1

Usually Meets
Expectations 2

Meets
Expectations 3

Exceeds
Expectations 4

Significantly
Exceeds
Expectations 5

Examples

1. Demonstrates accountability for the
regulatory obligations of a licensed
professional nurse including procurement
and renewal of license, continuing
education, and other regulatory
requirements, including the identification
and potential reporting of violations of the
nurse practice act

2. Practices solid communication skills and
is able to translate the patient’s condition
to physicians and other colleagues,
negotiate and make recommendations
for changes in patient care

3. Seeks constant feedback on
performance, adjusts behavior, and
actively participates in peer review

4. Serves as an active member of the
multidisciplinary team

5. Role models the professional image of a
nurse through the eyes of a patient at all
times and in all settings

6. Practices continuous learning to enhance
performance and shares opportunities
with staff.

7. Maintains a healthy working environment
by demonstrating respect and dignity for
all, creating positive relationships, and
supporting patients, families, and team
members

(Continued)

8. Serves as a leader in clinical nursing
practice, identifying patient- and staff-
focused opportunities for improvement

9. Flexible with staffing and works with
peers to meet the needs of patients

10. Works in harmony with coworkers, settles
conflict professionally, and serves as an
active member of the team

Position-Specific Performance Expectations

Does Not
Consistently
Meet
Expectations 1

Usually Meets
Expectations 2

Meets
Expectations 3

Exceeds
Expectations 4

Significantly
Exceeds
Expectations 5

Examples

1. Consistently uses the nursing process as a
framework for planning and coordinating
patient care that provides continuity and
patient involvement

2. Serves as a leader in clinical practice,
identifying patient- and staff-focused
opportunities for improvement and leads
efforts for change

3. Practices participatory leadership and
actively serves in shared leadership

4. Demonstrates critical thinking in the analysis
of clinical, social, safety, psychological, and
spiritual issues for the patient within the
episode of care

5. Practices solid communication skills and is
able to articulate and translate the patient’s
condition to physicians and other colleagues

6. Serves as an active member of at least one
professional organization

7. Mentors and supports the development of
other staff

8. Disseminates new professional knowledge
and innovations through presentations,
posters, and publications

9. Integrates best practices and research into
daily work through study and application of
research

10. Creates a caring and compassionate
patient-focused experience by building
healthy relationships

Development Goals for Coming Year

Describe three realistic and measurable goals that address opportunities for improvement and professional growth. Examples of goal categories
might be education, relationships, attitude, leadership, and so on. How can your manager support this goal?

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

Signatures

This verifies that this review was completed and does not necessarily signify agreement or disagreement with the contents of the review.

___________________________________________________________________________________________________________________________

Employee’s Signature

Date ___________

Manager’s Signature ____________________ Date ____________

Human Resource’s Signature ________________ Date ____________

Table 19-1 Employee Performance Evaluation Form (Continued)

Evaluating Staff Performance 287

There should be no surprises at the performance appraisal. The annual formal
performance evaluation should be a pool of observations collected for a year, an
opportunity to dialogue about performance improvement, and finally, the time for set-
ting goals for the coming year with a plan for achievement.

Management Responsibilities
Timely completion of annual performance evaluations for all staff is one of the most
important issues in responsible management. Creating, with the staff member, an
annual developmental plan with clear and measureable goals that will be used in the
performance evaluation in the coming year is critical to the performance appraisal
process. Other responsibilities of the manager include the following:

• Being consistently present and visible on the unit to directly assess individual
employee performance throughout the year (A manager who is never on the unit
cannot assess the overall performance of the unit. Feedback from physicians,
patients, and colleagues about the performance of the staff member should be col-
lected on a regular basis, not just once a year. Feedback should be shared with the
staff member as it occurs.)

• Providing concrete examples of performance that clarify the numeric rating

• Assessing employee performance within the dedicated position description, or
on a career ladder, as compared to others with like experience and position
descriptions

• Coordinating a peer review process that, if used, is open, transparent, and fosters
unit trust

• Collecting information from patients as well as other nonnursing colleagues—
such as physicians, pharmacists, and others—about the performance of the staff
member

• Coaching the staff member in how to write a self-evaluation with measurable
goals for the coming year

• Consistently following policies and procedures for evaluation of staff in order to
comply with regulatory, union, and other standards

• Preparing for the evaluation by reviewing all materials for concrete patterns, writing
the evaluation, and setting the stage for a respectful dialogue about performance

• Asking for help, if needed, from a mentor, seasoned colleague, or human resources
professional about a strong performance evaluation

Components of the Annual Performance Evaluation
The five primary components of the formal evaluation are (1) multifaceted behavior-
oriented criteria, (2) feedback on the level of performance of the criteria against a rat-
ing scale, (3) concrete examples of performance or the lack of performance, (4) staff
member self-evaluation of performance, and (5) developmental plan for performance
improvement.

The role of the nurse has many dimensions. The performance evaluation should
mirror the expectations of these dimensions. Expectations fall into different categories
and can be clustered in any number of ways, but all performance evaluations should
share core behaviors, and the expectations of all staff within a certain job category

288 Chapter 19

should be the same. In addition, evaluations should include performance or domain
clusters that reflect higher or unique expectations related to the functions of nursing.
These might include the nursing process, teaching, research, leadership, and clinical
quality (Honour, 2013). Each major cluster will have subcategories that may be clinical
or unit specific.

Developing Evaluation Tools
In order to clarify expectations and drive performance improvement, the evaluation
tools should link to the position description, be behavior oriented, and focus on the val-
ues of the organization and the expectations of staff required to create a healthy work-
place and a culture of quality and safety. Some examples of generic behaviors that might
be included in all performance evaluations are described in Table 19-1. This table also
provides examples of behaviors that might be unique to certain position descriptions.

Although there are many varieties of behavior-oriented performance evaluation,
effective systems will include the following elements:

• Values of the Organization. Each organization has a mission statement, and often
a values statement. Hospitals pursuing Magnet Recognition focus their evaluation
systems around creating exemplary professional practice that includes the appli-
cation of research in the clinical setting. Common threads in the performance eval-
uation for staff would include such areas as leadership, evidence-based practice,
shared governance, mentoring and developing staff, and improving quality.

• Position Descriptions. Career ladders include specific position descriptions that
clarify expectations for performance. The performance evaluation is then directly
linked to the behaviors in the performance evaluations.

• Cluster Behaviors. Group behaviors within the performance evaluation are clus-
tered within performance categories. Opportunities for performance improve-
ment become clearer when a weakness is visible in a performance category, such
as leadership or building relationships (with patients and colleagues).

• Examples. The evaluator should provide specific examples of behaviors that speak
to the rating given.

• Developmental Goals. The evaluation should include the individual’s goals for
the past year and how they were met. Goals should be realistic, measurable, and
attainable. Goals for the next year should be set at the annual evaluation.

Methods for Collecting
Performance Data
Evidence of an individual’s performance should be collected in a variety of ways.
These methods include peer review, self-evaluation, skill competency, and the man-
ager’s notes and evaluation.

Peer Review
The American Nurses Association (ANA) first published Peer Review Guidelines in
1988 and defined peer review as “the process by which practicing registered nurses
systematically assess, monitor, and make judgments about the quality of nursing care

Evaluating Staff Performance 289

provided by peers as measures against professional standards of practice” (American
Nurses Association, 1988). Peer review is seen as an essential component of contempo-
rary nursing practice by the Magnet Recognition Program, the ANA, and the Institute
of Medicine (Burchett & Spivak, 2014). The purpose of peer review is to reinforce the
quality of patient care and the caliber of professional nursing practice by evaluating
practice by peers. Peer review principles are listed in Box 19-1 (Haag-Heitman &
George, 2011).

The role of the manager in peer review is as follows:

• Set the stage for a positive and trusting peer review by creating a transparent pro-
cess with the staff.

• Work with the staff member to select peers who can provide current and unbiased
feedback.

• Coach staff members on how to write constructive and positive feedback that
speaks to the expertise of the nurse and the domains of practice.

• Review peer comments and circle back with staff if comments are unclear, puni-
tive, disrespectful, or not focused on professional practice.

• Coach the staff member on how to receive feedback from peers, including express-
ing thanks.

• Share the peer review feedback with the staff member, or create a safe space for
the delivery of peer review, in person or peer to peer.

Self-evaluation
Self-evaluation is a critical component of performance evaluation because it fosters
reflection, an essential component of professional nursing practice and a strategy for
learning. Reflection is the deliberate process of critically thinking about a clinical
experience. This self-analysis leads to insights in performance that may change pro-
fessional practice. Nursing scholars propose that reflection provides the nurse
with the opportunity to build on existing knowledge through clinical experiences,
develop clinical judgment, promote strong communication skills, build collaborative
practice, and improve patient care (Miraglia & Asselin, 2015). Reflection tools,

Box 19-1 Components of a Successful
Peer Review Process

1. The peer is someone of the same rank as the person evaluated.
2. Peer review is practice focused.
3. Feedback is timely, routine, and a continuous expectation.
4. Peer review fosters a continuous learning culture of patient safety and best practice.
5. Feedback is not anonymous.
6. Feedback considers the nurse’s developmental stage.

Source: Haag-Heitman, B., & George, V. (2011). Nursing peer review: Principles and practice. American Nurse Today, 6(9). Retrieved April 29,
2015, from http://www.americannursetoday.com/nursing-peer-review-principles-and-practice

http://www.americannursetoday.com/nursing-peer-review-principles-and-practice

290 Chapter 19

techniques, and strategies can be found in many resources and textbooks (Sherwood
& Horton-Deutsch, 2015).

It is the manager ’s responsibility to guide the staff member through self-
evaluation. The self-evaluation always includes the employee’s assessment of indi-
vidual performance as measured against the criteria in the performance appraisal.
Self-evaluation may also include a portfolio created by the staff nurse to provide
concrete examples of professional practice. The portfolio might include formal
education completed, conferences attended, articles written, classes taught, letters
from patients, and journal entries. It is best to accumulate the portfolio contents
throughout the year rather than at the end of the year. The self-evaluation may
point out blind spots of the employee—that is, performance areas where the nurse
is not aware of the need for improvement. (See Leading at the Bedside: Being
Evaluated.)

Leading at the Bedside: Being Evaluated
Everyone dreads the inevitable performance evaluation,
managers and staff alike. You read in this chapter how
managers can improve evaluations by keeping up with day-
to-day issues and addressing performance problems when
they occur. In the same way, you can keep track of your
progress throughout the year using your organization’s

criteria. Be sure to include positive events as well as prob-
lems, and try to be as honest as possible. Problems are
opportunities for growth.

By following the guidelines in this chapter and apprais-
ing your own performance, you will be prepared for your
formal evaluation.

Developmental plan The final component of the self-evaluation is the staff
member’s goals for the coming year, which are the basis of the developmental plan.
The goals are derived from a process of looking back at past performance and look-
ing forward at performance improvement. These goals become a part of the devel-
opmental plan. The developmental plan is built around the goals to create not only
a benchmark for measuring performance next year but also a hopeful career trajec-
tory for the staff member. The ability of staff members to crystallize their analysis of
behavior through goal development is an important piece of the developmental
process. It will give the manager great insight into further blind spots of the staff
member and/or their ambitions for the future. (See Box 19-2 for a sample develop-
mental plan.)

Skill Competency
Skill competency is the ability to perform a skill knowledgeably and safely. Health-
care organizations are required to assess their employees’ ability to perform the func-
tions, skills, and tasks of the position. Validation of competency is an ongoing process,
initiated in orientation, followed up by development, and assessed on an annual basis.
Skill evaluation should be carried out through a variety of methods, including simula-
tion, testing, direct observation, and case studies. The manager plays a key role in
determining the competencies required for each position in the manager’s span of con-
trol. Evidence of skill competency provides additional data for the performance review
as well as the developmental plan.

Evaluating Staff Performance 291

Manager’s Evaluation
The manager’s evaluation is the final piece in the performance evaluation process.
Manager evaluation is formative, meaning ongoing, and summative at the conclusion
of a period of time. Since managers are accountable for the evaluation and develop-
ment of all of their staff, the annual evaluation process can be daunting if the manager
does not view performance evaluation as a daily responsibility.

The manager should create a file for each staff member. This can be done electroni-
cally or on paper. The file can include anecdotal notes that describe, in detail, the per-
formance of the staff member, as a situation occurs. These can be notes of concern or
positive feedback. If constructive feedback is given, a note should be made and should
include the staff member’s response to the feedback. The manager might slip into the
file articles posted by the staff member, presentations given, and notes from patients or
medical staff. The file should be full of evidence by the time the annual performance
review comes around.

The manager prepares for the review by studying the material in the staff folder,
reviewing the skill competency checklist, the staff member’s self-evaluation, and the
results of the peer review. After considering all of the information, the manager writes
the final evaluation and a draft of the developmental plan. The final developmental
plan will be constructed with the staff member and agreed upon together.

Facing the Challenges
of Performance Review
Contemporary managers have many demands on their time. There are regulations to
meet, meetings to attend, budgets to develop and monitor, unannounced accreditation
surveys, patient complaints, and challenging issues that arise between staff and

Box 19-2 Sample Developmental Plan
Name: ________________________________________

Position: _____________________________________

Review Year: ________________________________________

Goal Category Goal Results

Education Enroll in a master’s in nursing program for this fall semester, take
courses and successfully complete them.

Evidence-Based Practice Once a month, search the literature for one professional article, from
any health science, that relates to the care of patients on our unit.
Post the article on the unit intranet site and in the staff lounge.

Relationships Practice conflict management skills that are win—win in nature. Keep
a journal of examples and review with nurse manager once a quarter.

Staff Member Signature: ____________________________ Date: ____________________________

Manager Signature: ____________________________ Date: ____________________________

292 Chapter 19

physicians. It is easy to become swept away by the putting-out-fire mentality of man-
aging operations. The successful manager makes performance assessment a daily
focus and a leadership priority (see Table 19-2).

Conducting the Annual
Performance Review
The evaluation interview is the capstone of a process that has been conducted all year
long and includes feedback from a variety of sources. Even though the evaluation pro-
cess should be transparent, it might still be an anxiety provoking time for even the
highest performing employee.

The following are six recommendations for conducting a successful perfor-
mance review:

1. Create a safe and respectful location in which to conduct the evaluation, and begin
by reminding the staff member how the process works and why performance
appraisal is important. Choose a private location for the meeting. Since most indi-
viduals are nervous at the start of the appraisal, especially new employees who
are facing their first evaluation or those who have not received frequent perfor-
mance feedback over the course of the evaluation period, begin by giving an over-
view of the type of information that was used in making the performance ratings,

Table 19-2 Performance Evaluation Dos and Don’ts

DO DON’T

Make performance evaluation a priority.
It is the finest tool for high unit performance and management success.

Do it just once a year.

Stay visible on the unit. A key accountability of the manager is
development of staff. If the manager is never on the unit, staff’s performance
cannot be assessed, given timely feedback, and coached to improve.

Lose track of employee performance, spend most of the
time off the unit or behind a closed door.

Give timely feedback. Feedback should be given to the staff member
when the behavior, positive and negative, occurs.

Blindside the staff member. Allow time to remediate behavior.

Provide positive as well as constructive feedback. Positive feedback is a
strong reinforcer of behavior. Catch staff doing things right, then recognize
and reward the behavior.

Surprise the staff member at the annual evaluation with
information that has not been shared earlier.

Prepare all year. Keep a file on every employee, take relevant and clear
notes, and respectfully check in with other team members about employee
performance.

Procrastinate and wait until the annual evaluation window.

Take notes that are behavior oriented and linked to the position description
and/or evaluation.

Take notes that are vague or judgmental—for example, the
nurse was “disorganized,” “careless,” or “insubordinate.”

Encourage the employee to engage in serious reflection on
performance through self-evaluation.

Skip the self-evaluation.

Collect feedback from a variety of viewpoints. Assess performance strictly from the manager’s point of view
(POV). The employee works across many relationships: peers,
managers, patients, physicians, other clinicians, and so on.
Assessment only from the manager’s point of view will be
incomplete and potentially inaccurate.

Be prepared. Prepare notes and documents, review all materials, and
appear composed and confident at the performance appraisal.

Be flustered and disorganized.

Be clear about process. Knowledge of process steps creates trust
among staff.

Be secretive. Spring the evaluation process on the staff.

Evaluating Staff Performance 293

such as “In preparing for this review, I relied on the notes I have taken and shared
with you throughout the year. In addition, we have the results of the peer review
process as well as your self-evaluation.” If the self-evaluation was superior, the
manager should specially comment—for example, “You did a great job! I espe-
cially liked how concrete you were with your examples. And your developmental
plan is quite ambitious.”

2. Go through the ratings one by one with the employee. Provide a number of spe-
cific examples of behavior that led to each rating. Be careful not to rush. By sys-
tematically going through the ratings and providing behavioral examples, nurse
managers project an image of being prepared and professional. This is important
for getting the staff nurse to accept the ratings and act on them. In addition, com-
ment when your ratings might be different from the staff member’s—for example,
“You were a little hard on yourself on this rating. Your peers think you’re one of
the best in managing conflict—even the physicians comment about how cool and
respectful you are and how you create win–win situations. Dr. Jones reminded me
of how well you did with Mr. Madden’s family—how upset they were when his
echo wasn’t on time. You diffused the situation beautifully.”

3. Ask the staff member to respond to the ratings. For example, “So what do you
think so far? Are we on target?” Listen, accept, and respond to the employee’s
opinion. This aspect of the evaluation is important as it gives the manager feed-
back on the employee’s ability to reflect on the year’s performance. To carry out
this phase of the interview effectively, the manager must have confidence in the
accuracy of the ratings.

When asked to express reactions, individuals who have received low ratings
might challenge the rater’s judgment—for example, “Don’t you think your stan-
dards are a little high?” If the manager’s judgment is questioned, it is important
not to get defensive. Listen and consider whether the rating was correct. Adjust
if it was not backed up by solid evidence of performance. Ask the nurse about
it—for example, “Can you give me an example? Why do you think this rating is
too low?”

The manager also might say something like “I hear you, but if you look at the
peer review results, your teammates think that you could lighten up on the new
graduates—adjust your expectations and be a little kinder and gentler with feed-
back. Remember when you were a new graduate? Just being a clinical expert
doesn’t make us good teachers or mentors.”

The staff member might say, “Could you be more specific? Give me an exam-
ple.” The manager could reply with something like “Remember Susie Mathis? She
was the new graduate I found crying in the bathroom. We talked about it—you
and I. Remember, your feedback to her was quite harsh, and frankly it particularly
upset her when you told her that she would never make a good nurse.”

4. Decide on specific ways in which performance areas can be strengthened. The
focus of the interview should now shift to the future. No one is perfect. Every per-
son has room for improvement, even the highest performing clinicians. Deficien-
cies or opportunities for improvement should be addressed jointly, creating an
action plan to improve. This should become a part of the developmental plan.
Such developmental activities may include formal training, academic course
work, or on-the-job coaching. Together, you and the staff nurse should write down
the resulting plans.

294 Chapter 19

Because the evaluation may become part of the evidence for career planning
or disciplinary action that might include termination, careful documentation of
performance is essential. If a staff member never receives feedback, the staff mem-
ber may question any decision of the manager.

5. Create an action plan and evaluate the process. Creating an action plan might
include a follow-up meeting to review a revised developmental plan. The man-
ager might have offered to find a mentor for the nurse in another area or help
research education options for professional growth. Or the manager might request
a meeting in a month to talk about how a performance deficiency has been
addressed. Keep an open door and invite the employee to check in with the man-
ager on a regular basis, especially if the employee has questions about how the
manager is viewing performance. It is important that the search for feedback is not just
the manager’s responsibility but also the staff member’s.

6. Ask for feedback. Ask for the employee’s opinion about the process. This is another
valuable evaluation step—for example, “Can you give me some feedback about
the process? How can we improve it for future evaluations?” Allowing the staff
member to provide opinions provides feedback to the manager from the staff
they serve.

What You Know Now
1. Performance evaluations are one component of a

performance management system.
2. Performance evaluation is much more than the

annual review. It should be frequent and regular,
providing immediate feedback, both positive and
constructive.

3. Evaluation tools should be behaviorally oriented,
based on concrete criteria such as position
descriptions, and include a rating scale and the
opportunity for providing concrete examples.

4. There should be no surprises at the annual perfor-
mance review. It should be a time of reflection and
planning developmental goals for the coming year.

5. Evaluating performance should include multiple
sources of feedback, such as peer review, self-
evaluation, skill competency, and the manager’s
evaluation.

6. Conducting an effective performance appraisal is
one of the most challenging yet important respon-
sibilities of the manager.

Tools for Evaluating Staff Performance
1. Familiarize yourself with the performance evalu-

ation policies and procedures, requirements, and
deadlines used in your organization.

2. Keep a file on every staff member with notes and
evidence of performance.

3. Seek assistance from a colleague, mentor, or human
resources professional if unsure how to conduct a
performance review.

4. Conduct the peer review process according to the
accepted guidelines of the American Nurses
Association.

5. Follow the guidelines for conducting a successful
performance appraisal and ask for feedback at
the end of the process.

Evaluating Staff Performance 295

Questions to Challenge You
1. What was your best evaluation experience? What

was important to you? How can you incorporate
the positive aspects of evaluation into your
reviews?

2. What might be the challenges of peer review?
Why should you be aware of them before you
begin the process?

3. What could be the consequences of not includ-
ing a variety of viewpoints in the performance
evaluation?

4. How would you manage a very defensive staff
review without becoming defensive in return?

References
American Nurses Association. (1988). Peer review

guidelines. Kansas City, MO: Author.
Burchett, M. L., & Spivak, M. (2014). Nurse peer

evaluation: A roadmap to professional growth and
development. Nursing Management, 34(8), 18–20.

Daniels, A. C., & Daniels, J. E. (2004). Performance
management: Changing behavior that drives
organizational effectiveness (pp. 49–58). Atlanta, GA:
Aubrey Daniels International.

Haag-Heitman, B., & George, V. (2011). Nursing
peer review: Principles and practice. American
Nurse Today, 6(9). Retrieved April 29, 2015,
from http://www.americannursetoday.com/
nursing-peer-review-principles-and-practice

Honour, M. (2013). Elevating nursing leadership at
the bedside. Newborn and Infant Nursing Reviews
(NAINR), 13(3), 127–130.

Miraglia, R., & Asselin, M. E. (2015). Reflection as
an educational strategy in nursing professional
development: An integrative review. Journal
for Nurses in Professional Development, 31(2),
62–72.

Schoessler, M. T., Aneshansley, P., Baffaro, C.,
Castellan, T., Goins, L., Largaespada, E., . . . &
Stinson, D. (2008). The performance appraisal as
a developmental tool. Journal for Nurses in Staff
Development, 24(3), E12–E18.

Sherwood, G., & Horton-Deutsch, S. (2015). Reflective
practice: Transforming education and improving
outcomes. Indianapolis, IN: Sigma Theta Tau
International.

Topjian, D. F., Buck, T., & Kozlowski, R. (2009).
Employee performance? For the good of all.
Nursing Management, 40(4), 24–29.

http://www.americannursetoday.com/nursing-peer-review-principles-and-practice

http://www.americannursetoday.com/nursing-peer-review-principles-and-practice

296 Chapter 20

Learning Outcomes

After completing this chapter, you will be able to:

1. Define feedback and the keys to successful feedback.

2. Describe the essentials for effective coaching.

3. Contrast the differences between coaching and feedback.

4. Explain how to address performance issues with confrontation.

5. Apply the guidelines for progressive discipline.

6. Identify the essential components of an equitable termination.

Key Terms
discipline

feedback

coaching

confrontation

progressive discipline

termination

verbal warning

written warning

Feedback
Coaching
Feedback versus Coaching

Confronting Behavior
Discipline
Termination

Chapter 20

Feedback
and Coaching,
Disciplining, and
Terminating Staff

296

Feedback and Coaching, Disciplining, and Terminating Staff 297

Introduction
One of the most important yet challenging roles of a manager is being in touch with
employee performance, providing timely and constructive feedback, and coaching for
success. Many managers, especially in their early years, can be conflict averse and
uncomfortable with providing feedback. The effective manager realizes that learning
creates a change in behavior. Often this teachable moment comes through feedback.
The savvy manager focuses on not just poor performance but also on the most impor-
tant reinforcer of behavior: positive feedback. The consequences of ignoring the devel-
opment of staff through feedback and coaching are inevitable. A unit riddled with
patient quality concerns, rising costs, poor workplace morale, and declining patient
and physician satisfaction is a unit void of feedback and performance management.

Feedback
Feedback is the day-to-day process of helping employees evaluate and improve their
performance. Feedback is both positive and constructive. Study after study has
reported that the best prepared nurses provide the finest patient care (Drenkard, 2010).
Therefore, the high-performing nurse manager selects the right blend of staff for the
patient population and makes staff performance improvement a priority. The nurse
manager is only one point of view in providing feedback. The best feedback is compre-
hensive and includes feedback from peers, colleagues (physicians, pharmacists, and
others), and sometimes patients.

Yet collecting information about an employee and providing feedback are proba-
bly among the most difficult responsibilities of a manager. The manager who lacks the
confidence to address performance or is never on the unit tends to avoid, neglect, or
poorly execute feedback. Feedback can address minor and major issues in perfor-
mance. A minor issue might be a new nurse who texts on the job or publicly flirts with
one of the medical students. A major issue ripe for feedback might be sleep impair-
ment, examples of poor judgment, recurrent absenteeism or tardiness, poor sterile
technique, unsafe clinical care, or conflict with peers.

In any situation where a nurse is not performing up to par, the manager must first
“peel the onion” and identify the “why” behind the “what” of behavior. Why is the nurse
performing at this level? Is there something else going on in the nurse’s life? Did the nurse
not receive appropriate training? Is anxiety at work here? Sleep deprivation? Family
problems? The dynamic healthcare environment as well as the mental health and some-
times toxic issues of the workforce, such as substance abuse and bullying, compound the
complexities of feedback. The manager who leads by walking around, by being physically
present on the unit, will be alert to workplace health, quality, and performance issues.

Wiggins (2012) describes essentials for successful feedback and performance
improvement. These and other essential components are listed in Box 20-1.

Coaching
Coaching is a collaborative relationship between a coach and a willing individual that
supports continuing personal, professional and career development through the
acquisition of appropriate skills, actions, and abilities that are crucial to professional
practice. Coaching is an interactive, interpersonal process. It is usually time limited

298 Chapter 20

and focused on achievement of goals. It demands skill on the part of the coach in
facilitating meaningful conversations and letting the nurse learn and, thereby, change
performance (Donner & Wheeler, 2009).

Staples (2012) described the essentials for coaching success, and the author has
adapted the list. For coaching to be effective, the nurse must be ready, willing, and able:

• Ready. The nurse needs to be psychologically able to accept coaching. Coaching is
not therapy or counseling. The chemically impaired nurse or the nurse suffering
from abuse at home may not be ready for coaching on professional development
and usually will require outside intervention. It is very important that the nurse
manager not take on the role of therapist or counselor.

• Willing. The nurse must be open to the process, interested in changing, and
motivated to improve performance. The nurse has to want to learn and improve.
(See Leading at the Beside: Learning from Coaching.)

• Able. The nurse must be capable of changing performance. The nurse must have
the right aptitude to learn the new process. For example, the new graduate in the
operating OR who repeatedly cries after a surgeon makes a gruff remark may not
be a fit for the OR. On the other hand, a new graduate who privately cries, then
asks for help, may have the resilience for the role.

Box 20-1 Keys to Successful Feedback
1. Timely and Ongoing: Feedback should be given as

close to the event or observation as possible. Effective
feedback is given frequently throughout the year, not
just at the performance evaluation. There should be no
surprises at the time of the performance evaluation.

2. Goal-referenced: Feedback should be linked to a
behavioral goal, include steps to achieve the goal, and
give the staff member information and time to achieve
the goal. For example, “Jenny, this is the third shift
you’ve come late to work. We need you here on time.
Patients are waiting for your care. The night shift nurse
sometimes can’t leave until you arrive. By missing
report, you are missing vital information on your
patients. Can you tell me what’s going on here?”

3. Constructive and Positive: Feedback should not be
limited to constructive feedback that addresses per-
formance issues. Give feedback through praise when
the employee does something well. Positive feedback
is a powerful reinforcer. For example, “I saw you sitting
down with Mrs. Garcia and talking with her about her
end-of-life choices and her beliefs. I went in to see her
afterward, and she told me she was so relieved to
know you told her she had choices and listened to her
concerns. I wish that every patient had a nurse like
you who is not afraid to have the hard conversations.
Great work. Thank you!”

4. Tangible and Transparent: Describe the behavior
clearly. For example, “When Dr. Jones entered Mrs. Mar-
ten’s room, I noticed that you left immediately. Can you
talk to me about what was going on?” In this particular
situation, the nurse manager knows that Dr. Jones has
raised his voice with young nurses who tend to scatter
when he comes on the unit. The manager is giving the
nurse the opportunity to reflect on past behavior. Later,
the nurse manager will need to provide coaching to
help the young nurse learn to manage relationships
with physicians. This coaching may take the form
of one-on-one with a mentor or an educational
program.

5. Respectful, Encourages Reflection: Pick a private
or appropriate location. Do not humiliate the
employee by correcting in front of others, whether
patients or staff. The nurse manager’s tone of voice
should be even and low. Regardless of what hap-
pened, the nurse manager should keep emotions in
check and avoid jumping to conclusions. Always pro-
vide the employee an opportunity to reflect and
explain the problematic behavior. Reflection increases
the potential for learning and change of behavior. Ask
how the employee plans to improve the behavior.
Partner with the employee in changing behavior by
providing coaching.

Feedback and Coaching, Disciplining, and Terminating Staff 299

Leading at the Bedside: Learning from Coaching
Although no one wants to hear about a weakness, coach-
ing is a positive way to improve. In this chapter, you learn
that in order to benefit from coaching, you must be ready to
learn, willing to improve, and able to change. Of course
you’ll make mistakes. You’re human. If you have a consci-
entious manager, that person will meet with you and calmly

explain the problem, ask for your suggestions for improve-
ment, and follow up later. Your task is to help your manager
problem solve and then carry out agreed-upon activities. In
this way, you will learn new skills of adaptation and change,
a lesson that will serve you well in the future.

It is important to note that the manager is not always the coach in the relationship.
Coaches may be a peer expert or a nurse off the unit. Coaching may involve a path of edu-
cation, a connection with a mentor, or partnering with a person from another discipline.

Feedback versus Coaching
Feedback and coaching go hand in hand, but they are different. Feedback without
coaching may not result in a change in behavior. Table 20-1 lists the differences.

Confronting Behavior
If a staff member has been given feedback on a behavior and that behavior does not
change, the manager needs to move to a more serious level of interaction called confron-
tation. Confrontation should put the employee on high alert, and the manager must
carefully document the process. The steps in confrontation are applied when the progres-
sive disciplinary process of the organization begins. A manager who has never conducted
an interview with confrontation might seek coaching from a professional colleague or a
contact in human resources. Recommended steps are described in Table 20-2.

Discipline
Discipline is a fact of life in management. Discipline calls the employee’s attention to
behavior that is not appropriate and must be corrected, and advises how to correct the
behavior. The process of discipline is progressive and highly dictated by organiza-
tional policies and procedures. The manner in which discipline is delivered is as

Table 20-1 Feedback versus Coaching

FEEDBACK COACHING

Focuses on behavior that has occurred Future forward; creates a trajectory for future performance

Assesses performance against a performance
standard and alerts the staff member

Improves and/or develops performance

Constructive with consequences May include remediation through skill development and
always includes behavior modification

Positive with rewards May include career advancement or development—for
example, through further education and continuing education

300 Chapter 20

important as the process. Discipline is not punishment, but it is a consequence of
employee behavior. It is a warning. It is not designed to embarrass an employee. It can
provide a course correction for an employee, a wake-up call, leading toward improve-
ment, or it can lead to termination.

Discipline is not personal and not about whether an employee is liked or not liked.
It is about addressing behavior. The consistent delivery of discipline sets the tone for
manager expectations about staff performance on the unit. Discipline can set an exam-
ple that will call peers to attention. (See Box 20-2.)

Box 20-2 Guidelines for Effective Discipline
1. Carefully and thoroughly obtain the facts. The cause of

discipline might be a series of incidents or a major
event. Verify the policies and procedures about pro-
gressive discipline and at what level.

2. Check in with your supervisor or human resources, as
your work culture requires. Ask for advice, and clarify if
your expectations are reasonable.

3. Never act while angry.
4. Be consistent in the application of discipline across

all staff.
5. Discipline in private. In neutral and behavioral terms,

make the offense clear. Specify what appropriate behav-
ior is. Give examples.

6. Get the other side of the story, but set a limit and avoid
excuses.

7. Create an action plan for remediation. Let the employee
know what potential future consequences will be if the
behavior continues.

8. Ask the employee to reflect on past behavior and
describe a personal view of the interview and what
must change.

9. Document the interview and place it in the employee
file. Many organizations will have the employee sign
the anecdotal note.

10. Circle back with your supervisor or human resources.
Give them feedback on how the interview went while
reflecting on your performance as a manager.

Table 20-2 Steps in Confrontation

1. Prepare before the meeting. Is the employee aware of the policy and procedure? Desired
behavior?

Has the policy/procedure been consistently enforced?

How will the employee react?

Seek advice or role play the meeting if uncertain of approach.

2. In a neutral voice, objectively describe
the behavior without attacking the
person. Tie the behavior to the
consequences for the patients,
organization, or employee.

“Jane, did you know that it is clinic policy to notify both the clinic
manager and the hospital supervisor when you will be absent
from work? Not only were we worried about you, but we had to
reschedule patient procedures because we did not have the staff
to attend to both clinic appointments and special procedures.”

3. Solicit and openly listen with empathy to
the employee’s reasons for the behavior.

“Can you tell me why you didn’t notify someone about your
absence?”

4. Explain why the behavior cannot
continue, and ask for suggestions in
solving the problem. If none are offered,
suggest solutions. Agree on steps each
will take to solve the problem.

“In the future, you will need to notify both the clinic manager
and the hospital supervisor if you cannot come in. Can you do
this?”

5. Place an anecdotal note in the file, noting
the issue and employee response, and
set and record a specific follow-up date.
Ask the employee to reflect back on the
conversation and make sure you are
both on the same track.

“Jane, since this is concerning, I’m going to put a note in your
file. Let’s set a date to meet in a month and see how you’re
doing. If you don’t follow the policy about call-ins during this
period of time, we’ll talk sooner. Can you tell me, in your own
words, why this is important and what you are going to do
about it?”

Feedback and Coaching, Disciplining, and Terminating Staff 301

Progressive discipline is the formal process of increasingly severe warnings for
repeated violations that can lead to termination. The astute manager builds a case that
begins with notes about performance that document feedback and includes the
employee response to feedback and a plan of action. The notes should also include any
relevant coaching or remediation. Progressive discipline moves in a stepwise fashion
unless the infraction is egregious, life threatening, or deadly. Progressive discipline
may begin and end with a precursor: an oral warning. The oral warning is a call to
action for the staff member. It is beyond feedback and draws attention to a behavior
that should not continue. Most managers will make an anecdotal note of the oral warn-
ing and place it in the employee’s file.

The formal steps in the progressive discipline process are verbal warning and
written warning. While the warning is called “verbal,” it is documented. It means step
one in the formal disciplinary process. Questions to consider in determining progres-
sion include the following:

• What is the nature and seriousness of the behavior?

• When, where, and how many times did the behavior occur?

• What is the previous work history? Has this emerged before?

• Are there complicating factors to consider, such as chemical dependency or other
mental health issues?

A verbal warning (see Box 20-3) is given for unacceptable behavior that is
repeated or serious behavior that occurs one time. For example, a manager may
give a verbal warning to a staff member who has a pattern of calling in sick on the
weekend. Or the manager may jump to a written warning (see Box 20-4) if a staff
member falls asleep on the job and seriously jeopardizes patient care. Though the
pathway is clear, discipline itself is often a gray area, open to interpretation. That is
why it is best to discuss the plan of action with an experienced supervisor and
acquire input.

Box 20-3 Verbal Warning Form
Employee’s name:
Date of verbal warning:
Specific offense or rule violation:
Specific statement of the expected performance:

Any explanation given by the employee or other significant information:

____________________________ ______________________
Supervisor Signature and Date

This information was discussed with me and I was given a copy of this document.

____________________________ ______________________
Employee Signature and Date

302 Chapter 20

In some cases, the progressive discipline system is bypassed. Swift action may be
required to protect patient safety or the workplace environment. The seriousness of
the behavior may be grounds for immediate termination or suspension that allows
for due process. These serious behaviors may include theft of equipment or drugs,
violating patient privacy by accessing the records of a patient, bringing a firearm to
work, administering the wrong drug resulting in a patient fatality, or substance abuse
on the job. Regardless, the incident should be meticulously documented and advice
sought from the immediate supervisor, human resources, and in some cases hospital
legal counsel.

At each stage of the disciplinary process documentation is essential, and equi-
table treatment of all staff on the unit is expected. That means if one employee
receives a verbal warning for calling in sick to attend a rock concert, then all employ-
ees who called in sick for the same reason receive a verbal warning. Case Study 20-1
shows how one nurse manager correctly handled a disciplinary issue in a progres-
sive fashion.

Box 20-4 Written Warning Form
Employee’s name:
Date of conversation:
Specific rule violation or performance problem:

Previous conversations about the rule violation or performance problem:

Specific change in the employee’s performance or behavior expected:

Employee’s comments:

Supervisor’s comments:

Continuation of this behavior may include termination.

__________________________ _________________________
Employee’s Signature and Date:

-or-

Employee was asked to sign this written warning on _______________________ but declined to sign.

_____________________________ ____________________
Supervisor’s Signature and Date

Feedback and Coaching, Disciplining, and Terminating Staff 303

Termination
Termination is a serious and difficult management responsibility with emotional, legal
and financial consequences. Termination is the process that ends employment. Since it
often becomes a part of the permanent record, it must be conducted carefully, objec-
tively without emotion, and in concert with hospital policy. Termination without due
process, with poor documentation, or outside of hospital policy can be fuel for an
employee grievance or lawsuit. This section covers termination due to unresolved per-
formance issues and not termination due to organizational downsizing. Though many
of the steps may be similar, employees terminated due to downsizing may not have
performance issues and may have benefits that require different conversations. As
with a disciplinary action, nurse managers must maintain close contact with the orga-
nization’s HR department and nursing administration. They must discuss the termi-
nation and seek approval for it.

Preparation before terminating an employee is essential. To prepare, consider the
following:

• Review the employee file. Do you have a track record of documented conversa-
tions with the employee about the specific issues that are leading to termination?

• Do you give employees on the unit feedback on a regular basis?

CAsE sTuDy 20-1 | Progressive Discipline
Katie Connors is nurse manager of the birthing center in a
metropolitan hospital. A student nurse, Amber Schroeder,
was assigned to work for her clinical shift with Natalie Cole,
RN. Their patient arrives at the birthing center for induction
of labor. During the admission process, the patient confides
to Natalie and Amber that she is terrified she might need a
cesarean birth. Amber whispered to the patient that a young
woman and her baby recently died at the hospital during an
emergency cesarean birth. The patient begins to hyperven-
tilate, refuses to let Natalie continue with the admission, and
threatens to leave the birthing center. Natalie is so angry at
Amber for scaring the patient that she grabs her by the arm
and pulls her out of the room. Natalie loudly berates Amber
in the hallway to the point that Amber is crying.

Katie hears the commotion in the hallway and instructs
Amber to sit in the staff lounge until her instructor can return
to the unit. Katie and Natalie reassure the patient, and Natalie
completes the admission process. Throughout the shift,
Natalie tells every staff member and physician about Amber’s
“stupid comment.” Katie speaks with the nursing instructor
and Amber about the incident. She also checks back with
the patient and gently gathers facts about the incident.

Katie is concerned about Natalie’s response to the
situation. While Natalie has excellent nursing skills, she has
often been abrupt or rude to other staff members. Katie has
given feedback to Natalie on her communication skills and

coached her, yet the behavior has continued, resulting in
three other incidents. Katie had already given Natalie a ver-
bal warning for lack of professional communication. After
discussing the incident with the human resources manager,
Katie agrees that a written warning will be placed in
Natalie’s personnel file.

At the end of the shift, Katie requests that Natalie
come to her office to discuss what happened with the stu-
dent nurse. Katie informs Natalie that she is very concerned
about how she reacted to the inappropriate comment
made by the student nurse. Specifically, physically grab-
bing the student and verbally attacking her in front of
patients and staff was unacceptable and violates hospital
policy. Further, Natalie continued to disparage the student
to other staff and physicians, which is also unacceptable.
Natalie expresses her frustration at the thoughtlessness of
Amber’s comment. Katie tells Natalie that while Amber’s
comment was inappropriate, Natalie’s response was also
unprofessional. Katie reinforces to Natalie the importance
of professional communication at all times and reviews the
communication points she had provided to Natalie in the
past. She also informs Natalie that she will have a written
warning placed in her personnel file. Natalie apologizes for
her actions and assures Katie she will work on her com-
munication skills. Katie documents the incident and follow-
up action in Natalie’s personnel file.

304 Chapter 20

• Are you being consistent in the application of performance standards against all
employees in your span of control?

• Did you offer remediation or coaching to address the performance issues?

• How might the employee challenge the termination? Prepare for the challenge.

• Is your supervisor aware of and behind your decision to terminate? Is human
resources aware of and behind your decision to terminate?

Each organization will vary in what it does during and after termination. Gener-
ally, employee access to email and any internal intranet web access is stopped dur-
ing or immediately before the interview. The ID badge and any hospital-sensitive
entry cards or keys are collected. The manager may accompany the staff member to
the staff member’s locker to collect personal items and then escort the terminated
employee out of the building, or the employee may be escorted by a member of
human resources or hospital security. Regardless of the reason for termination, this
is usually a devastating event for the employee, and it should be conducted firmly
but with compassion. When the staff member leaves the building, the manager must
document the incident and the reaction of the staff member in the personnel file. (See
Box 20-5.)

Box 20-5 Suggested Script for a Termination
Conversation

Manager: Lucy, we are here today to have the conversation
I told you we would be having about your attendance. I’m
not confident in your ability to be successful in your posi-
tion. We’re going to go over the details of repeated
absences. We’ve talked about each one of them. Do you
have any questions before I begin?

On March 13, you received a written warning for your
attendance. Since then, you have accumulated the follow-
ing unscheduled absences: March 17, you missed work
because of car problems. Then on May 2, you didn’t report
to work because you said you forgot you were working,
and then refused to come in. You have now accumulated
eight incidents of unscheduled absence this year. Our hos-
pital attendance policy states that the hospital relies on
employees being dependable to take excellent care of
patients and that when employee attendance interrupts the
ability to provide excellent care, we must advance the cor-
rective action process. At our hospital, eight absences in a
12-month period is considered an unacceptable, very seri-
ous violation of our hospital’s policy.

Prior to today, you received a verbal warning and a
written warning regarding your attendance. At the time
of your verbal warning, you had accumulated the follow-
ing unscheduled absences: August 23, last year, you
missed your shift at work, stating you had a family issue.

September 8, you missed work, stating you were ill. Sep-
tember 24, you called in reporting GI illness and did not
come to work. November 20, you called in to work report-
ing you had overslept and wouldn’t be reporting to work.

On November 25, you were given a verbal warning
concerning your attendance. A copy of the policy was
given to you at that time, your absences were reviewed,
and you acknowledged that you understood you should
not miss more work unplanned.

You continued to accumulate unscheduled absences
and were given a written warning on February 1. These
absences included the following: On December 16, you
called in to work reporting a scheduling conflict. On Janu-
ary 27, you called in and said you had a cold and weren’t
coming to work.

In addition to your verbal and written warnings, I spoke
with you on other occasions as well to remind you about
the attendance policy and the seriousness of your current
attendance situation. You have continued to accumulate
absences and have seriously violated the attendance policy
despite multiple attempts at coaching. Therefore, today,
May 3, your employment is terminated. Human resources
is here with us to provide you with all information on your
benefits and retirement fund, and to answer any questions
you have.

What You Know Now
1. Feedback is the regular practice of helping employ-

ees evaluate and improve their performance. It is a
management obligation. Staff should be encour-
aged to seek feedback on a regular basis.

2. Coaching goes hand in hand with feedback and
provides the support to improve performance.

3. Confrontation is the process of addressing consis-
tent, unrelenting behavioral issues.

4. Discipline is a consequence of poor performance.
It is a management tool that is challenging to use
but essential in order to improve the quality of

professional practice, patient care, and the health
of the workplace.

5. Progressive discipline is the orderly process of an
organization, according to policy, and usually
includes an oral warning, formal verbal warning,
and written warning, and it may end in termina-
tion of employment.

6. Termination of employment is a serious manage-
ment act that should be conducted in concert
with hospital policy and with the support of
nursing administration and human resources.

Tools for Feedback and Coaching, Disciplining
and Terminating Staff

1. Successful feedback is:
a. Timely and ongoing.
b. Goal referenced.
c. Positive as well as constructive.
d. Respectful and encourages reflection.

2. For coaching to be effective, the nurse must be
ready, willing, and able to learn.

3. To conduct an interview that involves discipline:
a. Be prepared. Have your notes in order. Be

poised and calm.
b. Ensure privacy of the dialogue.
c. Get both sides of the story.
d. Keep the focus on the behavior, not the person.
e. Arrange for follow-up. Keep your supervisor

and HR in the loop.
f. Document the conversation.

4. To prepare for a termination:
a. Work with your supervisor and administra-

tion to verify the documentation, determine
how equitable the situation is being managed,
and be consistent in the application of policies
and procedures.

b. Be prepared, calm, and poised. In a private
location, state the behavior of concern and
review the documentation of behavior. Explain
the termination process.

c. Follow hospital procedure in the exit of the
employee.

d. Document the interview and follow up with
your supervisor and human resources.

Questions to Challenge You
1. Have you ever received career-changing feed-

back? How was it delivered? How did it change
you?

2. What do think might be your personal challenges
in disciplining and terminating staff?

3. Select a situation regarding feedback, discipline,
or termination and role play with a trusted and
experienced colleague how you would manage it.

4. Do you ask for feedback about your performance
on a regular basis? Why is that important?

Feedback and Coaching, Disciplining, and Terminating Staff 305

306 Chapter 20

References
Donner, G., & Wheeler, M. M. (2009). Coaching in

nursing: An introduction. Geneva, Switzerland:
International Council of Nursing, and
Indianapolis: Sigma Theta Tau International.

Drenkard, K. (2010). The business case for Magnet®.
Journal of Nursing Administration, (40)6, 263–271.

Staples, S. (2012). Bringing coaching into your
nursing career. Retrieved May 1, 2015,
from http://www.nursetogether.com/
bringing-coaching-into-your-nursing-career

Wiggins, G. (2012). Seven keys to effective feedback.
Educational Leadership, (70)1, 10–16.

http://www.nursetogether.com/bringing-coaching-into-your-nursing-career

http://www.nursetogether.com/bringing-coaching-into-your-nursing-career

Chapter 21

Managing Absenteeism,
Reducing Turnover,
Retaining Staff

Learning Outcomes

After completing this chapter, you will be able to:

1. Explain absenteeism and how to manage it.

2. Describe how nursing turnover affects the organization.

3. Examine what organizations can do to improve retention of
nurses.

Key Terms
absence culture

absence frequency

attendance barriers

engagement

involuntary absenteeism

involuntary turnover

retention

salary compression

total time lost

turnover

voluntary absenteeism

voluntary turnover

Absenteeism
A Model of Employee Attendance

Managing Employee Absenteeism

Absenteeism Policies

Selecting Employees and Monitoring Absenteeism

Family and Medical Leave

Reducing Turnover
Cost of Nursing Turnover

Causes of Turnover

Understanding Voluntary Turnover

Retaining Staff
Job Satisfaction

Improving Salaries

Retention Strategies

307

308 Chapter 21

Introduction
Keeping higher-performing nurses is a priority in healthcare. Appropriate hiring deci-
sions begin the process, but once employment begins, organizations can do much to
ensure that they retain their best performers. Several methods of accomplishing this
are mentoring, coaching, nurse residency programs, and clinical ladder advancement
programs, which are discussed elsewhere in this text. In order to understand why
nurses are absent or leave the organization, and to develop ways to retain them, it is
necessary to consider absenteeism, turnover, and retention.

Absenteeism
Although the extent or the cost of nurse absenteeism is difficult to determine, it is
well established that absenteeism in healthcare organizations is both pervasive and
expensive. The costs of absenteeism, however, can also have a detrimental effect on
the work lives of the other staff. Working shorthanded, especially for an extended
period of time, can create both physical and mental strain. Even if temporary
replacements are called in, the work flow of the unit will still be disrupted as hur-
ried staff must take time to explain standard organizational procedures to replace-
ment nurses.

A Model of Employee Attendance
To understand employee absenteeism, it is important to distinguish voluntary from
involuntary absenteeism. For example, not coming to work in order to finish one’s
income taxes would be seen as voluntary absenteeism (i.e., absenteeism under the
employee’s control). In contrast, taking a sick day because of food poisoning would be
considered involuntary absenteeism (i.e., largely outside of the employee’s control).
Although this distinction seems reasonable in theory, in practice it is often difficult to
distinguish these two categories because of a lack of accurate information, as few
employees will admit to abusing sick leave.

Some organizations try to distinguish voluntary from involuntary absenteeism
by the way they measure absenteeism. Traditionally, healthcare organizations have
measured absenteeism in terms of total time lost (i.e., the number of scheduled
days an employee misses). Given that one long illness can drastically affect this
absenteeism index, total time lost is clearly not a perfect measure of voluntary
absenteeism. In contrast, absence frequency (i.e., the total number of distinct
absence periods, regardless of their duration) is somewhat insensitive to one long
illness.

This distinction between absence frequency and total time lost should make sense.
For example, an employee who missed nine Mondays in a row would have nine
absence frequency periods as well as nine total days absent. In contrast, a person who
missed nine consecutive days of work would have nine total days lost but only one
absence frequency period. Intuitively, it seems likely that the first individual was much
more prone to being absent voluntarily than the second.

An employee’s attendance at work is largely a function of two variables: the indi-
vidual’s ability to attend and motivation to attend as shown in Figure 21-1.

Managing Absenteeism, Reducing Turnover, Retaining Staff 309

As seen in Figure 21-1, an employee’s ability to attend can be affected by such
attendance barriers as the following:

• Personal illness or injury

• Family responsibilities (e.g., a sick child)

• Transportation problems (e.g., an unreliable automobile)

Although it is natural to view such barriers as resulting in involuntary absentee-
ism, sometimes this is too simplistic a judgment. For example, an employee whose car
was not running may consciously have not made alternative arrangements to get to
work the next day because he or she was not motivated to attend. This example illus-
trates that some of the distinctions portrayed in Figure 21-1 are not always clear-cut. In
trying to understand employee absenteeism, a manager will have to make assump-
tions about why the behavior is occurring (e.g., a manager cannot be certain that a
person was actually ill).

According to the attendance model, an employee’s motivation to attend is affected
by several factors: the job itself, organizational practices, the absence culture, generational
differences, management, the labor market, and the employee’s personal characteristics.

The Job ITself Employees holding more enriched jobs are less likely to be absent
than those with more mundane jobs. An enriched job is one that engages many of an
employee’s abilities, provides a sense of meaning, and offers autonomy. Enriched jobs
may increase attendance motivation because employees believe that what they are
doing is important and they know that other employees are depending on the job
holder (i.e., if the job holder does not do his or her job, other employees cannot do
theirs).

The nature of a job also influences attendance through its potential for attendance
barriers (i.e., illness and injuries). For example, a job that requires heavy lifting (e.g.,
moving patients from beds to stretchers) may increase the likelihood that a staff nurse
will be injured. Similarly, a job that exposes a nurse to patients with highly contagious
conditions, such as in an outpatient clinic, may increase the likelihood of illness.

Attendance barriers
lllness and injuries
Family responsibilities
Transportation problems
Past experiences

Job itself

Organizational
practices

Supervision

Labor market

Absence culture
Employee attitudes,
values, and goals

Attendance
Attendance
motivation

Perceived ability
to attend

Figure 21-1 A diagnostic model of employee attendance.

310 Chapter 21

organIzaTIonal PracTIces As portrayed in Figure 21-1, organizational prac-
tices can also influence attendance motivation. Some healthcare organizations have
absence control policies that reward employees for good attendance, punish them for
excessive absenteeism, or both. An organization may also be able to increase atten-
dance motivation by carefully recruiting and selecting employees. In addition to affect-
ing attendance motivation, organizational practices may influence an employee’s
ability to attend. Organizational activities, such as offering wellness programs,
employee assistance programs, van pools, on-site child care, or coordinating car pools
can influence an employee’s ability to attend work.

absence culTure The absence culture of a work unit (or an organization)—the
general attitude toward and tolerance of absenteeism—can also influence employee
attendance motivation. Some work units have an absence culture that reflects a toler-
ance for absenteeism; other units have a culture in which being absent is frowned
upon. Although an organization’s absence culture can be affected by organizational
practices (e.g., attendance policies) and the nature of the jobs involved (e.g., people in
higher-level jobs tend to be less accepting of coworkers calling in sick), it is also
affected by informal norms that develop among work-group members. For example,
people in a cohesive work group may develop an understanding that missing work,
except for an emergency or a serious illness, is unacceptable. Such an attendance cul-
ture is likely to emerge if the employees work in jobs that they see as important (e.g.,
providing direct patient care) and if an employee’s being absent causes a hardship for
coworkers (e.g., forced overtime, being called in on a day off).

generaTIonal DIfferences Today’s workforce includes nurses from three
generations, and each cohort (baby boomers; generation X; and generation Y, also
known as millennials) has different expectations in the workplace (Dols, Landrum, &
Wieck, 2010). Generation Z (teenagers in grades 7 through 12) will soon join these
older cohorts (Levit, 2015).

Older nurses may resent the younger ones, especially their technology skills and
their lower need for social interaction. Here is an example:

Kirsten McNamara is 24 years old. She spends her lunch break relaxing and returning
text and email messages on her phone while she eats; she uses the quiet time to rejuve-
nate. Her older coworkers are offended and complain that she was “on her phone and
rude” the entire lunch hour.

Generational differences affect retention as well. Generation X and Y nurses want
challenging careers that offer opportunities for growth and advancement as well as
time for lives outside of work. Flexible schedules and time off are valued by these
cohorts, and organizations can expect high turnover if these expectations are not met
(Edge et. al., 2011).

Expectations of the younger generational cohorts affect supervision as well. They
expect independence and to be involved in decision making (Farag, Tullai-McGuinness,
& Anthony, 2009). Thus, shared governance is an appropriate structure, and consulta-
tion is an effective management strategy.

ManageMenT Management can also influence attendance motivation of all staff.
A nurse manager can influence the nature of a staff nurse’s job (e.g., the degree of
responsibility given and participation in decision making), decisions about personnel,
the consistency with which organizational practices are applied (e.g., whether

Managing Absenteeism, Reducing Turnover, Retaining Staff 311

sanctions are enforced for abuse of sick leave), and—by stressing the importance of
good attendance—a work unit’s absence culture.

A shared governance organizational model encourages attendance because of the
emphasis on cooperative decision making. The manager who consults frequently with
staff supports this model. Knowing that their input is valuable to the unit’s function-
ing promotes participation and, thus, attendance.

labor MarkeT Another factor that influences attendance is the labor market. If
the nurse believes that plenty of equivalent jobs are available locally, he or she might
be less motivated to attend than if fewer jobs were available.

To the extent that the local employment market for nurses leads an employee to
perceive it would be easy to find an equivalent job if she or he lost or disliked the cur-
rent one, one would expect a lower level of attendance motivation than if market con-
ditions were less favorable. This might happen during a nursing shortage.

Personal characTerIsTIcs Although features of the job itself, organizational
practices, absence culture, generational differences, supervision, and the labor market
can all have a direct effect on employee attendance motivation, these factors can also
interact with an employee’s attitudes (e.g., job satisfaction), values (e.g., personal work
ethic), or goals (e.g., desire to get promoted). If a person who seeks variety works in a
job that does not provide it, the employee may become dissatisfied and thus more
likely to abuse sick leave.

The reverse is also true. Employees’ attitudes, values, and goals can also have a
direct effect on attendance motivation. For example, a staff nurse with a high personal
work ethic or a goal of getting promoted should be more highly motivated to attend
work than a nurse who lacks such a work ethic.

An employee’s attendance behavior is also influenced by past experiences. For
example, if an employee’s perfect attendance in the previous year was not recognized,
we might expect the employee’s attendance motivation to decrease in the coming year.
Conversely, if a coworker with an outstanding attendance record received a promo-
tion, peers who value a promotion and who witnessed this link between performance
and reward would be more motivated to attend work in the upcoming year.

Managing Employee Absenteeism
The attendance model in Figure 21-1 is useful not only for understanding why absen-
teeism occurs, but also for developing strategies to control it. Some causes of absentee-
ism, such as transportation difficulties or child care problems, may be beyond the
control of the organization.

To diagnose the key factors leading to absenteeism, the organization needs infor-
mation from several sources, including staff, the human resources department, other
nurse managers, and administration. Absence patterns can answer such questions as
the following:

• Is absenteeism equally distributed across all nurses?

• In comparison to other units, does your area of responsibility have a high absen-
teeism rate?

• Are most absences of short or long duration?

• Does the absenteeism have a consistent pattern (e.g., occur predominantly on
weekends or shortly before a person quits)?

312 Chapter 21

Clearly, the best way for nurse managers to control absenteeism is by encouraging
their staff’s motivation to attend, including the following:

• Enriching the staff nurse’s job by increasing its responsibility, variety, or challenge

• Reducing job stress (e.g., by providing timely and more concrete information)

• Creating a norm of excellent attendance (e.g., by emphasizing the negative impact
of a nurse not coming to work)

• Enhancing advancement opportunities (e.g., by providing developmental experi-
ences so that the best employees are promotable)

• Improving coworker relations (e.g., by considering coworker compatibility when
scheduling work and/or creating work teams)

• Trying to select employees who will be satisfied with and committed to their jobs

• Being a good role model by rarely taking sick days

• Discussing the employee’s attendance during the performance appraisal interview

• Rewarding good attendance with salary increases and other rewards

• Enforcing absenteeism control policies (e.g., carrying through on employee disci-
pline when there is an attendance problem)

Absenteeism Policies
Most organizational policies allow employees to accrue paid sick days—typically,
one sick day for every month employed. Unused sick days accrue across time to
some maximum number (e.g., 60 days). Typically, if an employee leaves the organi-
zation with accumulated sick leave or days above the maximum, the person simply
loses them.

Although such a policy may seem reasonable, it may actually encourage
unwanted behavior. For example, once a nurse has reached the maximum limit for
accrued sick days, the person may see no reason for not using sick days that would
otherwise be lost. Such a policy also encourages employees who know they will be
leaving the organization (e.g., those about to retire or change jobs) to use accumulated
sick leave.

An innovative approach for managing absenteeism is substituting personal days
for unused sick days. Two problems arise if personal days are not given: Employees
are forced to lie (i.e., say they are sick when they are not) to carry out what they see
as legitimate activities (e.g., attending a conference with their child’s teacher), and
their manager has no warning and therefore may have difficulty covering for the
absent employee.

By substituting personal days for sick days, the employee no longer has to lie,
and the nurse manager may have time to plan for a replacement. In moving to a pol-
icy that incorporates the use of personal days, an organization typically allocates
fewer paid sick days but adds personal days. For example, instead of 12 sick days, an
employee may annually receive 9 sick days and 3 personal days. With the availability
of personal days, a staff nurse can inform the manager in advance of the need for a
personal day off. In many cases, the two of them can arrive at a day off that is optimal
for both of them.

Realizing that they have not been motivating good attendance, some progressive
organizations have allowed sick days to accumulate without an upper limit. Then,
when an employee leaves the organization, she or he is paid for unused sick days

Managing Absenteeism, Reducing Turnover, Retaining Staff 313

(e.g., one-half of a day’s pay for each unused sick day). Other organizations allow
retiring employees to add unused sick days to days worked. Still other organizations
have paid employees for their sick days, or allowed the conversion of sick days to
vacation days or additional pay.

Selecting Employees and Monitoring Absenteeism
Controlling absenteeism begins with recruitment. Given a realistic job preview, a new
hire will be aware of the job characteristics and employer expectations. Similarly,
basing merit pay and advancement opportunities on an employee’s overall perfor-
mance appraisal rating (which is partly based on attendance) will motivate better
attendance.

Strategies for dealing with employees with excessive absences include the following:

• Set expectations with each new employee. Give her or him the attendance policy
in writing, and clarify any questions.

• Monitor each individual’s attendance, and document it.

• Intervene early and consistently, coaching and dealing with policy or procedure
violations as appropriate.

• Be sure to reward staff who have good attendance. Ensure any organizational
rewards are delivered, and give your personal reward through feedback in perfor-
mance appraisals.

• Be a role model for good attendance yourself.

Family and Medical Leave
The Family and Medical Leave Act (FMLA) took effect in 1993 and has been
amended by federal statute as well as court decisions (U.S. Department of Labor,
2011). Under this act, all public employers (federal, state, and local) and all pri-
vate employers employing 50 or more individuals must provide their eligible
employees with leave of up to 12 weeks during any 12-month period for the
employee’s own serious illness, the birth or adoption of a child, the placement
of a foster child into the household, or the care of a seriously ill child, spouse, or
parent.

Employees are eligible to take leave if they meet the following conditions:

• Have worked for the employer for at least 12 months

• Have worked at least 1,250 hours during the previous 12 months

• Are at a work site with 50 or more employees, or at a site where 50 workers are
employed within 75 miles of the work site (50 employees/75 miles rule).

The FMLA also allows eligible employees to maintain health insurance coverage
while on leave and allows them to return to the same or equivalent position at the
end of the leave period. The leave may be taken all at once, intermittently, or by
working a reduced work schedule, if available. The employee must be allowed to
take leave for qualified purposes without pressure or discouragement by the
employer or manager. More generous collective bargaining agreements or state laws
supersede the FMLA, but the FMLA supersedes any inconsistent or less generous
provisions. FMLA may run concurrently with other leaves, including state workers’
compensation leave.

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Reducing Turnover
Closely related to absenteeism is employee turnover, the number of staff members
who vacate a position. Reducing turnover begins with recruitment and selection and
continues with motivation and development of staff. Retaining both experienced
nurses and new graduates is essential (Hill et al., 2010; Hirschkorn, West, Hill, Cleary,
& Hewlett, 2010).

Cost of Nursing Turnover
Two interrelated factors affect the nurse turnover rate: market opportunities and the
economy. When the economy is robust, healthcare organizations tend to hire more
staff; during a recession, the hospital may cut staff or leave positions vacant. At the
same time, nurses are more apt to stay in a position if the economy is poor or if few
other opportunities exist (Healthcare Association of New York State, 2010).

Data from a national survey in 2009 found that turnover rates that year (7.1%) had
declined from the 10.1% of the previous year (Healthcare Association of New York
State, 2010). The surveyors attributed the change to the poor economy and the lack of
opportunities.

Given the expense in hiring a new nurse (e.g., recruiting, selection, orientation,
on-the-job training) and temporarily replacing a nurse who quits or is fired (e.g., pay-
ing other nurses to work overtime or filling the vacancy with a temporary replace-
ment), the costs are sizable (Oyeleye, Hanson, O’Connor, & Dunn, 2013). Thus, nursing
turnover must be understood better and controlled more effectively.

Turnover has been thought of in simplistic terms and seen as universally negative.
Such a primitive view of turnover is not helpful to organizations as they attempt to
deal with this costly problem. Rather, varieties of turnover need to be differentiated:

• Did the employee leave of her or his own accord, or was the person asked to leave?

• Was the departed individual’s performance exceptional or mediocre?

• Did the employee leave for career development (e.g., return to school) or because
of dissatisfaction with the organization?

• Will the departed nurse be easy or difficult to replace?

Turnover has consequences that go far beyond direct dollar costs. Turnover can
have a number of repercussions among other nurses who worked with the departed
nurse. Those others may have to work longer hours or simply work harder to cover for
a departed nurse; this can cause both physical and mental strain, and may result in
additional departures. Thus, departed nurses may begin a cycle of nurses leaving,
resulting in a turnover spiral. If temporary replacements are used, problems still can
result as the work flow of the unit is disturbed, and communication patterns within
the unit are disrupted.

Turnover is not always undesirable. Anyone with work experience can remember
some individual (e.g., coworker, administrator) whose departure would have impro-
ved the organization’s functioning significantly. Furthermore, what may be seen as a
desirable departure by some (e.g., the nurse manager) may be viewed as a loss by
others (e.g., a subset of coworkers). If the departed nurse was a poor performer, perfor-
mance may improve. Recently hired staff may be more enthusiastic, long-running con-
flicts between people may be reduced or eliminated, or administration may be
challenged to improve the work environment.

Managing Absenteeism, Reducing Turnover, Retaining Staff 315

Causes of Turnover
Before turnover can be managed, its causes must be understood. Voluntary turnover
occurs when an employee chooses to leave an organization, which for many reasons
can occur (e.g., a better job, moving). Termination of employment by the employer is
called involuntary turnover. This can occur because of poor performance by the
employee, a change in organizational structure, or staff cuts. If an organization finds
a significant amount of involuntary turnover (i.e., employees being terminated),
then it needs to carefully examine the way it recruits, selects, motivates, and devel-
ops employees.

Understanding Voluntary Turnover
Traditionally, organizations have attempted to determine the reasons for voluntary
turnover through two sources: by asking the exiting employee’s supervisor why the
employee is leaving, and by an exit interview with the departing employee conducted
by someone in the human resources department.

Such an approach for determining the cause of voluntary turnover is certainly
straightforward, but departing employees may not give honest answers in their exit
interviews because they know that future employers will ask for references. Thus, exit-
ing employees may provide safe responses (e.g., “a better opportunity came along”)
during an exit interview.

Although this tendency for departing employees to make safe responses is under-
standable, it makes it difficult to determine why turnover is occurring. Surveys sent to
former employees several weeks after they have resigned may be more useful. Former
employees need to be assured that their responses will not influence any future refer-
ence information furnished about them but, rather, will be used only to help the orga-
nization identify the reasons why nurses are leaving. Another way to attempt to
discover the cause of nurse turnover is to conduct interviews with the former employee’s
coworkers, who often know why an employee left.

The goal should be to reduce voluntary turnover. The manager’s first opportunity
to reduce turnover is when the decision to hire is made. An individual’s length of stay
at past employers is an indication of how long the person could be expected to stay on
a new job.

Turnover is a direct function of a nurse’s perceptions of both the ease and the
desirability of leaving the organization. Perceived ease of movement depends on the
nurse’s personal characteristics, such as the following:

• Education

• Area of specialization

• Age

• Geographic mobility

• Contacts at other hospitals

• Transportation

External forces also have an effect on ease of movement, such as the following:

• Job openings at other organizations

• Non-healthcare organizations hiring nurses for nursing or non-nursing positions

• The economy

316 Chapter 21

As with ease of movement, perceptions of the desirability of movement can be
affected by several factors. One is the opportunity for movement within the organi-
zation. If other positions exist within the organization, the less turnover there
should be—that is, a nurse may be able to leave the current position by means of a
lateral transfer, promotion, or demotion. For example, a nurse who is having prob-
lems with a coworker may be able to transfer to a new unit rather than leave the
organization.

Turnover and employee absenteeism have been referred to as withdrawal behav-
iors because they allow an employee to leave the workplace, in one case temporarily
and, in the other, permanently. In many cases, these withdrawal behaviors share a
common cause: job dissatisfaction.

Retaining Staff
Job satisfaction is a key component to retaining staff (Wisotzkey, 2011). Job satisfaction
is affected by various facets of the work environment, including the following:

• Relationships with the nurse manager, other staff nurses and unit employees,
patients, and physicians

• Shift worked (e.g., day versus evening, rotating versus fixed)

• Fit between nurse values and institutional culture

• Expectations of practice setting

• Compensation level

• Equal and fair distribution of rewards and punishments

Job Satisfaction
Numerous factors affect job satisfaction for nurses. Patients’ satisfaction with their
care, nurses’ commitment to their colleagues and the organization, and environmental
conditions all affect nurses’ satisfaction with their jobs.

PaTIenT saTIsfacTIon Patient satisfaction was found to be linked to nurses’
job satisfaction in a survey of more than 95,000 nurses (McHugh, Kutney-Lee,
Cimiotti, Sloane, & Aiken, 2011). Nurses employed in Magnet hospitals report
significantly higher job satisfaction scores than nurses employed in non-Magnet
hospitals (Kelly, McHugh, & Aiken, 2011). Employee engagement was found to
be correlated with employee retention as well as patient satisfaction (McHugh
et al., 2011).

eMPloyee engageMenT Rivera, Fitzpatrick, and Boyle (2011) studied factors
that affect employee engagement, or the degree to which an employee is inspired by,
willing to invest effort for, likely to recommend, and plans to remain in an organiza-
tion. These factors were control over practice, professional development and growth,
teamwork, and nurse–physician collaboration. The least important factors related to
engagement were salary and benefits, a finding supported in McHugh et al. (2011).
The implications suggest that an organizational structure which encourages staff
input, frequent communication and attention to problems as soon as they occur, and
development opportunities encourages employee engagement.

Managing Absenteeism, Reducing Turnover, Retaining Staff 317

healThy Work enVIronMenT A healthy work environment increases nurse
job satisfaction, a necessary condition for retaining nurses (Paris & Terhaar, 2011;
Weston, 2010). Environmental factors can improve job satisfaction and reduce the
intention to leave. Such factors as noise, light, and odor affect environmental stress
and contribute to nurses’ dissatisfaction (Applebaum, Fowler, Fiedler, Osinubi, &
Robson, 2010).

The American Association of Critical Care Nurses (2016) established the following
six criteria for a healthy work environment to “foster excellence in patient care” (p. 1):

• Skilled communication—This trait is as important as clinical skills.

• True collaboration—Collaboration exists between and among nurses and other
healthcare professionals.

• Effective decision making—Nurses are involved as partners in making policy and
leading organizations.

• Appropriate staffing—An effective match between patient needs and nurse com-
petencies occurs.

• Meaningful recognition—Nurses are recognized for the value of their work.

• Authentic leadership—Leaders embrace, live, and engage others in the process.

Leading at the Bedside: Supporting Your Organization
As a staff nurse, you affect how your hospital, clinic, or
agency maintains an adequate number of employees to
care for patients. Your own attendance, your encourage-
ment of others, and your support for the unit and organiza-
tion all contribute to how well the organization functions
and, thus, its ability to care for and support patients, fami-
lies, and, even, you. On the other hand, if you engage in
gossip or encourage others’ complaints, but do nothing to

solve problems or take the problem to the appropriate per-
son, you are undermining the organization’s ability to func-
tion. You may not realize that you have that much power,
but as the largest group of employees in a healthcare orga-
nization, nurses have the power to support or undermine
an organization.

Respect yourself, your colleagues, and your orga-
nization.

Improving Salaries
As the largest group of healthcare professionals, nurses’ wages account for the major-
ity of an organization’s salary budget. It is reasonable (although not cost-effective) that
organizations imagine they can reduce expenses by constraining nurses’ salaries or
allowing open positions to go unfilled. Thus, nurses employed for many years find
their salaries only slightly greater than (or even less than) nurses with only a few years
of experience. This effect is known as salary compression. Paying new nurses a higher
starting salary, or rewarding those with fewer years of experience with higher
increases, results in the salaries of long-term employees being at or below those of less-
experienced nurses.

Sign-on bonuses and loan-forgiveness programs, for example, are strategies used
to attract new graduates. They are, however, only quick fixes that serve to disadvan-
tage already employed nurses whose salary ceilings remain fixed. Pay scales, however,
can be reconfigured to reflect achievement and accomplishment.

318 Chapter 21

Retention Strategies
To retain nurses, the Children’s Hospital of Philadelphia implemented the following
five strategies that reduced turnover by 91% (Hinson & Spatz, 2011):

• On-boarding—This process welcomed new hires to the organization and the unit.

• Employee rounding—Weekly rounds with team leaders and monthly rounds with
administrators were made to identify and resolve problems.

• Social networking—Team-building social events encouraged and developed rela-
tionships among staff members.

• Employee recognition—Notices were distributed and events held to commend
exceptional performance and achievements.

• “Stretch” assignments—Specific activities based on an employee’s proposal were
designed to help the employee reach career goals.

recognIzIng sTaff PerforMance Recognizing the contributions of staff is
not necessarily expensive or time-consuming. Some strategies, such as the following,
can be integrated into the everyday managing of staff:

• Provide personalized, immediate feedback for a job well done.

• Write a personal note acknowledging an employee’s good performance. Leave it
in the employee’s mailbox or mail it to a home address.

• Publicly recognize an employee’s good performance—at a staff meeting, in an
email to all, with kudos on the unit bulletin board.

• Encourage staff to post notes on the bulletin board to thank a coworker for a great
job or to recognize a peer for impressive work with a patient.

• Design a bulletin board to highlight one employee. Change it every 2 weeks or
once per month. The employee can bring in personal and family photos as well as
post facts about them. This facilitates employee recognition and a sense of camara-
derie as employees get to know each other better.

Examples of low-cost and formal rewards for staff are shown in Box 21-1.

aDDITIonal reTenTIon sTraTegIes In addition to creating a healthy work
environment, making salary adjustments, and recognizing staff, managers can use
several other strategies to retain valued employees in the organization, including pro-
viding realistic job previews to new hires, facilitating movement within the organiza-
tion, and, if necessary, adapting to the turnover rate.

Provide Realistic Job Preview and Follow-up. Retaining nurses begins with the inter-
view, when the manager has an opportunity to present the job realistically. Retention
continues with orientation and socialization of the new nurse to the unit (Hatler,
Stoffers, Kelly, Redding, & Carr, 2011). Both clinical advancement programs and pre-
ceptorships have been found to improve retention (Allen, Fiorini, & Dickey, 2010).

Facilitate Intraorganizational Movement. If a staff nurse is “burned out” from working
at a difficult job, such as on an oncology floor, one option is to allow a transfer to another
service area in the organization (e.g., home care). Unfortunately, some managers hinder
or even prohibit such a transfer, due to not wanting to lose a good nurse, particularly
if  the potential transferee is an excellent performer. However, this perspective is

Managing Absenteeism, Reducing Turnover, Retaining Staff 319

shortsighted. If the staff nurse cannot transfer to another area (intraorganizational
mobility), she or he may leave the organization entirely (interorganizational mobility).

One nurse manager decreased voluntary turnover on her unit without incurring
additional costs (see Case Study 21-1).

Box 21-1 Rewarding Employees
Low-Cost Rewards for Employees
• Allow staff to have a half day, whole day, or Friday off

for excellent performance by flexing hours and com-
pleting hours for a week in fewer days. For example,
allow an employee to choose four 10-hour shifts one
week as a treat instead of five 8-hour days.

• Give magazine subscriptions.
• Have a monthly birthday celebration potluck to recog-

nize all employees with a birthday that month—rotate
the theme for different kinds of food/activities.

• Initiate an employee-of-the-month program—reward
the employee with a gift card, certificate of recogni-
tion, or some other small gift.

• Start a newsletter and devote a section to describing
excellent employee performance and including staff
kudos to one another.

Formal Rewards for Employees
• Give awards for perfect attendance, patient advocate,

clinical leader, expert nurse, most cost-effective, for

example. Present the awards at a hosted annual
awards banquet, with food and formal recognition.

• Start a reward points system in which employees
earn points for great customer service and team-
work. Make a “treat box” that contains small gift
items such as snacks, pens, or notepads, for
example. Assign a point value to each gift item and
let staff accumulate points. Staff can then “buy”
items with their points.

• Provide continuing education opportunities pre-
sented by physician sponsors or nurses from the
community. Start a program that gives staff the
opportunity to take time off to attend an educational
offering once per year or a set number of times as
determined by the group.

• Help with tuition reimbursement for continuing edu-
cation.

• Give customer service awards based on years of
service.

CASE STudy 21-1 | Retention
Mona Karnes is nurse manager of labor and delivery at a
suburban hospital. Over the past 12 months, the voluntary
turnover rate among full-time RNs has been 25% for her
unit and 15% for the hospital as a whole. Despite increas-
ing starting salary rates and offering signing bonuses, turn-
over rates have remained high. Administration recently
conducted an annual salary and benefits review.

Mona collected information from the exit interviews
conducted during the annual review. From these data, Mona
has developed three strategies to aid in retention for her unit:

1. Rotate leadership responsibilities on the unit to offer all
nurses the opportunity to develop leadership and man-
agement skills. These responsibilities currently include a
weekly charge nurse role for each shift, education com-
mittee chair, physician relations liaison, women’s health
service line representative, and information technology

representative. Other leadership roles will be added as
appropriate.

2. Survey staff to determine interests and strengths and
connect staff members with a mentor. For example,
Debbie Edwards, RN, enjoys developing patient edu-
cation modules. Debbie will work with Heather Adams,
new nurse graduate, to develop Heather’s patient
education skills.

3. Schedule free monthly CEU offerings during staff
meetings that are presented by staff members, physi-
cians, or pharmaceutical company representatives. By
attending monthly staff meetings, most RNs will com-
plete 90% of state-required CEUs for license renewal.

All three strategies are at no cost to the unit or hospi-
tal. After 6 months, the voluntary turnover rate on Mona’s
unit had decreased to 8%.

320 Chapter 21

Adapt to Turnover Rate. Sometimes the organization may simply need to adapt to
a high turnover rate. Even if this is the case, potential problems can be lessened in
two ways:

1. Manage beliefs about why a nurse left. Sometimes, the reason is unclear, and the
grapevine will often provide an inaccurate and less attractive reason from the
organization’s perspective (e.g., “He left for $1.05 more an hour at another institu-
tion”).

2. Provide human resources with a preferred list of replacement workers. Some orga-
nizations keep an up-to-date list of former nurses who will fill in on an occasional
basis. Such former employees are familiar with organizational procedures and can
handle the work more efficiently.

The strategies outlined in this chapter have been shown to be effective in address-
ing absenteeism and reducing turnover. However, not all are equally applicable to all
situations. Situational factors determine what is appropriate. For example, flexible
work hours may be suitable for a clinic but not for an around-the-clock operation. By
being creative and providing incentives for exceptional nurses to stay and doing less
to retain mediocre nurses, nurse managers not only can reduce absenteeism and turn-
over but also can influence nurses’ attendance and which nurses leave.

What You Know Now
• Employee attendance is affected by the job, organi-

zational practices, absence culture, generational dif-
ferences, labor market, management, and employee
characteristics.

• Innovative solutions to absenteeism problems
include substituting personal days for sick days,
allowing sick days to accrue and unused days to
be paid to the employee, or converting unused
sick days to paid days at retirement.

• Turnover may be voluntary or involuntary, but it
is always costly to the organization.

• Many factors cause voluntary turnover, including
job dissatisfaction, undesirable work environ-
ment, and ease of movement.

• Organizations can help retain nurses by promoting
job satisfaction, encouraging employee engage-
ment, providing healthy work environments,
improving salaries, and recognizing performance.

• Managers can help reduce turnover by providing
realistic job previews and follow-up, and facilitat-
ing intraorganizational movement, but they may
have to adapt to turnover rate.

Tools for Reducing Turnover, Retaining Staff
1. Become familiar with your organization’s policies

on employee attendance.
2. Identify attendance problems and monitor them,

if necessary.
3. Monitor turnover and evaluate the causes.

4. Provide realistic job previews to new hires, espe-
cially new graduates.

5. Monitor new graduates’ performance and offer
additional support and training as needed.

6. Consider ways to improve the work environment.

Managing Absenteeism, Reducing Turnover, Retaining Staff 321

Questions to Challenge You
1. What suggestions do you have to reduce absen-

teeism in your school or workplace?
2. Can you recall instances when an employee’s

leaving has benefited the organization? Describe
what happened.

3. Have you voluntarily left a job?
a. What was the reason? Was there more than

one reason?
b. What reason did you give your supervisor?
c. Was it the same rationale that you answered in

part a of this question?

4. In addition to ideas presented in this chapter,
can you think of other ways to reduce voluntary
turnover?

5. Have you seen managers be effective in retain-
ing staff? What did they do that worked espe-
cially well?

6. If you were a manager, what specific actions
would you take to retain staff?

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http://www.nytimes.com/2015/03/29/jobs/
make-way-for-generation-z.html

McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P.,
Sloane, D. M., & Aiken, L. H. (2011). Nurses’
widespread job dissatisfaction, burnout, and
frustration with health benefits signal problems
for patient care. Health Affairs, 30(2), 202–210.

http://www.aacn.org/wd/hwe/docs/hwestandards

http://www.aacn.org/wd/hwe/docs/hwestandards

http://www.hanys.org/workforce/reports/2010-06-07_nurse_survey_results_2010

http://www.hanys.org/workforce/reports/2010-06-07_nurse_survey_results_2010

322 Chapter 21

Oyeleye, O., Hanson, P., O’Connor, N., & Dunn, D.
(2013). Relationship of workplace incivility, stress,
and burnout on nurses’ turnover intentions and
psychological empowerment. Journal of Nursing
Administration, 43(10), 536–542.

Paris, L. G., & Terhaar, M. (2011). Using Maslow’s
pyramid and the National Database of Nursing
Quality Indicators™ to attain a healthier work
environment. The Online Journal of Issues in Nursing,
16(1). Retrieved August 22, 2011, from http://
www.nursingworld.org/MainMenuCategories/
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TableofContents/Vol-16-2011/No1-Jan-2011/
Articles-Previous-Topics/Maslow-and-NDNQI-to-
Assess-and-Improve-Work-Environment.aspx

Rivera, R. R., Fitzpatrick, J. J., & Boyle, S. M.
(2011). Closing the RN engagement gap: Which

drivers of engagement matter? Journal of Nursing
Administration, 41(6), 265–272.

U. S. Department of Labor. (2011). The Family and
Medical Leave Act (FMLA). Retrieved November 3,
2015, from http://www.dol.gov/whd/regs/
statutes/fmla.htm

Weston, M. J. (2010). Strategies for enhancing
autonomy and control over nursing practice. The
Online Journal of Issues in Nursing, 15(1). Retrieved
August 22, 2011, from http://www.nursingworld.
org/MainMenuCategories/ANAMarketplace/
ANAPeriodicals/OJIN/TableofContents/
Vol152010/No1Jan2010/Enhancing-Autonomy-
and-Control-and-Practice.aspx

Wisotzkey, S. (2011). Will they stay or will they
go? Insight into nursing turnover. Nursing
Management, 42(2), 15–17.

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http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No1-Jan-2011/Articles-Previous-Topics/Maslow-and-NDNQI-to-Assess-and-Improve-Work-Environment.aspx

http://www.dol.gov/whd/regs/statutes/fmla.htm

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http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No1Jan2010/Enhancing-Autonomyand-Control-and-Practice.aspx

Chapter 22

Dealing with Disruptive
Staff Problems

Learning Outcomes

After completing this chapter, you will be able to:

1. Identify harassing behaviors, including bullying, incivility, and
horizontal violence.

2. Describe strategies to manage staff with problem behaviors.

3. Explain how to handle staff with a substance abuse problem.

Key Terms
horizontal violence marginal employees

Introduction
A major challenge confronting managers today is improving individual performance
and productivity while also enhancing the efforts of the entire work group. Some of
the general techniques for enhancing performance are ineffective because individual
problems affect group functioning.

Harassing Behaviors
Bullying

Lack of Civility

Horizontal Violence

How to Handle Problem Behaviors
Marginal Employees

Disgruntled Employees

The Employee with a Substance Abuse
Problem

State Board of Nursing

Strategies for Intervention

Reentry

The Americans with Disabilities Act and
Substance Abuse

323

324 Chapter 22

Harassing Behaviors
Harassing behaviors include bullying, lack of civility, and horizontal violence. All of
these behaviors affect staff and the functioning of the healthcare setting.

Bullying
Bullying in healthcare threatens not only the victim (the “target”) but also poses a danger
to patients (Stokowski, 2010). Furthermore, bullying increases staff dissatisfaction and
can lead to absenteeism and turnover (Wilson, Diedrich, Phelps, & Choi, 2011). Called
bullying, incivility, verbal abuse, relational aggression, or horizontal violence, all such
behaviors are examples of bullying (Dellasega, Volpe, Edmonson, & Hopkins, 2014).

Bullying can occur online, via text messages, or in person. Bullies use words and
nonverbal behaviors, and they sometimes involve other people, as with gossiping.
Bullying behaviors can range from mildly irritating to dangerously violent (Stokowski,
2010). The following are some examples:

• Ignoring someone or giving the silent treatment

• Treating someone in a condescending or patronizing manner

• Making derogatory remarks about someone within that person’s hearing

• Using dismissive body language, such as eye rolling

• Ridiculing and using sarcasm

• Verbally abusing someone

• Scapegoating someone

• Isolating the target

• Failing to assist

• Sexually harassing

• Physically attacking

Policy efforts to combat bullying in healthcare settings have been launched by the
Joint Commission and the American Nurses Association. Joint Commission recom-
mends zero tolerance of disruptive or abusive behavior (Joint Commission, 2015). The
American Nurses Association (ANA) recommends strategies to combat hostility,
abuse, and bullying in the workplace (American Nurses Association, 2010).

Several states are considering healthy workplace bills that would allow workers to
sue for harm from abusive treatment (Stokowski, 2010). As widespread reports of abuse
surface, it is hoped that swift legal action will offer redress for victims (Sullivan, 2013).

Lack of Civility
At times, an instance of bullying is not so obvious. Lack of civility is an example.
Uncivil behavior creates an environment that also endangers patients (Covell, 2010).
Lack of civility includes any of the following behaviors:

• Rude

• Disrespectful

• Impolite

• Ill-mannered

Dealing with Disruptive Staff Problems 325

Aggressive behaviors, such as the following, are also forms of bullying:

• Yelling

• Swearing

• Spreading rumors

• Destroying or taking another’s property

Here’s an example:

Reid Martin, nurse manger, has encouraged new graduate nurse Joy Gabriel to develop
an informational presentation for a staff meeting as a strategy to improve her self-
confidence. At the next monthly staff meeting, Joy presents information about a new
occlusive dressing. Joy is shy, and public speaking is difficult for her. Her voice shakes,
and she drops the box of new dressings she has brought to demonstrate. Kristi Sanderson,
RN, has been rolling her eyes and sighing loudly throughout Joy’s presentation. At the
end of the meeting, Kristi makes a point of telling several other staff members that it was
“painful” to sit through Joy’s presentation. Joy overhears Kristi’s comments.

This example is a situation that does not quite rise to the level of bullying. None-
theless, the manager must confront Kristi and explain why nonverbal signals are inap-
propriate. Kristi must be also told that even softly voiced criticisms will not be
tolerated. Following the suggestions on coaching and progressive discipline, the man-
ager must explain the consequences for repeated instances of discourtesy to her fellow
staff members and insist that Kristi conduct herself in a civil manner. The manager also
followed up with Joy and shared that her presentation was excellent and apologized
for the inappropriate comments. The manager told Joy that the issue was being han-
dled so another staff member would not face such uncivil behavior in the future.

Horizontal Violence
Another example of the complexity of bullying is horizontal violence, or harassment
between employees of equal rank. See the following example:

Jeana Rossi, RN, is a staff nurse on a medical unit. At 0700, she took over care for five
patients from Greg Robeson, RN, an agency nurse who had worked the 7p—7a shift.
During her review of patient medication administration records, Jeana noted that an IV
antibiotic scheduled to be administered at 2300 had not been charted. Checking the IV
bin, Jeana found the 2300 dose. Greg had already left the unit. Per hospital policy, Jeana
completed a missing dose report and turned it in to her manager. Two days later, Greg
cornered Jeana in the staff lounge and loudly berated her in front of other staff members
for completing a missing dose report. “You’re so stupid!” Greg shouted. “You just
wanted to make me look bad, didn’t you?”

This example shows how difficult some staff problems can be to manage. If you
were the manager on this unit, how would you handle the situation? Here are some
alternatives: The manager could report Greg to the agency and request that he no lon-
ger be assigned to the unit, but then a replacement must be found and the manager
may have concerns about the competency of other nurses this agency might send.
Remember, Greg was the only nurse on the night shift. The manager could also discuss
the event with Greg and counsel him on violating hospital policy. In the end, the man-
ager reported the situation to her supervisor and called the director of the agency, who

326 Chapter 22

Leading at the Bedside: Solving Staff Problems
You’ve probably experienced problems in your school or
workplace. You may have seen bullies disrupt a group’s
functioning, or had to do more because a marginal individ-
ual didn’t do the job, or tried to ignore a disgruntled person.
Sadly, you may have noticed someone impaired by alcohol
or drugs in the workplace.

Probably you thought you could do nothing to change
those individuals’ behavior, but you can do more than you
realize. Here’s how: After checking the employee handbook
for organizational policies on these problems, resolve to do
all you can to help individuals and your workgroup.

Then if you see someone being harassed or bullied,
speak up to the bully and/or a supervisor. Report a marginal

employee’s actions without judgment. Just state the facts.
Do your best to ignore the disgruntled individual. Such peo-
ple rely on listeners to validate their claims. Don’t allow
them that.

One note of caution: If you find a colleague impaired
by alcohol or drugs at work, report that person immedi-
ately. Do not intervene yourself, but you cannot allow the
person to continue to work in a healthcare setting. Allow a
supervisor to handle this difficult situation.

Problems in the workplace are common, but many
can be solved or ameliorated with careful attention to the
problem and its solution.

assured the manager that the agency would provide a competent nurse for the next
shift. Involving the supervisor is always indicated (see Leading at the Bedside: Solving
Staff Problems).

The manager has a special duty to protect staff from bullying by others, to each
other, or to students. Take every report of verbal aggression seriously, document
events, and use the appropriate conflict strategy to resolve it. Left on its own, bullying
is likely to continue and escalate. One caveat regarding bullying: If the situation
becomes threatening, seek help immediately, preferably from security.

How to Handle Problem Behaviors
Here is another example of a complex staff problem.

The staff at the outpatient imaging center all share a common break room. Over the
past several months, several staff members have complained to their nurse manager,
Julie Fredrickson, that their lunches or particular items such as desserts or cans of
soda are missing from the break room refrigerator. One afternoon, Julie enters the
break room to get a cup a coffee and sees one of the radiologists, Dr. Gibson, eating a
brownie and looking through several lunch bags. “I never get a chance to get out for
lunch,” Dr. Gibson said. “I’m sure your staff doesn’t mind sharing with a hungry
physician.”

If you were the nurse manager at this outpatient center, how would you handle
this situation? Dr. Gibson was committing theft, even if the items he stole were
inexpensive. Nonetheless, his behavior caused nurses to go without some of their
own food, and, more important, it was disrespectful to them. It implied that he
thought his needs were more important than theirs. When informed, the manager
alerted his supervisor then confronted Dr. Gibson who, after threatening to report
the manager to administration, calmed down, said he would donate pizza for the
staff the next day, and agreed to stop stealing (yes, the manager used the word
stealing).

Dealing with Disruptive Staff Problems 327

Managers and nurses are faced with any number of other problems presented by
employees, including staff who are marginally competent, perpetually complaining,
verbally abusive, or lack civility in the workplace. Still others may have a substance-
abuse problem.

Marginal Employees
Some staff, no matter how many times they are coached or disciplined, never seem to
reach the level of competence expected of an experienced nurse. These are marginal
employees. Work habits may be sloppy, communication skills poor, or decision mak-
ing inadequate. Discipline does not help either in spite of the employee’s attempts to
improve.

Marginal employees present a unique challenge. Ignoring the problem and hop-
ing that the employee will improve is generally ineffective. This also leaves the unit
vulnerable to complaints from other staff who must cover for the marginal employee,
and high-performing employees may be discouraged (Weston, 2009).

The organization’s procedures for progressive discipline and termination must be
followed if the problem behaviors do not improve. If the manager is persistent, fair,
and consistent, employees are more likely to perceive the policies as just (Henle,
Kohut, & Booth, 2009).

Disgruntled Employees
Disgruntled employees are those who are always complaining; their behavior affects
morale on the unit. They complain about anything and everything, but they direct most of
their complaints against the organization. They may air them in public, which can affect
how others view the organization. Although the temptation is to label this as an attitude
problem, complaining is a behavior and as such can be addressed by the following:

• Set standards of performance and communicate them to the employee.

• Keep notes about incidents of complaining in behavioral terms.

• Take action early, and be consistent among employees.

• Follow up as scheduled.

Case Study 22-1 describes one manager’s experience with an employee with
another problematic behavior.

The Employee with a Substance
Abuse Problem
As substance abuse has become increasingly prevalent in society, nursing has not
remained immune. Substance abuse not only is detrimental to the impaired nurse, but
it also jeopardizes patients’ care, thereby also exposing the employing agency to
greater liability (Monroe, Vandoren, Smith, Cole, & Kenaga, 2011).

Early recognition of alcohol or drug dependency and prompt referral for treat-
ment are essential. Some general signs and symptoms may become evident as a nurse’s
dependency progresses (Boxes 22-1 and 22-2).

In addition to the signs and symptoms listed in Boxes 22-1 and 22-2, the nurse man-
ager should be alert for workplace indications of drug abuse as shown in Box 22-3.

328 Chapter 22

Box 22-1 Signs of Alcohol or Drug Dependency
• Family history of alcoholism or drug abuse
• Frequent change of work site (same or other institution)
• Prior medical history requiring pain control
• Conscientious worker with recent decrease in perfor-

mance
• Decreased attention to personal appearance
• Frequent complaints of marital and family problems
• Reports of illness, minor accidents, and emergencies

• Complaints from coworkers
• Mood swings, depression, or suicide attempts
• Strong interest in patients’ pain control
• Frequent trips to the bathroom
• Increasing isolation (night shift request; eating alone)
• Elaborate excuses for tardiness
• Difficulty in meeting schedules and deadlines
• Inadequate explanation for missing work

Box 22-2 Physical Symptoms of Alcohol
or Drug Dependency

• Shakiness, hand tremors, jitteriness
• Slurred speech
• Watery eyes, dilated or constricted pupils
• Diaphoresis
• Unsteady gait

• Runny nose
• Nausea, vomiting, diarrhea
• Weight loss or gain
• Blackouts (memory losses while conscious)
• Continuous wearing of long-sleeved clothing

Case study 22-1 | Problem staff
Gene Marshall is the nurse manager for a general
medical—surgical unit in a Veterans Affairs (VA) hospital.
His busy unit primarily serves elderly male patients. Felicia
Ralston, RN, has worked on the medical—surgical unit for
3 years. Since her hiring, Felicia has obtained several body
piercings, including her nose, eyebrow, and tongue. She
usually wears large hoops or bars in her facial piercings.
Not long ago, Felicia added a visible tattoo to the back of
her neck and upper shoulder. The tattoo on her lower back
can often be seen despite her uniform. Recently, she came
to work after adding purple highlights to her hair.

As the number and prominence of Felicia’s piercings
and body art have increased, several patients and their
family members have told Gene that they were “uncomfort-
able” having Felicia as their nurse. Some patients feel intim-
idated by her unusual appearance. Gene speaks with
Felicia about the patient and family member concerns and
reviews the hospital’s dress code with her. Felicia becomes
angry and tells Gene that hair color, body piercings, and
tattoos are a form of individual expression and have nothing
to do with her performance as a nurse.

Later, Felicia tells everyone on the unit about her dis-
cussion with Gene, speaking loudly and inappropriately in
patient care areas. She asks the unit clerk if she knows
which patients or family members complained to Gene
about her appearance. The following day, Felicia asks each

of her assigned patients if they “have a problem” with her.
Felicia reports back to Gene that none of her patients said
they had any problems with her or her appearance. After
discussing the situation with the human resources depart-
ment, Gene meets with Felicia and provides her with a writ-
ten warning regarding her body piercings, tattoos, and hair
color as well as her unprofessional behavior following their
initial meeting. Gene tells Felicia that she must remove jew-
elry from her nose and eyebrows prior to reporting for work
and that her hair color must be a natural color. He also tells
her that her tongue jewelry must be small and unnoticea-
ble. Felicia’s uniforms are to cover her tattoos completely.

Gene also provides Felicia with a copy of the federal
court ruling in which the court ruled that body piercings
and tattoos are not considered protected as free speech,
and that employers have the right to set standards of
dress and appearance for their employees. Gene tells Feli-
cia that not only has her behavior been inappropriate and
unprofessional, but because it made staff and patients
uncomfortable, it could be considered harassment or
workplace violence. Finally, Gene emphasizes to Felicia
that she should speak directly with him regarding any per-
formance issues or problems and not involve staff or
patients in the situation. If Felicia does not comply with
these standards within 10 working days, she will be termi-
nated from her position.

Dealing with Disruptive Staff Problems 329

Box 22-3 Workplace Indications of Drug Abuse
• Incorrect narcotics counts
• Alterations of narcotics containers
• Discrepancies on medication records or frequent

corrections on them
• High wastage of narcotics

• Marked shift variations in the quantity of narcotics
required on the unit

• Excessive patient reports that pain medication was
ineffective

If the manager discovers signs or symptoms in an employee or becomes aware of
the unit changes described in Box 22-1, Box 22-2, and Box 22-3, further investigation is
warranted, and administration should be informed.

State Board of Nursing
State boards of nursing are charged with protecting the public, including the practice
by nurses impaired by substance abuse. Reporting laws vary from state to state, as do
consequences, but most state boards require the nurse manager to report an impaired
colleague.

Diversion programs offering referral, assistance, and monitoring may be offered
in lieu of disciplinary action in some states. For example, the Kansas Nurses Assis-
tance Program (KNAP) is offered to nurses whose practice is impaired by substance
abuse (Kansas State Board of Nursing, 2015). Nurses who successfully complete the
program are not reported to the Kansas State Board of Nursing.

Strategies for Intervention
Once a nurse has been identified with a substance abuse problem, intervention
with that nurse must be planned. With the assistance of the human resources
department and administration, the manager should examine the organization’s
policies and procedures and licensure laws as well as determine if a diversion
program exists. Then documentation about the nurse’s behavior must be col-
lected, including records of absenteeism and tardiness (especially recent changes),
patient complaints about ineffective medications or poor care, staff complaints
about job performance, records of controlled substances, and physical signs and
symptoms noticed at different times. Dates, times, and behaviors should be care-
fully noted. Any one behavior means very little; it is the composite pattern that
identifies the problem.

Next, appropriate resources to help the nurse should be identified. Resources
include an employee assistance program counselor, if available; treatment center con-
tacts; other recovering nurses (if known); and Alcoholics Anonymous or Narcotics
Anonymous. It is absolutely essential to provide several sources in order for the nurse
to feel confident that help from someone who knows how he or she feels is available,
and the nurse also knows how to get help. This support cannot be emphasized enough.
Failing to offer this assistance is like telling a diabetic he has diabetes and failing to tell
him where he can get insulin.

The goal of the intervention is to get the nurse to an appropriate place for an eval-
uation of the possible problem. Most experts in treating nurses with addictions recom-
mend that the nurse be offered the option of substance abuse evaluation and, if needed,

330 Chapter 22

treatment. If she or he does not agree to that, then the usual disciplinary process must
be followed and a report made to the state board of nursing.

The intervention should be scheduled as soon as possible at a time and place when
and where interruptions can be avoided. Treatment centers or therapists who special-
ize in substance abuse are recommended to conduct the evaluation. It is important to
focus on the problem behaviors, not on the inadequacy of the person. If the nurse is
using alcohol or drugs at the time, immediate removal from patient care is necessary.

Reentry
Reentry to the workplace must be carefully planned. State law or organizational policy
may require that recovering nurses in the early posttreatment period be restricted from
handling controlled substances, carrying narcotic keys, being in charge, or working
overtime. Thus, the individual could be reassigned for a period of time to a job or a
unit where few mood-altering drugs are given, such as the nursery, department of edu-
cation, rehabilitation, home care, dialysis, or patient care audits. Each case should be
individually decided based on the amount of stress in the job, the need for rotating
shifts, and other factors that may inhibit recovery. The reentry contract also may require
documentation of participation in recovery groups and random urine drug tests.

The Americans with Disabilities Act
and Substance Abuse
The Americans with Disabilities Act (ADA) went into effect in 1990 and was amended
in 2009 (U.S. Department of Justice). Because alcohol or drug dependency limits one or
more of a nurse’s activities, it is considered a disability under the ADA. Furthermore,
the employee’s drug abuse history must be kept private. The ADA confidentiality pro-
visions require the employer to keep records (i.e., disability) on employee substance
abuse in separate, locked files with access limited to a need-to-know basis.

Dealing with employee problems presents ongoing challenges for nurse manag-
ers. You must identify the problem, intervene appropriately, and follow up as neces-
sary. In addition, the manager must be persistent, fair, and consistent when intervening
with problem employees.

What You Know Now
• Bullying increases staff dissatisfaction and turn-

over and can pose a danger to patients as well.

• Incivility and horizontal violence are examples of
bullying.

• The behavior of employees who harass others, are
marginal performers, are disgruntled, or abuse sub-
stances affect coworkers as well as patient care.

• Staff problems must be identified early and inter-
vention planned, if necessary.

• Identifying, intervening, and returning nurses with
substance abuse problems to the workplace help the
organization, the manager, and the affected nurse.

• The manager must be persistent, fair, and consis-
tent when intervening with problem employees.

Dealing with Disruptive Staff Problems 331

Tools for Managing Staff Problems
1. Identify bullying behavior promptly and inter-

vene as appropriate.
2. Document all instances of problem behavior.
3. Try to resolve conflicts and deal with problems as

they appear.

4. Consult administration and the human resources
department before intervening in serious prob-
lems, such as substance abuse.

5. Follow up problem behaviors with coaching, dis-
ciplining, or terminating if needed.

Questions to Challenge You
1. Have you ever worked or shared a class with a

person who caused problems? (Most of us have.)
How did the problem manifest itself? How was it
handled? How do you wish the problem had
been handled?

2. Have you ever experienced bullying or seen oth-
ers bullied? How did you or they handle it?

3. Are you familiar with the signs and symptoms of
substance abuse? Have you seen someone exhibit
these characteristics? What signs or symptoms
did they exhibit? What happened?

4. Using the examples in this chapter, consider how
you would respond to the problem behaviors.

References
American Nurses Association. (2010). House of

Delegates Resolution: Hostility, abuse and bullying
in the workplace. The Kansas Nurse, 85(6), 17.

Covell, C. L. (2010). Can civility in nursing work
environments improve medication safety? Journal
of Nursing Administration, 40(7/8), 300–301.

Dellasega, C., Volpe, R. L., Edmonson, C., & Hopkins,
M. (2014). An exploration of relational aggression
in the workplace. Journal of Nursing Administration,
44(4), 212–218.

Henle, C. A., Kohut, G., & Booth, R. (2009). Designing
electronic use policies to enhance employee
perceptions of fairness and to reduce cyberloafing:
An empirical test of justice theory. Computers in
Human Behavior, 25(4), 902–910.

Joint Commission. (2015). Behaviors that undermine
a culture of safety. Retrieved November 5,
2015, from http://www.jointcommission.org/
assets/1/18/SEA_40.PDF

Kansas State Board of Nursing. (2015). The Kansas
Nurses Assistance Program (KNAP). Retrieved
November 2, 2015 from http://www.ksbn.org/
knap.htm

Monroe, T., Vandoren, M., Smith, L., Cole, J., &
Kenaga, H. (2011). Nurses recovering from
substance use disorders. Journal of Nursing
Administration, 41(10), 415–421.

Stokowski, L. A. (2010). A matter of respect and
dignity: Bullying in the nursing profession.
Retrieved October 15, 2010, from http://www.
medscape.com/viewarticle/729474

Sullivan, E. J. (2013). Becoming influential: A guide
for nurses (2nd ed.). Upper Saddle River, NJ:
Pearson.

U.S. Department of Justice. (2009). Americans with
disabilities act of 1990, as amended. Retrieved
November 6, 2015, from http://www.ada.gov/
pubs/ada.htm

Weston, M. J. (2009). Managing and facilitating
innovation and nurse satisfaction. Nursing
Administration Quarterly, 33(4), 329–334.

Wilson, B. L., Diedrich, A., Phelps, C. L., & Choi, M.
(2011). Bullies at work: The impact of horizontal
hostility in the hospital setting and intent to
leave. Journal of Nursing Administration, 41(11),
453–458.

http://www.jointcommission.org/assets/1/18/SEA_40.PDF

http://www.ksbn.org/knap.htm

http://www.medscape.com/viewarticle/729474

http://www.ada.gov/pubs/ada.htm

http://www.jointcommission.org/assets/1/18/SEA_40.PDF

http://www.ksbn.org/knap.htm

http://www.medscape.com/viewarticle/729474

http://www.ada.gov/pubs/ada.htm

Learning Outcomes

After completing this chapter, you will be able to:

1. Identify examples of disasters that require preparation.

2. Determine emergency preparedness for hospitals.

3. Discuss staff requirements to respond to emergencies.

Key Terms
all-hazards approach

emergency operations plan (EOP)

mass casualty events (MCE)

surge capacity

Introduction
Terror attacks, wars in the Middle East, mass shootings, and violence in the United
States and around the world have been the focus of national and local efforts in emer-
gency preparedness. At the national level, the Joint Commission and the federal
government have created initiatives to help prepare first responders and health-
care organizations to handle emergencies (Sauer, McCarthy, Knebel, & Brewster, 2009).
The Joint Commission expanded its emergency management standards to include

Types of Emergencies
Natural Disasters

Man-made Disasters

Levels of Disasters

Hospital Preparedness for Emergencies
All-hazards Approach

Emergency Operations Plan

Surge Capacity

Disaster Triage

Continuation of Services

Staff Utilization in Emergencies

332

Chapter 23

Preparing for
Emergencies

Preparing for Emergencies 333

Box 23-1 Examples of Disasters
Natural Disasters Man-made Disasters

Floods Accidental

Hurricanes Structural collapse of buildings or bridges

Earthquakes Industrial spills

Landslides and mudslides Power outages

Wildfires Intentional

Epidemics and pandemics (influenza, SARS, H1N1) Explosive or incendiary devices

Sniper or mass casualty shootings

Release of toxins (chemical, physical, biological, radiological, nuclear)

Arson fires

Natural Disasters
Natural disasters include any disaster that is not man-made. Floods, hurricanes, torna-
does, volcanoes, heat waves, and blizzards are examples of natural disasters. Location
is a key element in preparing for natural disasters. Coastal areas must prepare for hur-
ricanes, river towns should prepare for flooding, and plains areas should plan for tor-
nado disasters.

Health disasters are also natural disasters. Disease epidemics that spread rapidly
through the population and pandemics that spread disease around the planet are
health disasters. Severe acute respiratory syndrome (SARS), AIDS, antibiotic-resistant
bacteria, Ebola, H1N1 influenza, and the Zika virus are examples of health threats that
can cause epidemics and pandemics.

Man-made Disasters
Man-made disasters can be accidental or intentional. Industrial hazards, structural col-
lapses of buildings or bridges, and power outages are examples of accidental hazards.
Subways, sports stadiums, and airplanes may be attacked. Chemical, physical,

mitigation, preparedness, response, and recovery (The Joint Commission, 2016). The
executive branch of the U.S. government issued executive orders establishing, among
other initiatives, the Office of Homeland Security. The U.S. Congress passed legislation
addressing bioterrorism and pandemics. Congress also directed the Federal Emergency
Management Agency (FEMA) to coordinate disaster relief efforts.

Types of Emergencies
Emergencies can be natural disasters (e.g., tornadoes, hurricanes, earthquakes, or
floods), or they may be man-made accidents (e.g., hazardous material spill) or inten-
tionally created (e.g., acts of terrorism). Regardless of the cause, healthcare organizations
must be prepared to deal with the mass casualties (MC) that may occur due to any
type of emergency (see Box 23-1).

334 Chapter 23

biological, radiological, or nuclear toxins may spread to the population, causing illness
and death. Anthrax, a bacterial toxin, and asbestos, a physical toxin, are examples of
poisonous substances that can cause environmental disasters. Cybersecurity is an
increasing issue, and infiltration of a health organization’s computer systems can
cause disruption to individuals as well as to the computer infrastructure.

Levels of Disasters
Disasters are further categorized by level as follows (Smeltzer, Bare, Hinkel, &
Cheever, 2010):

• Level I: Local level response and containment suffice.

• Level II: Regional level response is necessary.

• Level III: Statewide or national assistance is needed.

Every healthcare organization must prepare for both natural and man-made
disasters and the resulting mass casualty events (MCE). Unfortunately, efforts some-
times fall short of the goal.

Hospital Preparedness for Emergencies
Plans for emergency management are required of all hospitals (The Joint Commission,
2016). Key to successful emergency management is preparation. The organization,
however, does not need to prepare for any and all possible catastrophic events.

All-hazards Approach
The all-hazards approach, contrary to popular thinking, does not mean that every
organization must be prepared for every possible catastrophic event (Canton, 2013).
Such preparation is impossible due to the amount of resources (time, money) required
and unnecessary and could lead to staff confusion during an actual event. Instead,
Canton suggests that a risk analysis of the community’s vulnerability to specific threats
should direct the organization’s planning efforts. In fact, preparedness for one type of
event (e.g., disease pandemic) correlates with preparedness for all other types of
events (Adini, Goldberg, Cohen, Laor, & Baar-Dayan, 2012).

The Institute of Medicine’s report entitled Crisis Standards of Care: A Systems Frame-
work for Catastrophic Disaster Response (Hanfling, Altevogt, & Gostin, 2012) recom-
mends that hospitals, emergency services, and local government agencies integrate
their plans to respond to disastrous events. In addition, the report suggests that local
community members become involved in the planning, and that nurses play a key role
in developing the community’s response to crises (Murray, 2012).

Emergency Operations Plan
A hospital emergency operations plan (EOP) includes preparation, education and
training, and implementation of the hospital’s response to emergency situations. The
hospital’s EOP includes the following components:

• Activation response

• Communication plan

Preparing for Emergencies 335

Leading at the Bedside: Preparing for Disasters
Have you participated in a disaster practice exercise? What
about an actual mass casualty event? Did the organization
function as well as could be expected in the exercise and/
or in the event? What did you learn from your experience?

If you have neither practiced nor participated in an
actual event, are you familiar with your organization’s

emergency operations plan? Do you know where to find it?
Do you know what to do in emergencies? If your answer is
no to any of these questions, then find out. Never take
emergency preparedness for granted. Your life and those of
your patients and colleagues may be at stake.

PraCtiCing Hospitals are required to test their EOP twice a year (The Joint Com-
mission, 2016). One practice can be a tabletop event, but one must involve realistic
situations and simulated patients. The timing of exercises should include occasions
when the hospital is at low capacity to test its readiness in the most adverse situations.
The hospital’s EOP and performance should be evaluated annually.

Surge Capacity
Surge capacity describes an institution’s ability to mobilize when suddenly confronted
with a vast increase in patient demand (Adams, 2009). By planning ahead for an influx
of patients, strategies can be put in place to marshal emergency procedures. A surge
system includes the following:

• Supplies

• Personnel

• Patient care coordination plan

• Security plan

• Traffic flow plan

• Data management strategy

• Resources availability (Smeltzer et al., 2010)

Finally, the EOP must include plans to deactivate the response and follow up with
a post-incident review and a schedule for practice drills.

Implementation of the EOP includes three components: planning, preparing, and
practicing (Smeltzer et al., 2010).

Planning Planning involves determining the hospital’s top three to five vulnera-
bilities based on its geographic location. For example, if the hospital is near a factory,
the EOP would include plans for possible industrial accidents. If the hospital is located
in a city near the Atlantic Ocean, staff would prepare for hurricane victims. On the
other hand, if the hospital sits on the Kansas plains, tornadoes are more likely. Once
vulnerabilities have been determined, planning can proceed based on the possible
patient injuries.

PrEParing Preparation includes staff education and training. Both knowledge and
skills training are needed. Techniques may include computer simulations, video dem-
onstrations, and disaster drills. (See Leading at the Bedside: Preparing for Disasters.)
An incident command center must be identified, and the individuals in charge of oper-
ations during a disaster appointed and trained. All staff need a clear understanding of
communication systems and the incident command center (Gardner & Frazier, 2013).

336 Chapter 23

• Physical space

• Management infrastructure

These components are known as “stuff, staff, structure, and systems” (Adams,
2009). At the onset of a disaster and the impending arrival of mass casualties, a hospi-
tal incident command structure can be implemented, a rapid needs assessment con-
ducted, and appropriate activities mobilized. Preparation and drills ensure that all
components are in place. Post-incident follow-up is essential to continually evaluate
performance and initiate improvements.

Disaster Triage
Similar to the triage system used by the military in war situations, hospitals must
reverse their usual triage method of treating the most seriously injured person first.
Instead, they must prioritize scarce resources to those who can benefit the most
(Kirwan, 2011). The goal is to treat as many injured people as possible in the shortest
time possible. Inundated with mass casualties, precious time must be directed to the
least seriously injured first, then the more seriously injured, and so on.

Continuation of Services
Complicating emergency preparedness is the need to provide for continuation of ser-
vices during an emergency. Routine services may be disrupted. Loss of electrical power
may be countered by backup generators, but if computer capabilities close down, how
will the electronic medical record and the medication system work? How will docu-
mentation continue? Resupply of medications, food, water, and supplies may be inter-
rupted. What if resupply lines are impacted by a disaster (e.g., trucks delivering meds
cannot get through due to flooded or washed-out roads)? Furthermore, how will the
facility handle a large influx of patients and/or casualties? If needed, how will the
evacuation of the facility be handled? The EOP must address all of these issues.

Risk assessment is necessary to identify the hospital’s vulnerability. Hospitals are
often the frontline responders to mass casualty events, but maintaining services in the
face of overwhelming numbers of casualties can be challenging. Capabilities, resources,
and education and training needs must be assessed.

Staff Utilization in Emergencies
Depending upon the nature of the emergency, staff may be required to help evacuate
patients (e.g., because of flooding) or may need to shelter in place (e.g., because of a live
shooter). Regardless, their lives will be affected. They may become ill themselves, for
example, or a tornado may devastate their homes, such as in Joplin, Missouri, in 2011;
they may need to get to their children or other family members. With the loss of staff,
how will the agency continue to accept and care for new patients?

Employee fatigue and exhaustion, including mental fatigue, must be addressed.
Personal protective equipment must be available, and staff must be trained to use the
equipment and know how to access it in an emergency. Protective equipment includes
respiratory protection, eye and face protection, and hand, arm, and body protection.

Education, training, and practice drills help staff prepare for an unanticipated crisis.
Key to maintaining operational readiness is the staff’s willingness to come to work

Preparing for Emergencies 337

CaSE STUDy 23-1 | Preparing for an Impending Emergency
Weather forecasters were predicting 15 inches of snow to
fall in the next 24 hours. It was likely to be the biggest
snowstorm the town had seen in as many years as any-
one could remember. Everyone was in an uproar over the
impending severe storm that threatened to shut down
the city. Mount Bethel Hospital administration wanted to
make sure they were prepared for this blizzard ahead of
time and had an effective emergency plan in place to pro-
vide patients with effective, uninterrupted care.

The snow was expected to start at 4:00 p.m. Hospital
managers and administrators met early that morning at
7:00 a.m. to get a plan in place. It was decided that a mes-
sage would go out to all staff who were scheduled to work
that night, advising them to come into the hospital early for
their night shift. The hospital would serve dinner in the cafe-
teria to those waiting for their shift to start. Getting night staff
to the hospital before the blizzard was projected to be at its
worst would allow the hospital to run in routine fashion over-
night. The hospital also encouraged night shifters to bring a
bag to stay over the next day at the hospital and asked them
to consider working the following night shift, too.

The administration team increased its linen and gro-
cery orders with vendors so the hospital would be well
stocked in case deliveries couldn’t be made for a few days.
The grocery order was delivered and included all items
requested. The linen order was delivered that day; it was
only double the routine delivery, because many other

facilities had also requested excess linens to be delivered.
The administration made a note in its plan to notify staff
to  conserve linen resources if a normal linen delivery
couldn’t occur the next day.

The administration announced to the daytime staff
that all staff had been invited to spend the night at the hos-
pital after their shift and were asked to work the next day as
well. Each staff member was provided with a cot to sleep
on, blankets and pillows, meals, and clean scrubs. In addi-
tion, the hospital made shower facilities within the building
available for staff, and even put up sign-up sheets for each
shower so staff could schedule their time. Most day staff
agreed to stay at the hospital to avoid driving home, and so
they would be available the next day when people at home
were likely not going to be able to drive in for their shift.

Mount Bethel was well prepared for the impending
blizzard. With proper advance preparation, the hospital was
able to operate under normal patient care standards. The
staff had been so gracious to stay at the hospital and meet
the staffing needs for patient care. Within 36 hours, the
streets were cleared and the city was back to its usual
operations. Staff were able to commute to work, deliveries
of groceries and linens were back on schedule, and the
hospital was operating under normal conditions again.
Mount Bethel’s administration was pleased that it had been
able to successfully plan and work through the weather
emergency.

during a disaster (Davidson et al., 2009). The hospital’s surge capacity includes a callback
system for requesting staff to return to work during an emergency, but it does not address
the staff member’s willingness to come to work (Adams & Berry, 2012). Several factors
determine staff members’ decisions to come to work, including vulnerability of family,
personal safety concerns, professional accountability, past experience with disasters,
caring connection with the organization, and the desire to help (Davidson et al., 2009).

These factors suggest appropriate management responses. Developing a caring
relationship with staff members and a compassionate response during and after a
disaster may slightly help mitigate staff concerns about family vulnerability and per-
sonal safety. Worry about pets, children, dependent adults, and their own security will,
of course, still affect employees’ decisions to return to work (Davidson et al., 2009).

In addition to the complications of preparing for emergencies, the hospital also
may not be reimbursed for care provided, standards of care may not be established or
able to be maintained, and the hospital may incur liability for volunteers’ safety or
their performance (Hodge, Garcia, Anderson, & Kaufman, 2009). A natural disaster, a
terrorism attack, an epidemic, or another mass casualty event may, and probably will,
occur at some time. All healthcare organizations must be prepared to care for a surge
in casualties while reducing the impact on patients and staff.

See how one hospital prepared for an impending emergency in Case Study 23-1.

What You Know Now
• Emergencies include natural disasters, man-made

accidents, mass shootings, and acts of terrorism.

• Emergency preparedness is the focus of national
efforts and is expected to increase in the coming
decade.

• Every hospital is required to have an emergency
operations plan (EOP).

• Triage in a mass casualty incident is the reverse of
normal standards: The goal is to treat the most
people in the shortest time with the resources
available.

• Planning, preparing, and practicing are the steps
necessary to manage potential emergencies.

• Surge capacity describes an institution’s ability to
mobilize when confronted with an influx of
patients.

• Education, training, and practice drills help staff
prepare for a sudden mass casualty incident.

• Employees’ caring connection with the institution
may help mitigate their concerns about family
vulnerabilities and personal safety.

Tools for Preparing for Emergencies
and Preventing Violence

1. Become familiar with your organization’s emer-
gency operations plan (EOP).

2. Participate in education and training sessions to
prepare for emergencies.

3. Refresh your training regarding reverse triage.

4. Recognize that an actual disaster will challenge
your ability to handle family situations and con-
cerns about your personal safety and will affect
your decision to come to work.

5. When an emergency occurs (practice or actual),
recall your training and participate as required.

Questions to Challenge You
1. Do you know what to do in an emergency? List

the steps you would take. Then locate a copy of
your organization’s policies and procedures for
emergencies and evaluate yourself.

2. Create a fictitious emergency situation with a
classmate or colleague. Challenge each other on
how each of you would handle the situation.
Share your experience with others.

3. Have you participated in disaster drills? How
well did you follow your training? How well
did the organization handle the drill? Did you see
areas for improvement?

4. Have you been involved in an actual disaster
experience? If so, share your experience with
classmates or colleagues. Nothing makes a situa-
tion real better than a factual account.

338 Chapter 23

Preparing for Emergencies 339

References
Adams, L. M. (2009). Exploring the concept of surge

capacity. The Online Journal of Issues in Nursing,
14(2). Retrieved February 24, 2016 from http://
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Previous-Topics/Surge-Capacity.html

Adams, L. M., & Berry, D. (2012). Who will show up?
Estimating ability and willingness of essential
hospital personnel to report to work in response
to a disaster. The Online Journal of Issues in Nursing,
17(2). Retrieved February 24, 2016, from http://
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TableofContents/Vol-17-2012/No2-May-2012/
Articles-Previous-Topics/Essential-Hospital-
Personnel-and-Response-to-Disaster.html

Adini, B., Goldberg, A., Cohen, R., Laor, D.,
& Baar-Dayan, Y. (2012). Evidence-based
support for the all-hazards approach to
emergency preparedness. Israel Journal of
Health Policy 1(40). Retrieved February 25,
2016, from http://ijhpr.biomedcentral.com/
articles/10.1186/2045-4015-1-40

Canton, L. G. (2013, August 7). “All-hazards”
doesn’t mean “Plan for everything.” Emergency
Management (blog). Retrieved February 25,
2016, from http://www.emergencymgmt.com/
emergency-blogs/managing-crisis/Allhazards-
Doesnt-Mean-Plan-for-Everything.html

Davidson, J. E., Sekayan, A., Agan, D., Good, L.,
Shaw, D., & Smilde, R. (2009). Disaster dilemma:
Factors affecting decision to come to work during

a natural disaster. Advanced Emergency Nursing
Journal, 31(3), 248–257.

Gardner, C., & Frazier, E. (2013). Will you be ready
when a disaster strikes? Nursing Management,
44(8), 30–35.

Hanfling, B. M., Altevogt, K. V., & Gostin, L. O.
(Eds.) Crisis standards of care: A systems framework
for catastrophic disaster response. Washington, DC:
National Academy Press.

Hodge, J. G., Garcia, A. M., Anderson, E. D., &
Kaufman, T. (2009). Emergency legal preparedness
for hospitals and health care personnel.
Disaster Medicine and Public Health Preparedness,
3(Supplement 1), S37–S44.

Kirwan, M. M. (2011). Disaster planning: Are you
ready? Nursing Made Incredibly Easy, 9(3), 18–24.

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framework for responding to catastrophic
disasters. American Journal of Nursing, 112(10),
61–63.

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P. (2009). Major influences on hospital emergency
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http://ijhpr.biomedcentral.com/articles/10.1186/2045-4015-1-40

Learning Outcomes

After completing this chapter, you will be able to:

1. Summarize components involved in workplace violence.

2. Explain strategies for preventing violence in healthcare
organizations.

3. Describe responses to violent incidents.

Key Terms
bullying

horizontal violence

incivility

workplace violence

Introduction
Unfortunately, violence is all too common today. Terrorism, bombing, and mass
shootings are reported frequently. Healthcare settings are no exception. Violence from
coworkers, patients, family members, and even outsiders can invade the workplace
and harm healthcare workers.

Violence in Healthcare
Incidence of Workplace Violence

Horizontal Violence

Consequences of Workplace Violence

Factors Contributing to Violence in Healthcare

Preventing Violence
Zero-tolerance Policies

Reporting and Education

Environmental Controls

Dealing with Violence
Verbal Intervention

A Violent Incident

Other Dangerous Incidents

Post-incident Follow-up

340

Chapter 24

Preventing Workplace
Violence

Preventing Workplace Violence 341

Violence in Healthcare
Workplace violence is any violent act, including physical assaults and threats of
assault, directed toward persons at work or on duty. Those working in healthcare are
among the most vulnerable to attack (Papa & Venella, 2013). Most assaults in health-
care are initiated by patients, but attacks are also made by disgruntled family mem-
bers, coworkers, vendors, employers, or even colleagues (Gates, Gillespie, & Succop,
2011b). Some assaults are episodes of domestic violence that occur at work (Pollack
et al., 2010).

Violence includes the following:

• Threatening actions, such as waving fists, throwing objects, or threatening body
language

• Verbal or written threats

• Physical attacks, including slapping, hitting, biting, shoving, kicking, pushing,
beating

• Violent assaults, including rape, homicide, and attacks with weapons such as
knives, firearms, or bombs

Incidence of Workplace Violence
Violence in healthcare occurs more often than in other workplace settings (Occupa-
tional Safety and Health Administration, 2015). Public focus, however, has been on
other occupational settings with violence in healthcare receiving little attention (Gates
et al., 2011b). This is in spite of an increase in assaults in healthcare (U.S. Department
of Labor, Bureau of Labor Statistics, 2014).

Horizontal Violence
Sadly, violent perpetrators are not always outsiders. In fact, healthcare workers com-
mit acts of aggression against their coworkers (Sellers, Millenbach, Ward, & Scribani,
2012). Such aggression is known as horizontal violence. Regardless of who the perpe-
trator is, aggressive behavior known as bullying or incivility can be as mild as innoc-
uously irritating or as extreme as dangerously violent (Stokowski, 2010). Such
behaviors ranging from mild to severe include the following (Sullivan, 2013):

• Ignoring the person or giving the silent treatment

• Treating in a disdainful or belittling manner

• Making disparaging remarks purposely within hearing

• Ridiculing the individual

• Speaking sarcastically to or about the person

• Direct verbal abuse

• Sexual harassment

• Physical attack

Although the strategies differ, healthcare organizations must attend to acts of
bullying against their employees with the same zeal they use to address violence
from outsiders (Longo, 2010) as addressed in Leading at the Bedside: Keeping
Everyone Safe.

342 Chapter 24

Consequences of Workplace Violence
Violence can range in intensity and cause physical injuries, temporary or permanent
disability, psychological trauma, or death (Howard & Gilboy, 2009). Violence in health-
care organizations is more likely to occur in psychiatric settings, emergency depart-
ments, waiting rooms, and geriatric units.

In addition to harming employees, violence in the workplace can affect worker
morale, increase staff stress, cause a mistrust of administration, and exacerbate a hos-
tile work environment (Gates et al., 2011a). Furthermore, absenteeism and turnover
are expensive, and the organization may incur additional costs for care of injured
workers and settlements from lawsuits.

Factors Contributing to Violence in Healthcare
Working with the public carries with it inherent risks, and the added stress by staff,
patients, and families in healthcare settings increases that risk (Gates et al., 2011a).
Furthermore, hospitals have an open-door policy for visitors. Visiting hours are not
restricted, and visitors are often not required to check in when they enter.

Patients with head trauma, seizure disorders, dementia, or alcohol or drug with-
drawal, as well as those who are homeless, may lash out in violence. Crime victims
and the perpetrators might be admitted to the same hospital, and gang violence
could spill over into the hospital. In addition, family members’ stress and fear as
well as long waits can contribute to the possibility of violent actions. Finally, the
absence of visible, armed, and adequately trained security personnel may make the
setting less secure.

No workplace can be assured of freedom from violence—especially random vio-
lence. Some additional risk factors for potential violence in healthcare organizations
include the following:

• Working understaffed, especially at mealtimes and during visiting hours

• Long waiting times

• Overcrowded waiting rooms

• Working alone

• Inadequate security

• Unlimited public access

• Poorly lit corridors, rooms, and parking lots

Leading at the Bedside: Keeping Everyone Safe
As a staff nurse, you are the most important person in the
organization to spot and handle potential violence. You are
the front line to reduce aggression from patients, visitors, and
coworkers. You can spot difficulties almost before they
happen. In order to handle possible violence, you must know
the signs of potential problems as enumerated in this chapter.

In addition to watching for potential violence from out-
siders, bullying (horizontal violence) is a continuing problem in

the profession. Again, you can identify problem behaviors and
report them to the appropriate supervisor. If you see someone
being bullied, you can intervene.

Vow that you won’t allow anyone you work with to
become a victim of bullying. Nursing is the profession
the public considers the most trustworthy. Let’s live up
to that!

Preventing Workplace Violence 343

Injuries to nurses from violence are likely underreported for several reasons
(Gacki-Smith et al., 2009). The definition of workplace violence may not be clear,
reporting policies may not be in place, and employees may simply believe that assaults
are part of the job. Staff also may fear that reporting an assault will be construed as
poor job performance (Gacki-Smith et al., 2009).

Preventing Violence
Preventing violence, as with any other disruptive behavior, is best dealt with as soon
as possible. The tendency to hope a problem will go away, although tempting, is usu-
ally fruitless. In fact, if problems are ignored, they tend to escalate (Occupational Safety
and Health Administration, 2015).

Zero-tolerance Policies
The healthcare organization should cultivate a culture of intolerance to violence and
set its violence prevention policies to reflect that position (Gates et al., 2011b). Appro-
priate personnel policies must state clearly what will happen if violence or the threat
of violence occurs. Policies regarding patients and visitors must do the same. Specifi-
cally, anyone who becomes violent or who exhibits threatening behavior must be
removed from the setting and the authorities contacted.

Also, the organization must develop a code of conduct specifying behaviors
that will not be tolerated, and the consequences of violating the conduct code must
be clearly stated (Longo, 2010). The code must include the reporting channel for
addressing code violations. Leaders in the organization must be committed to mon-
itoring and enforcing the code.

Reporting and Education
Employees must be educated to recognize the warning signs of violence and poten-
tial assailants or agitators, and they must be taught conflict resolution skills and de-
escalation tactics (LaGrossa, 2015). They should also be alerted to use care when
storing instruments that could be used as weapons (e.g., stethoscopes, hemostats,
scissors).

Once adequate policies are in place, employees must be informed about them so
that they are prepared in case of an event or crisis. In addition, employees need to
know how to report an incident and to whom to report it as well as how to document
problem situations. Employees should be reassured that reporting threatening
behavior will not result in reprisals.

Environmental Controls
The organization should institute environmental controls to ensure patient, visitor,
and employee safety. These include the following:

• Adequate lighting

• Security devices

• Bullet-resistant barriers in the emergency department

• Curved mirrors in hallways

344 Chapter 24

Box 24-1 Verbal Intervention Strategies
1. State the problem.
2. Tell how the problem is affecting the work unit and/or

organization.

3. State what you want to have happen.
4. Ask if the person is willing to do what you asked.
5. Schedule follow-up.

In addition, safe work practices should be implemented, such as the following:

• Escort services

• Adequate staffing

• Judicious use of restraints or seclusion

• Staff alerts about patients with histories of violent behavior, dementia, or
intoxication

Dealing with Violence
Despite all the efforts an organization takes to prevent violence, it may still occur.
Patients, family members, visitors, and even staff can be unpredictable. Whether the
problem is bullying or a threat of physical violence, intervening early is the organiza-
tion’s best strategy.

Verbal Intervention
Verbal intervention is appropriate for instances of bullying if the behavior is not physi-
cal or dangerous (e.g., disparaging remarks, eye rolling). To intervene, identify the
person whose behavior is disruptive and speak with the person privately. Then follow
the steps in Box 24-1.

Because verbal threats may precede a physically violent event, all employees
should be trained in how to reduce aggression in people who are making verbal
threats. When faced with a potentially violent situation, try to keep calm even when
another person is screaming threats or abuse. Try to get the person away from others.
A crowd might encourage the abuser, or the person might be afraid to lose face in the
presence of others.

Nonverbal communication is more powerful than your words, so watch your
body language and keep a distance from the person. Use clear and direct words; the
person’s anxiety could make comprehension difficult. Reflect the person’s words back;
this lets the person know that you hear him or her. Silence is often effective because it
forces the person to think about what is being said and may be calming in itself. Finally,
keep your tone of voice calm, keep your volume normal, and slow your rate of
speech. Together, these strategies may reduce the person’s anxiety and aggression
(Gates et al., 2011b).

A Violent Incident
In spite of all that an organization and individuals do to try to prevent violence, the per-
son’s aggression may escalate. In the event that such a situation occurs, the organization

Preventing Workplace Violence 345

should make certain that all employees are prepared. Each employee should be versed in
the following:

• How to recognize the signs of escalating violence

• Familiarity with the organization’s violence policies

• How to protect patients, visitors, and oneself

Every employee should learn how to watch for threatening behaviors in order to
evaluate when a person is likely to become violent. Law enforcement personnel
recommend watching for these behaviors:

• Clenched fists

• Blank stare

• Fighting stance (one foot back with arm pulled back ready to strike)

• Arms raised in a fighting position

• Standing too close or advancing toward you

• Holding anything that might be used as a weapon, such as a pen, letter opener,
heavy object, or an actual weapon—a gun or knife

• Overt intent (saying they intend to “kick your—” or similar statements)

• Movement toward the exit to prevent you from leaving (Sullivan, 2013)

When these threatening behaviors are present, or if someone becomes physically
violent, you must protect your patients, visitors, other staff, and yourself. Contact
security immediately and follow the steps in Box 24-2.

Box 24-2 How to Handle a Violent Incident
1. Notify security immediately.
2. Never try to disarm someone with a weapon.

3. If not armed, enlist staff help in restraining a violent
person.

4. Put a barrier between you and the violent person.

Other Dangerous Incidents
An infant abduction, a bomb threat, or a gun on the unit are some examples of other
dangerous incidents that could occur. Most organizations now have a specific code to
alert staff to a potential or real infant abduction, such as Code Pink, and many hospi-
tals now also place security bands on babies and parents to prevent abduction of a
baby from the nursing unit.

Policies are in place in most hospitals to address bomb threats or a gun on the unit
and indicate the procedures to follow, and the staff are trained to call the hospital’s 911
number. Specific codes for alerting security and obtaining assistance for other threats
are also used. In addition, drills for infant abductions, bomb threats, and firearms on
the unit are practiced on a routine basis and included in yearly competency testing for
employees. Keeping patients safe is always the focus.

Post-incident Follow-up
After a violent incident, everyone involved will suffer some degree of emotional, if not
physical, trauma. Gates et al. (2011b) found that 94% of emergency department nurses

346 Chapter 24

Box 24-3 How to Handle Post-incident Follow-up
1. Be certain that everyone is safe following a violent

event.
2. Arrange immediate treatment for the injured.
3. Complete injury and incident reports.
4. Follow up with human resources regarding the work-

ers’ compensation process for the injured employees.

5. Contact security to determine if a police report should
be filed.

6. Later, contact the injured employee at home to
express concern for the person’s well-being and
follow up with any questions the person may have.

Case study 24-1 | Workplace Violence
Melanie Sanchez is nurse manager of a 30-bed skilled
nursing unit (SNU) in an urban hospital. Patient confusion
and aggression are not uncommon occurrences for her
staff. Nursing and assistive staff have been trained in con-
flict resolution and methods for dealing with aggressive
patients.

Sandra Porter, RN, has worked in the SNU for the past
6 years. Today, while administering medication to patients
before lunch in the common dining room, Sandra noticed a
newly admitted patient, Mr. B, yelling obscenities at another
staff member. Sandra secured her medication cart and
came to the aid of the nursing assistant. Sandra attempted
to verbally de-escalate the situation, but Mr. B became
increasingly aggressive. When Sandra turned to instruct the
nursing assistant to clear patients from the dining room,
Mr. B picked up a chair and struck Sandra in the arm and
shoulder. The nursing assistant alerted Melanie and several
nurses to the problem. Melanie immediately called the hos-
pital operator to request that security respond to a violent
patient on the SNU. Upon entering the dining room, nursing

staff were able to restrain Mr. B while Melanie accompanied
Sandra to the emergency department for treatment of her
injuries. Sandra sustained a broken arm, a laceration to her
shoulder, and several contusions.

As soon as Sandra’s injuries were treated and she was
released from the emergency department, Melanie con-
tacted the medical/surgical nursing division director and the
human resources department about the assault and filled
out an incident report. She also completed an injury report
for Sandra’s workers’ compensation claim. Melanie con-
tacted the security department and requested a meeting
with the security director to determine if a police report
should be filed regarding Mr. B’s assault of Sandra. The
next day, Melanie contacted Sandra at home and informed
her that a case manager from human resources would call
her within the week regarding her workers’ compensation
claim. Melanie also checked to see how Sandra was doing
and encouraged her to call Melanie directly if she had ques-
tions or concerns.

experienced at least one symptom of posttraumatic stress disorder (PTSD) following
an incident of violence, with 17% diagnosed with probable PTSD.

Post-incident follow-up is essential for the well-being of patients, visitors, and
staff members. The steps to take are shown in Box 24-3.

A nurse manager used the steps in handling a violent incident and its follow-up in
Case Study 24-1.

Violence in the workplace is a reality of life today, but organizations and indi-
viduals can take steps to reduce potential threats. Because the nursing shortage is
continuing, and because nurses and women are more likely to be attacked, organiza-
tions must take all the necessary steps to ensure that their nurses are kept safe from
harm. In addition, nurses themselves must be informed about how to recognize
potential threats and how to prevent violence from escalating. In this way violence
may be prevented or, at the least, reduced.

What You Know Now
• Healthcare organizations are vulnerable to vio-

lence in the workplace, including horizontal
violence.

• Risk factors for violence in healthcare organiza-
tions include understaffing, patient’s condition,
family members’ anxiety, unlimited public access,
inadequate security, and an unsafe physical
environment.

• The organization should establish a policy of zero
tolerance for violence and make certain that all
employees know it.

• All employees should be able to recognize poten-
tial threats and the warning signs of violence.

• All employees should know how to report threats
and threatening behavior, to whom to report such
episodes, and how to document the incidents.

• Employees should be assured that reporting
potential threats will not result in reprisals.

• All employees should know the steps to take if a
violent incident occurs.

Questions to Challenge You
1. Evaluate your current workplace or clinical site.

See if you can find potential opportunities that
would allow violence to occur. Describe them.

2. Ask to see the workplace violence policies at your
school, clinical site, and/or workplace. Evaluate
them. Are they adequate? Can you suggest changes?

3. Have you ever been the victim of bullying? Did
you report it? How did the authorities respond?
Could you suggest changes for them?

4. Are you aware of specific action that your school,
workplace, or clinical site has done to protect
people from violence? What more could you
suggest?

Tools for Preventing Violence
1. Recognize potential threats and threatening behav-

ior, including bullying, and know how to report
them.

2. Alert staff and administration to these threats.
3. Learn how to respond to a person who becomes

violent.

4. Know what to do following a violent incident.
5. Monitor the environment for dangerous areas

and report your observations to administration.
6. Remain alert for potential violence and instruct

staff to stay vigilant.

References
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer,

C., Robinson, L., & MacLean, S. L. (2009). Violence
against nurses working in U.S. emergency
departments. Journal of Nursing Administration,
39(7/8), 340–349.

Gates, D., Gillespie, G., Smith, C., Rode, J.,
Kowalenko, T., & Smith, B. (2011a). Using action
research to plan a violence prevention program
for emergency departments. Journal of Emergency
Nursing, 37(1), 32–39.

Preventing Workplace Violence 347

348 Chapter 24

Gates, D. M., Gillespie, G. L., & Succop, P. (2011b).
Violence against nurses and its impact on stress
and productivity. Nursing Economics, 29(2),
59–66.

Howard, P. K., & Gilboy, N. (2009). Workplace
violence. Advanced Emergency Nursing Journal,
31(2), 94–100.

LaGrossa, J. (2013). Confronting workplace violence
in nursing. Advance Healthcare Network for Nurses.
Retrieved April 14, 2015, from http://nursing.
advanceweb.com/Features/Articles/Confronting-
Workplace-Violence-in-Nursing.aspx.

Longo, J. (2010). Combating disruptive behaviors:
Strategies to promote a healthy work
environment. The Online Journal of Issues in
Nursing, 15(1), Manuscript 5. Retrieved February
29, 2016, from http://www.nursingworld.org/
MainMenuCategories/ANAMarketplace/
ANAPeriodicals/OJIN/TableofContents/
Vol152010/No1Jan2010/Combating-Disruptive-
Behaviors.html

Occupational Safety and Health Administration.
(2015). Preventing workplace violence in healthcare.
Retrieved February 29, 2016, from https://www.
osha.gov/dsg/hospitals/workplace_violence.
html

Papa, A., & Venella, J. (2013). Workplace violence
in healthcare: Strategies for advocacy. The Online
Journal of Issues in Nursing, 18(1), Manuscript 5.

Pollack, K. M., McKay, T., Cumminskey, C., Clinton-
Sherrod, A. M., Lindquist, C. H., Lasater, B. M., . . .
& Grisso, J. A. (2010). Employee assistance program
services of intimate partner violence and patient
satisfaction with these services. Journal of Occupational
and Environmental Medicine, 52(8), 819–826.

Sellers, K. F., Millenbach, L., Ward, K., & Scribani, M.
(2012). The degree of horizontal violence in RNs
practicing in New York State. Journal of Nursing
Administration, 42(10), 483–487.

Stokowski, L. A. (2010). A matter of respect and
dignity: Bullying in the nursing profession.
Medscape Nurses. Retrieved February 29,
2016, from http://www.medscape.com/
viewarticle/729474

Sullivan, E. J. (2013). Becoming influential: A guide
for nurses (2nd ed.). Upper Saddle River, NJ:
Pearson.

U.S. Department of Labor, Bureau of Labor Statistics.
(2014). Nonfatal occupational injuries and illnesses
requiring days away from work, 2014. Retrieved
February 29, 2016, from http://www.bls.gov/
news.release/osh2.nr0.htm

http://nursing.advanceweb.com/Features/Articles/Confronting-Workplace-Violence-in-Nursing.aspx

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No1Jan2010/Combating-Disruptive-Behaviors.html

https://www.osha.gov/dsg/hospitals/workplace_violence.html

http://www.medscape.com/viewarticle/729474

http://www.bls.gov/news.release/osh2.nr0.htm

http://nursing.advanceweb.com/Features/Articles/Confronting-Workplace-Violence-in-Nursing.aspx

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No1Jan2010/Combating-Disruptive-Behaviors.html

http://www.medscape.com/viewarticle/729474

http://www.bls.gov/news.release/osh2.nr0.htm

https://www.osha.gov/dsg/hospitals/workplace_violence.html

Chapter 25

Handling Collective
Bargaining Issues

Learning Outcomes

After completing this chapter, you will be able to:

1. Discuss the laws that govern collective bargaining.

2. Describe the process of unionization.

3. Explain what is involved in handling grievances.

4. Summarize collective bargaining for nurses.

Key Terms
closed shop

collective bargaining

grievances

open shop

right-to-work state

strike

Introduction
The purpose of collective bargaining units is to protect employees from unfair prac-
tices, such as mandatory overtime or firing without cause. Collective bargaining units
also may stipulate criteria for advancement that must be followed. Ambitious, career-
minded nurses might chafe against these rigid standards that may not allow excep-
tions. So, both nurses and their employers have cause to complain about unions.

Laws Governing Unions

Process of Unionization

Handling Grievances
Unfair Labor Practices

The Grievance Process

Collective Bargaining and Nurses
Legal Issues of Supervision

The Future of Collective Bargaining for Nurses

349

350 Chapter 25

Laws Governing Unions
Before federal laws governing labor relations in this country were enacted, disputes
between the owners or managers of a company and the company’s labor force were
settled by the judiciary branch of government. During this period of U.S. history, the
courts often ruled that collective bargaining—collective action taken by workers to
secure better wages or working conditions—was illegal. Today, however, labor laws
enacted by Congress, decisions by the U.S. Supreme Court, and activities of the
National Labor Relations Board (NLRB) guide labor relations between employers and
employees. Since enactment of the National Labor Relations Act in 1935, nurses and
other employees of private, for-profit healthcare institutions have been protected in
their right to organize for collective bargaining purposes (National Labor Relations
Act, 1935).

Under the provisions of the act, as amended in 1974, employees of voluntary, not-
for-profit healthcare institutions also were granted the same rights and protections
(National Labor Relations Board, 1974).

In the United States, a closed shop is a business in which union membership
(often of a specific union and no other) is a precondition to employment. An open
shop is a business in which union membership is not a component in hiring decisions
and union members do not receive any preference in hiring.

A right-to-work state is a state in which no person can be denied the right to work
because of membership or nonmembership in a labor union. Trade unions and employ-
ers cannot make membership in a union or payment of union dues or fees a condition
of employment, either before or after hiring.

Collective bargaining laws differ depending on whether nurses are employed in
the private sector—in either nonprofit or for-profit organizations—or in the public sec-
tor as city, county, state, or federal employees. Negotiations may be classified as man-
datory, prohibited, or permitted. Parties are obligated to negotiate on mandatory
subjects of bargaining.

In the private sector, wages, hours, and other terms and conditions of work are
considered mandatory subjects for negotiation. In the public sector, the scope of man-
datory subjects of bargaining is often far narrower.

The Civil Service Reform Act of 1978 gave certain federal employees the right to
organize, bargain collectively, and participate through labor organizations of their
choice in decisions affecting their work environment, depending on what federal
agency employed them. Wages—a mandatory item in the private sector—is a prohib-
ited subject (Civil Service Reform Act, 1978).

State or local employees, however, fall under state regulations, which vary greatly
from state to state. Nurses in state hospitals, for example, would be governed by their
state laws. Some states do not allow employees to strike or form collective bargaining
units; other states do not allow wages or overtime pay to be part of a union contract.

Process of Unionization
The process of establishing a union in any setting begins when at least 30% of eligible
employees sign a card to indicate interest in a union. (See Leading at the Bedside: The
Right to Organize.) Then the union petitions the National Labor Relations Board
(NLRB) to conduct an election. The NLRB meets with both the union and the employer.

Handling Collective Bargaining Issues 351

Leading at the Bedside: The Right to Organize
If your healthcare organization does not have a collective
bargaining agreement for its nurses, you may think this
chapter doesn’t apply to you. But it might. Your colleagues
or others might initiate organizing efforts. Do you know
what to do if you decide to join them?

Here are a few guidelines:

• You have the right to organize.

• You have the right to be free of harassment either at
work or at home due to your organizing efforts.

• You have the right to keep your job in spite of your
organizing activities.

You may never need to use these guidelines, but if you
do, remember: You have rights!

At the conclusion of this meeting, the NLRB will determine who is eligible to partici-
pate in the union, will establish that the signers are employees of the organization, and
will set a date for the union election.

The process of selecting a bargaining agent produces a tense, emotional climate
that affects everyone in the organization. Both nurse managers and staff nurses need to
remember that the rules of unfair labor practice apply during this period. Managers
must refrain from any action that could be seen as interfering with the employees’
right to determine their collective bargaining representative. Such actions include
individually questioning staff nurses about their knowledge of collective bargaining
activities and making promises or threats to individual staff members based on the
outcome of the election.

Staff nurses also must be careful that their discussions regarding collective bar-
gaining take place away from the work site and not on work time. Nor may employees
use their employer’s email system to communicate about unionizing activities.

Certification by the NLRB of a union to be the bargaining agent does not auto-
matically mean employees have a contract. The contract is considered to be in effect
when both management and employees of the organization agree on its content. The
final agreement is subject to a ratification vote by a simple majority of eligible mem-
bers who vote.

The role of administering the contract then falls to an individual designated as the
union representative. This individual may be an employee of the union or a member of
the nursing staff.

Handling Grievances
Grievances result when employees believe that the organization has violated the con-
tract agreement. Healthcare organizations can avoid the time-consuming and costly
process of resolving grievances by adhering to the specifications of the contract.

Unfair Labor Practices
Five categories of unfair labor practices are described by labor law:

• Interference with the right to organize

• Domination

• Encouraging or discouraging union membership

352 Chapter 25

• Discharging an employee for giving testimony or filing a charge with the NLRB

• Refusal to bargain collectively

The Grievance Process
The grievance procedure will be specified in the agreement and will contain a series of
progressive steps and time limits for submission and resolution of grievances. Griev-
ances are formal complaints that must be resolved by the process delineated in the
contract.

Grievances can usually be classified as one or more of the following:

• Contract violations

• Violations of federal or state law

• Failure of management to meet its responsibilities

• Violation of agency rules

To ensure a balance between the rights of employees and the rights of the public to
healthcare, Congress passed a special set of dispute-settling procedures to be applied
in the healthcare industry:

• Before changing or terminating a contract, one party must notify the other of its
intent to do so 90 days prior to the contract expiration date. This is 30 days more
than specified for other industries.

• If after 30 days of this notification both sides cannot agree, then the Federal Medi-
ation and Conciliation Service (FMCS) must be notified.

• The FMCS will appoint either a mediator or an inquiry board within 30 days.

• The mediator or board must make recommendations within 15 days.

• If after 15 more days both sides cannot agree, then a strike vote can be conducted
and a strike—the organized stoppage of work by employees—can be scheduled.

If a strike vote is affirmed, then a 10-day written notice indicating the date, time, and
place of the strike must be given to management. This is intended to ensure a hospital
has adequate time to provide for continuity of patient care in the event of a strike
(Cohen, 2013).

Collective Bargaining and Nurses
The majority of nurses in the United States do not work under a collective bargaining
agreement, but for those who do, National Nurses United represents the majority of nurses
and has affiliates in every state. In addition, employees of individual healthcare organiza-
tions often form their own collective bargaining organization and include nurses. Nurses
at some healthcare organizations have formed their own union. So, collective bargaining
in nursing runs the gamut from national collaboration of state organizations, to coordina-
tion with other employees in healthcare, to individual units of nurses.

Conflicting results about how satisfied union nurses are with their jobs has been
reported (Seago, Spetz, Ash, Herrara, & Keane, 2011). The researchers posit, however,
that union nurses may simply be more willing to voice their dissatisfaction. In addi-
tion, no correlation has been found between unionization and patient outcomes (Spetz,
Ash, & Seago, 2011).

Handling Collective Bargaining Issues 353

Legal Issues of Supervision
The following three areas of supervision over subordinates have been debated for a
number of years:

• Responsibility to assign

• Responsibility to direct

• Independent judgment

The NLRB issued several landmark decisions regarding the supervisory status of
nurses (National Labor Relations Board, 2006). Three cases were considered together
and have become known as the Kentucky River trilogy. They are Oakwood Healthcare,
Inc., Golden Crest Healthcare Center, and Croft Metal, Inc. These rulings are important to
nurses because those employees deemed as supervisors are prohibited from joining a
union.

The NLRB clearly defined the supervisory status of nurses in its ruling in 2006,
and that ruling stands today. It ruled as follows:

• The responsibility to assign includes nurses’ responsibility to assign other nurses
and assistants to patients.

• The responsibility to direct includes the responsibility for the actions of those to
whom tasks have been assigned.

• Independent judgment includes the nurse’s decision to match staff skills to patient
needs.

This ruling has an impact on the eligibility of many nurses who heretofore were not
considered supervisors and were thus eligible to be members of a collective bargaining
unit. Nurses who are charge nurses, either permanently or part-time on a regular basis,
and who meet the above criteria for assigning, directing, and using independent judg-
ment are considered supervisors and therefore are not eligible to join a union (National
Labor Relations Board, 2006).

Therefore, union nurses who meet the criteria of charge nurses may be forced to
choose between the role of charge nurse to advance their career or decline such a role
to maintain their membership in the union (Matthews, 2010).

Nurse managers in healthcare organizations in which nurses are organized into a
collective bargaining unit may be involved in the agreement in several ways. For exam-
ple, the manager could participate in helping resolve grievances. Furthermore, the
manager must adhere to the terms of the agreement while carrying out supervisory
responsibilities, such as coaching, disciplining, and, especially, terminating employees.

See how one nurse manager handled discipline in a hospital with a collective bar-
gaining agreement in Case Study 25-1.

The challenge for healthcare organizations in a collective bargaining environment
is to retain high-performing nurses and help them become more satisfied with their
jobs (Lawson, Miles, Vallish, & Jenkins, 2011). Partnering nursing staff with manage-
ment personnel is one strategy to improve nurse retention. For example, after a part-
nership between nursing and management was established at a Magnet-certified
institution, turnover decreased and satisfaction improved (Porter, 2010; Porter, Kol-
caba, McNulty, & Fitzpatrick, 2010). Such partnerships are supported by the trend
toward labor—management partnerships in other occupational sectors (Hayter,
Fashoyin, & Kochan, 2011).

354 Chapter 25

The Future of Collective Bargaining for Nurses
The use of collective bargaining as a way for nurses to influence the practice environ-
ment and to ensure their economic security presents both concerns and promises,
especially with the radical changes occurring in healthcare today. The concerns are
that the very processes of collective bargaining separate rather than unite nurses, nota-
bly between staff nurses and those in management. What the future holds for collec-
tive bargaining in nursing is uncertain and unknown.

What You Know Now
• Laws governing unions are administered by the

National Labor Relations Board.

• Subjects for union negotiations may be manda-
tory, prohibited, or permissive.

• Private sector subjects differ from public ones,
which are generally more restrictive.

• The process of unionization involves selecting a
bargaining agent, developing a contract, and
administering the contract.

• Grievances may be filed if employees believe that
the organization has violated the terms of their
contract.

• The grievance process is a set of specific steps and
a timetable for resolution of grievances.

• The status of supervisory nurses has been a con-
tinuing legal issue.

• The future of collective bargaining for nurses is
uncertain and unknown.

CASE STUDY 25-1 | Discipline Procedure in a Hospital
with a Collective Bargaining Unit

Maria Sanchez is the nurse manager for 4 South Pediatrics
in a university medical center hospital, where the nurses
established a collective bargaining agreement with the hos-
pital several years ago. Maria has a disciplinary problem
with Tia, a staff nurse, about not completing intake and out-
put documentation or vital sign documentation on her
patients during her last shift. Maria notes that Tia had a
friendly reminder about failing to complete documentation
last month. Per hospital policy, Susan, as Tia’s manager,
must complete verbal counseling with Tia.

During recent union negotiations between the hospital
and the nursing union, it was agreed that when verbal
counseling is needed, the manager must formally say to the
staff member, “I am providing you with verbal counseling

today about your performance. This is official, will be docu-
mented in your file, and if you fail to meet the expectation,
the next step in this process is a written notice of warning
about failure to meet your job expectations. Do you have
any questions about the verbal counseling process before
we proceed?” The manager then continues with the verbal
counseling about the unmet specific performance issue
and policies.

Maria follows the guidelines established in the current
agreement in her meeting with Tia, and Tia agrees that she
has not been consistent in completing documentation. Tia
agrees that Maria should monitor her performance for a
week, when they will meet again to determine if Tia has been
completing documentation appropriately and consistently.

Handling Collective Bargaining Issues 355

Tools for Handling Collective Bargaining Issues
1. Determine if your organization has a collective

bargaining agreement with its registered nurse
employees.

2. If so, become familiar with provisions of the pol-
icy and grievance procedure.

3. Contact administration for any questions you
may have with contract policies.

4. If your organization does not have a union contract,
be aware of the possibility that efforts to establish a
collective bargaining unit may be initiated.

5. If attempts are made to unionize your workplace,
obtain information on the legal obligations you
have as an employee and/or manager.

6. Remember, collective bargaining is an agreement
between an employer and its employees; it does
not need to be adversarial.

Questions to Challenge You
1. Are you a member of a collective bargaining unit?

Do you know anyone who is?
2. Have you been involved in union organizing?

What happened during and after the process?
3. If you have not been involved in union organiz-

ing, find someone who has been and ask what
happened.

4. What is your opinion of unions for nurses? Name
the pros and cons.

5. You are negotiating a union contract on behalf of
the nurses. List your demands in priority order.

6. You are negotiating a union contract on behalf of
administration. Respond to the demands on your
list generated in question 5.

References
Civil Service Reform Act, Pub.L. 95–454, 92 Stat. 1111

(1978).
Cohen, J. D. (2013). Strike: Preparing nursing

departments for work stoppage. Nursing
Management, 44(7), 42–47.

Hayter, S., Fashoyin, T., & Kochan, T. A. (2011).
Collective bargaining for the 21st century. Journal
of Industrial Relations, 53(2), 225–247.

Lawson, L. D., Miles, K. S., Vallish, R. O., & Jenkins,
S. A. (2011). Recognizing nursing professional
growth and development in a collective
bargaining environment. Journal of Nursing
Administration, 41(5), 197–200.

Matthews, J. (2010). When does delegating make
you a supervisor? The Online Journal of Issues in
Nursing, 15(2), Manuscript 3.

National Labor Relations Act, 49 Stat. 449, 29 U.S.C.
§ 151–169 (1935).

National Labor Relations Board. (1974). 1974
Healthcare Amendments. Retrieved March 1,

2016, from https://www.nlrb.gov/who-we-are/
our-history/1974-health-care-amendments

National Labor Relations Board. (2006). Golden Crest
Healthcare Center, 348 NLRB No. 39.

Porter, C. (2010). A nursing labor management
partnership model. Journal of Nursing
Administration, 40(6), 272–276.

Porter, C. A., Kolcaba, K., McNulty, S. R., & Fitzpatrick,
J. J. (2010). The effect of a nursing labor management
partnership on nurse turnover and satisfaction.
Journal of Nursing Administration, 40(5), 205–210.

Seago, J. A., Spetz, J., Ash, M., Herrara, C. N., &
Keane, D. (2011). Hospital RN job satisfaction and
nurse unions. Journal of Nursing Administration,
41(3), 109–114.

Spetz, J., Ash, M., & Seago, J. A. (2011). Presentation:
Effect of hospital unions on staffing and patient
outcomes in California. Retrieved March 1, 2016,
from http://www.academyhealth.org/files/2012/
sunday/spetz2

https://www.nlrb.gov/who-we-are/our-history/1974-health-care-amendments

http://www.academyhealth.org/files/2012/sunday/spetz2

https://www.nlrb.gov/who-we-are/our-history/1974-health-care-amendments

http://www.academyhealth.org/files/2012/sunday/spetz2

356 Chapter 26

Learning Outcomes

After completing this chapter, you will be able to:

1. Explain why stress is necessary.

2. Describe the organizational, interpersonal, and individual factors
that cause stress.

3. Summarize the consequences of stress.

4. Examine how individuals and organizations can manage stress.

Key Terms
burnout

compassion fatigue

mindfulness

posttraumatic stress
disorders (PTSD)

reality shock

role ambiguity

role conflict

role redefinition

stress

Introduction
Consider the following scenario:

Keandra is a medical nurse with 10 years of experience. She is married and has two
children under the age of 6 who attend preschool while she is at work. As a nurse manager,
Keandra has 24-hour responsibility for supervision of two 30-bed medical units. She
frequently receives calls from the unit nurses during the evenings and nights,

The Nature of Stress

Causes of Stress
Organizational Factors

Interpersonal Factors

Individual Factors

Consequences of Stress

Managing Stress
Personal Methods

Organizational Methods

356

Chapter 26

Managing Stress

Managing Stress 357

and approximately once a week she has to return to the unit to intervene in a situation or
replace nurses who are absent. Keandra is responsible for scheduling all the nurses on her
unit and has no approval to use agency nurses, in spite of a 20% staff vacancy rate. In
addition, Keandra serves on four departmental committees and the hospital task force on
consumer relations. She consistently takes work home, including performance appraisals,
quality assessment reports, and professional journals. Although Keandra has an office, she
has little opportunity to use it because of constant interruptions from nurses, physicians,
other departmental leaders, and her clinical director. Recently, Keandra saw her family
physician and complained of persistent headaches, weight loss, and a feeling of constant
fatigue. After a complete diagnostic workup, she was found to have a slightly elevated
blood pressure, with a resting pulse of 100. Her physician prescribed an exercise program,
and she was advised to lighten her workload, take a vacation, and reduce her stress level.

Stress is the nonspecific reaction that people have to demands from the environ-
ment that pose a threat. Stress results when two or more incompatible demands on the
body cause a conflict. Recognized as the pioneer of stress research, Selye (1978) sug-
gests that the body’s wear and tear result from its response to normal stressors. The
rate and intensity of damage increase when an organism experiences greater stress
than it is capable of accommodating.

Selye maintains that the physiological response to stress is the same whether the
stressor is positive, eustress, or negative, distress. It is easy to see how negative events,
such as job loss, can cause stress. However, positive events also may cause stress.

Anthony was the director of nursing for critical care in a 400-bed hospital. He was
offered the opportunity to develop a hyperbaric unit. In assuming the additional
responsibility, Anthony began putting in long hours and working weekends. As the
project progressed, Anthony became unable to sleep and gained 10 pounds. After the unit
opened, Anthony’s sleep pattern and weight returned to normal. Clearly, Anthony
displayed emotional and physical signs of stress although he was experiencing a
“positive” promotion and career opportunity.

A certain amount of stress is essential to sustain life, and moderate amounts serve
as stimuli to performance; however, overpowering stress can cause a person to respond
in a maladaptive physiological or psychological manner.

The Nature of Stress
A balance must exist between stress and the capability to handle it. When the degree of
stress is equal to the degree of ability to accommodate it, the organism is in a state of
equilibrium. Normal wear and tear occur, but sustained damage does not. When the
degree of stress is greater than the available coping mechanism, the individual experi-
ences negative aspects of stress. The situation is often described metaphorically
through such statements as “carrying a load on one’s shoulders” or “bearing a heavy
burden.” This often leads to physiological and psychological problems for the person
and poor performance for the organization. When the degree of stress is not stimulat-
ing enough, lack of interest, apathy, boredom, low motivation, and even poor perfor-
mance can result.

The experience of stress is subjective and individualized. One person’s stressful
event is another’s challenge. One individual can experience an event, positive or nega-
tive, that would prove overwhelming for someone else. Even a minor change in

358 Chapter 26

organizational policy may cause some individuals to experience stress, whereas others
welcome it. Some nurses seem to thrive on the demands of work, family, school, and
community involvement, whereas others find even minimal changes in their expecta-
tions a source of great discomfort.

Causes of Stress
For nurses, stress in the workplace can develop from several sources and may be due
to organizational, interpersonal, or individual (intrapersonal) factors.

Organizational Factors
Stress can result from job-related factors, such as task overload, conflicting tasks, inabil-
ity to do the tasks assigned because of lack of preparation or experience, and unclear or
insufficient information regarding the assignment. Nurses’ jobs are often performed in
life-or-death situations; emergencies may cause periods of extreme overload.

The physical environment may also be stressful. Consider the intensive care unit
with its constant alarms, beeps, and other noises. Studying the effect of environmental
factors (e.g., odor, noise, light, and color) on nurses’ stress, Applebaum and colleagues
found that noise, in particular, correlated with stress, job dissatisfaction, and intent to
leave (Applebaum, Fowler, Fiedler, Osinubi, & Robson, 2010). In addition to noise lev-
els, lighting and other comfort factors may increase stress within the environment.
Tight quarters, poorly organized work environments, and lack of equipment also aug-
ment stress levels.

Today’s technology demands that employees be in perpetual contact with their
employers. Besides, most of us are compelled to check our communication devices
many times a day, and once a message or email is read, it is difficult to forget it regard-
less of the time. It is as if we are tied to technology from an invisible cord, a cord none-
theless firmly attached.

Nurse managers, especially, are prone to stress due to the scope of their responsi-
bilities. Shirey and associates (Shirey, McDaniel, Ebright, Fisher, & Doebbeling, 2010)
found that experienced nurse managers used a combination of emotion-focused and
problem-centered coping strategies to handle stress and had fewer negative outcomes
from stress than novice managers. Furthermore, novice managers reported experienc-
ing more physical exhaustion, sleep problems, and hypertension than did their more
experienced colleagues.

Other organizational factors that can lead to stress include organizational norms
and expectations that conflict with an individual’s needs. Managers trying to do more
with less, overworked staff, and more acutely ill patients can lead to an organizational
environment that by its very nature is stressful. New technology, increased expecta-
tions from patients and their families, liability concerns, and increased pressures for
efficiency, in addition to the dramatic changes in healthcare resulting from healthcare
reform legislation, increase stress in nursing and make the role of nurses and nurse
managers more difficult, conflicting, and stressful.

Interpersonal Factors
To add to the pressures created by organizational changes, nurses must contend with
strained interpersonal relationships with other healthcare professionals and

Managing Stress 359

administrators. Interprofessional difficulties may precipitate tension. As resources in
healthcare continue to shrink, nurses are being asked or told to assume responsibility
for tasks that had been performed by other departments (e.g., phlebotomy, electrocar-
diography, respiratory therapy).

In a rehabilitation setting, therapists expect the patients to be bathed, to have eaten
breakfast, and to be dressed and ready to start therapy by 8:30 a.m. This expectation
places undue stress on rehabilitation nurses, who must motivate patients who complain
that they have had far too little sleep.

Here is another example of stress due to interprofessional conf lict: A radiology
technician responds to a 9:00 p.m. page for a chest x-ray examination and informs the
registered nurse that the patient will have to be brought back down because the radiology
department is understaffed.

Interactions between physicians and nurses are often strained. Most nurses have
experienced an irate response from a physician who is awakened during the night for
something the physician thinks should have been handled earlier or might have
waited until morning.

An internist in a small community hospital was well known for his outbursts during
middle-of-the-night calls. One experienced nurse dealt with necessary calls to him by
directly stating when he answered the phone, “This is Jane Jones from St. Matthew’s. I
have two important things to tell you about Mrs. Smith . . . .” This helped the internist
focus on the problem at hand and eliminated his outbursts.

The need to fulfill multiple roles is another source of stress. A role is a set of expec-
tations about behavior ascribed to a specific position in society (e.g., nurse, spouse,
parent). Conflict between family and professional roles results in stress. Adding to
stress is the shift and weekend work required in nursing jobs in hospitals that must be
staffed 24 hours a day, 7 days a week.

Nurses who work evening or night shifts may experience family problems if their
spouse and children are on different schedules, especially if the nurse rotates shifts. It
takes several weeks to adjust physiologically to a change in shifts; however, rotation
patterns often require nurses to change shifts several times a month. Managers can
reduce the physiological pressure by ensuring that nurses receive adequate rest and
work breaks, rotating staff only between two shifts, and never scheduling “double
backs” (working 8 hours, off 8 hours, working 8 hours).

Individual Factors
Stress can result from personal factors as well. One of these factors is the rate of life
change. Changes throughout life, such as marriage, pregnancy, or purchasing a new
home, generate stress. Each individual responds to stress differently, but the cumula-
tive effects of stress often lead to the onset of disease or illness. The ways people inter-
pret events ultimately determine whether the person sees the event as stressful or as a
positive challenge.

New graduates, for example, often do not recognize that they have demonstrated
a definitive set of skills and knowledge in having passed all the requirements to
become a registered nurse. The stress they experience when changing from the student
role to the professional practitioner role has been explained by Kramer (1974) as

360 Chapter 26

reality shock. When students move from a familiar school culture to a work
culture—where values, rewards, and sanctions are different and often seem
illogical—they experience surprise and disequilibrium.

Moving from a staff nurse position to management also creates surprise and dis-
equilibrium. New managers often experience a sense of isolation from the peer group
of staff nurses who previously provided support. Doing a job and directing others to
do a job are different. Directing others is stressful, and a person may be tempted to
believe that it will be faster to complete a task by doing it herself or himself.

Role ambiguity results from unclear expectations for one’s performance. Indi-
viduals with high tolerances for ambiguity can deal better with the strains that come
from uncertainties and, therefore, are likely to be able to cope with role ambiguity. Role
underload and underutilization can also occur. Being underutilized or not having much
responsibility may be seen as stressful by a person who is a high achiever or who has
high self-esteem.

Role conflict is the result of incompatibility between the individual’s perception
of the role and its actual requirements. Novice nurse managers experience this type of
conflict when they find that administration expects primary loyalty to the organiza-
tion and its goals, whereas the staff expects the nurse manager’s first loyalty to be to
their needs.

Role conflicts also occur when an individual has two competing roles, such as
when a nurse manager both assumes a patient care assignment and needs to attend a
leadership meeting. Another example is the conflict between nurses’ personal role as a
parent or spouse versus their role as a professional nurse.

Consequences of Stress
What happens to a person when he or she experiences stress overload? Both physio-
logical and psychological responses can cause structural or functional changes, or
both. The warning signs of too much stress include the following:

• Undue, prolonged anxiety; phobias; or a persistent state of fear or free-floating
anxiety that seems to have many alternating causes

• Depression, which causes people to withdraw from family and friends; an inabil-
ity to experience emotions; a feeling of helplessness to change the situation

• Abrupt changes in mood and behavior, which may be exhibited as erratic
behavior

• Perfectionism, which is the setting of unreasonably high standards for oneself and
leads to a feeling of constant stress

• Physical illnesses, such as an ulcer, arthritis, colitis, hypertension, myocardial
infarction, and migraine headaches

Ineffective coping methods for reducing stress include excessive use of alcohol
and other mood-altering substances, which can result in substance abuse or depen-
dence (Epstein, 2010). Some people become workaholics in an attempt to cope with
real or imagined demands.

The term burnout refers to the perception that an individual has used up all avail-
able energy to perform the job and does not have enough energy to complete the task
(Epstein, 2010). Burnout is a combination of physical fatigue, emotional exhaustion,

Managing Stress 361

and cognitive weariness. As a result, the individual may reduce hours worked or
change to another profession.

Compassion fatigue is secondary traumatic stress experienced by caregivers
(Newsom, 2010). Similar to posttraumatic stress disorder, the term includes those
involved in caring for others who are suffering from physical or emotional pain (Yoder,
2010). Symptoms are similar to those of burnout but may be more severe if the care-
giver is providing care to those traumatized by crime, war, or war-related traumatic
stress or are emergency workers or first responders.

In addition, nurses themselves may experience posttraumatic stress disorders
(PTSD). Gates, Gillespie, and Succop (2011) found that 17% of emergency room nurses
who had been involved in a violent incident were symptomatic for PTSD.

Job performance suffers during times of high stress; so much energy and attention
are needed to manage the stress that little energy is available for performance. In addi-
tion, increased absenteeism and turnover may result. Although absenteeism and turn-
over have various causes, either or both may occur when the individual attempts to
withdraw from a stressful situation. Such a situation is financially costly in industry
but even more costly in human health and well-being.

A director of nursing at a 120-bed nursing home stated that she could no longer handle
the overwhelming needs of the patients; the ever-present shortage of qualified, caring
nurses; and the consistently dwindling resources. When a for-profit chain purchased the
home and further reduced economic resources, the director of nursing left to become a real
estate agent.

Managing Stress
We will always have situations in our lives that create stress. To manage those times
effectively and keep stress at levels that enhance one’s performance rather than deplete
energy, the key is to develop resiliency. Stagman-Tyrer (2014) explains that nurses can
“build resilience through equanimity, optimism, and perseverance” (p. 49). Resilient
nurses keep their commitments, respond to problems with courage, and use difficul-
ties as opportunities for self-growth.

Personal Methods
One of the first steps in managing stress is to recognize stressors in the environment.
Nurses tend to think they can be “all things to all people.” Therefore, it is important to
improve one’s self-awareness regarding stressors.

Keeping your life in balance is difficult, but it can be done (Sullivan, 2013). Effec-
tive habits include role redefinition, time management, and self-care. Development of
interpersonal skills and identifying and nurturing social supports can also facilitate
stress management.

Role redefinition involves clarifying roles and attempting to integrate or tie
together the various roles that individuals play. If there is role conflict or ambiguity, it
is important to confront others by pointing out conflicting messages. Role redefinition
may also involve renegotiation of roles in an attempt to lessen overload.

Much of the stress that nurses and nurse managers experience results from the
perception that staff, patient, and workgroup needs must be met immediately and
simultaneously. A notable method of coping with and reducing this stress of time is

362 Chapter 26

through time management. We determine how, where, and when our time is used.
Time is the essence of living, and it is the scarcest resource. One lost hour a day every
day for a year results in 260 hours of waste, or 6.5 weeks of missed opportunity,
annually.

Caring for yourself physically (e.g., eating a well-balanced diet, exercising regu-
larly, getting adequate sleep) and developing effective mental habits are important
self-care strategies for coping with stress. To be able to care for others, nurses need to
replenish themselves and practice relaxation techniques. This is not easy, especially for
an individual with a high-stress job. Some relaxation methods are listening to music,
reading, and socializing with friends. Developing outside interests, such as hobbies
and recreational activities, can provide diversion and enjoyment and can also be a
source of relaxation. Taking regular vacations, regardless of job pressures, is important
for renewal and revitalization.

Mindfulness, yoga, and tai chi are other strategies for dealing with stress. Mind-
fulness, in particular, has been in the news in recent years. Mindfulness is the ability
to attend to whatever is happening in the present moment, and to accept the situation
as it is without judgment (Kabat-Zinn, 2013). Reducing stress is one of the benefits of
mindfulness practice (Lindquist, Witt, & Crane, 2014). Ponte and Koppel (2015) found
that nurses in a mindfulness pilot program reported less stress and improved interac-
tions with patients and families. Another study found that relaxation practice restored
nurses’ energy levels (Hoolahan, Greenhouse, Hoffmann, & Lehman, 2012). Yoga and
tai chi are additional practices that require attention to the present moment and are
often used to help reduce stress.

Leading at the Bedside: Handling Stress suggests self-evaluation to assess the
need to manage stress. More personal strategies can be found in Chapter 14, “Balanc-
ing Your Life,” in Eleanor J. Sullivan’s Becoming Influential: A Guide for Nurses, 2nd ed.
(Sullivan, 2013).

Organizational Methods
When stress is job related, several strategies can be used. First, proper matching of the
job with the applicant during the selection and hiring process is an important step in
reducing stress. Adequate orientation about what to expect on the job and using more
experienced nurses as preceptors can reduce stress in novice nurses (Epstein, 2010).
Skills training also reduces stress and promotes better performance and less turnover.

Leading at the Bedside: Handling Stress
Stress is inevitable. How you react to it is up to you. Nurses
tend to put others first. It’s the hallmark of a caring profes-
sional. However, both work and self-care are equally impor-
tant to keep life in balance.

Ask yourself the following:

• Do you engage in activities that relax and renew you?

• Do you feel you must answer every email or text mes-
sage immediately?

• Do you take time to consider how you allocate your
time and determine your priorities?

If you answered “no” to any of the above, reread this
chapter. You will find many ideas to reduce stress and
improve both your personal and work life.

Managing Stress 363

In addition, the organization can provide employee assistance programs (EAPs).
Organizations that not only provide EAPs but promote their use report greater use of
the service than organizations that promote wellness and prevention instead of EAPs
(Azzone, Hiatt, Hodgkin, & Horgan, 2009). It is essential, however, to help remove the
stigma about using such services (Epstein, 2010). In addition, mindfulness, yoga, or tai
chi classes can be offered to staff members.

Communication and social support are additional factors in reducing stress. Both
upward and downward communication channels should be open. Keeping personnel
informed about what is going on in an organization helps reduce suspicion and rumor.
Team building encourages staff to build a network of support with each other.

Policies that reduce the stress of shift work are also important. The number of
hours in the night shift, weekend, and holiday work assignments also affects the level
of stress. Providing adequate opportunities for breaks and meals is an important func-
tion of the organization.

Nurse managers are also vulnerable to stress. Shirey and colleagues (2010) found
lower stress among nurse managers with more experience, those with a greater span
of control, and those empowered by their chief nurse. Thus, in addition to individual
coping strategies, organizations can provide support for nurse managers and make
them more likely to remain in their positions.

See Case Study 26-1 for an example of how one nurse managed her own stress and
helped her staff manage theirs.

CASE STUDY 26-1 | Managing Stress
Madeline Mears, RN, is nurse manager of emergency ser-
vices and critical care units at two corporately owned sub-
urban hospitals. The corporation recently purchased three
not-for-profit hospitals located in the urban center of the
metropolitan area. Madeline and several other nurse man-
agers at the suburban hospitals have been informed by the
vice president for patient care services that they will now be
responsible for managing the same service lines at the
newly acquired hospitals. Managers at the urban hospitals
will move into charge nurse roles on their respective units.

Madeline has the challenge of effectively and efficiently
managing emergency services and critical care units at five
separate facilities, all located within a 60-mile metropolitan
radius. Her past experience in merging the management
responsibilities at the two suburban hospitals will be
extremely useful as she works to transition the new hospi-
tals into the healthcare system.

Madeline anticipates that staff at the hospitals will be
concerned over the changes in ownership and manage-
ment. Some staff may be fearful of the unknown and wor-
ried about their jobs, while others may be excited at the
opportunity for increased pay and job mobility in the health-
care system. Former managers at the hospitals may be
angry about their demotion. Human resources representa-
tives have indicated that they will offer former managers the

opportunity to apply for open management positions in the
healthcare system.

Myriad reactions among the staff members are
expected, as well as the potential for increased stress.
Madeline and the other nurse managers meet and develop
a transition plan. The transition plan defines the tasks, time
frames, and expectations for merging the patient care units.
In addition, the plan helps decrease the stress Madeline and
her fellow managers experience by organizing and delineat-
ing roles and responsibilities. Consistency in implementing
change will help decrease stress among the staff at the
urban hospitals. Each manager is committed to meeting
with staff on each unit to address questions, concerns, and
morale issues. Madeline plans to schedule a lunch meeting
with each former manager to discuss the unit’s strengths
and weaknesses as well as her goals for the unit.

Three months into the transition, Madeline’s units have
had low turnover, and staff members report they are satis-
fied with the new management structure. In particular, staff
nurses enthusiastically have accepted the clinical ladder
promotion program and evidence-based practice imple-
mentation. Two of the former managers have moved into
management roles in the healthcare system. The transition
has been stressful, but Madeline has enjoyed the opportu-
nity to stretch her leadership skills.

364 Chapter 26

Regardless of the work or life situation, everyone experiences stress, both positive
and negative. It is how stress is handled that makes life interesting or excessively dif-
ficult. Stress-management strategies enable nurses to improve job performance and
professional satisfaction.

What You Know Now
• Stress is a person’s reaction to demands from the

environment.

• Stress can be both positive and negative; regard-
less, the physiological response is the same.

• Causes of stress come from organizational, inter-
personal, and individual factors.

• Stress can cause physical and psychological prob-
lems, including burnout and compassion fatigue.

• Technology adds to stress with constant demands
for immediate attention.

• Individuals can help manage stress by recogniz-
ing stressors, redefining roles, time management,
and self-care.

• Mindfulness, yoga, and tai chi are attention-
oriented strategies to help reduce stress.

• Relaxing activities, recreation, hobbies, and vaca-
tions are all necessary for a balanced life.

• Organizations can support employees to manage
work-related stress by matching applicants to
appropriate jobs, providing adequate orientation
and skills training, and using experienced nurses
to preceptor novice nurses.

• Organizations can provide employee assistance
programs and relaxation classes to help their staff
deal with stress.

Tools for Managing Stress
1. Recognize that stress is necessary for life.
2. Acknowledge the impact of stress, both positive

and negative, on your professional and personal
life.

3. Review your stress-management strategies and
evaluate them for effectiveness.

4. Pay attention to your stress levels, and try to cre-
ate opportunities to help deal with stress.

5. If you are experiencing an exceptional amount
of stress, consider various ways to care for your-
self.

Questions to Challenge You
1. What causes you the most stress?
2. What methods do you use to cope with stress?
3. Have you seen others respond negatively to

stress? Explain what happened.
4. Have you experienced any of the consequences of

stress described in this chapter? How did you
handle it? Explain.

5. Have you experienced role ambiguity or role
conflict? Describe the situation. How did you
handle it?

6. What ways do you care for yourself? What other
ways might you add to your repertoire of self-
care skills?

Managing Stress 365

References
Applebaum, D., Fowler, S., Fiedler, N., Osinubi, O.,

& Robson, M. (2010). The impact of environmental
factors on nursing stress, job satisfaction,
and turnover intention. Journal of Nursing
Administration, 40(7/8), 323–328.

Azzone, V., Hiatt, D., Hodgkin, D., & Horgan, C.
(2009). Workplace stress, organizational factors
and EAP utilization. Journal of Workplace Behavioral
Health, 24(3), 344–356.

Epstein, D. G. (2010). Extinguish workplace stress.
Nursing Management, 41(10), 34–37.

Gates, D. M., Gillespie, G. L., & Succop, P. (2011).
Violence against nurses and its impact on stress
and productivity. Nursing Economics, 29(2), 59–66.

Hoolahan, S. E., Greenhouse, P. K., Hoffmann, R. L.,
& Lehman, L. A. (2012). Energy capacity model for
nursing: The impact of relaxation and restoration.
Journal of Nursing Administration, 40(2), 103–109.

Kabat-Zinn, J. (2013). Full catastrophe living: Using the
wisdom of your body and mind to face stress, pain, and
illness. New York, NY: Bantam.

Kramer, M. (1974). Reality shock. St. Louis, MO: Mosby.
Lindquist, R., Witt, D. R., & Crane, L. (2014).

Integrative nursing management of stress. In M. J.

Kreitzer & M. Koithan (Eds.), Integrative Nursing
(pp. 200–213). Oxford, UK: Oxford University
Press.

Newsom, R. (2010). Compassion fatigue: Nothing left
to give. Nursing Management, 41(4), 42–45.

Ponte, P. R., & Koppel, P. (2015). Cultivating
mindfulness to enhance nursing practice. American
Journal of Nursing, 115(6), 48–55.

Selye, H. (1978). The stress of life (2nd ed.). New York,
NY: McGraw-Hill.

Shirey, M. R., McDaniel, A. M., Ebright, P. R.,
Fisher, M. L., & Doebbeling, B. N. (2010).
Understanding nurse manager stress and work
complexity. Journal of Nursing Administration,
40(2), 82–91.

Stagman-Tyrer, D. (2014). Resiliency and the nurse
leader: The importance of equanimity, optimism,
and perseverance. Nursing Management, 45(6),
46–50.

Sullivan, E. J. (2013). Becoming influential: A guide
for nurses (2nd ed.). Upper Saddle River, NJ:
Pearson.

Yoder, E. A. (2010) Compassion fatigue in nurses.
Applied Nursing Research, 23(4), 191–197.

366 Chapter 27

Learning Outcomes

After completing this chapter, you will be able to:

1. Describe how to envision your future.

2. Relate the steps needed to obtain your first job.

3. Explain how to create your career.

4. Plan for your next position.

5. Learn to adapt to change.

Key Terms
activity log

certification

mentor

résumé

Introduction
A nurse met with the advisor in a baccalaureate program designed for RNs. After talking

about the requirements of the program, the classes she needed, and her own schedule, they
concluded that by taking one course a semester, it would take the nurse 5 years to complete
the program. The RN looked discouraged. The advisor asked her what was wrong.

Envisioning Your Future

Acquiring Your First Position
Applying for the Position

The Interview

Accepting the Position

Declining the Position

Progressing in Your Career
Tracking Your Progress

Identifying Your Learning Needs

Finding and Using Mentors

Considering Your Next Position
Finding Your Next Position

Leaving Your Present Position

Adapting to Change

366

Chapter 27

Advancing Your Career

Advancing Your Career 367

Leading at the Bedside: Your Future
This chapter is for you. If you are a novice nurse, it comes at
the perfect time. You can build your career from the beginning.
If you are more experienced, you can start now to think about
what you want to do next. Where do you want to be in 1 year?

5 years? 10? When you retire? Take your time to consider
your interests. Ponder the possibilities. Explore your options.
Don’t rush it, but don’t wait too long because the future will
happen regardless. Just let it be your preferable future.

“If I enroll in this program I’ll be thirty-five in five years,” she said.

The advisor smiled. “Yes, and you’ll be thirty-five in five years if you don’t.”

Envisioning Your Future
The future seems like something over which we have so little control that planning for
it does not seem realistic. Wait to see what happens, try to handle the circumstances,
and hope for the best are as much planning as most people do.

Instead, imagine yourself in 1 year, creating in your mind the life you most desire.
What are you doing? What have you done over the course of the past year?

Now imagine what you are doing in 5 years. How about what you are doing in
10 years? Finally, what will you be doing right before you retire? Will you be satisfied
with what you’ve done? What will you wish you had done? (See Leading at the Bed-
side: Your Future.)

Searching for your first job after graduation is a priority. Worrying about your
career can wait. Or so you think. Shirey (2009) advises otherwise. She divides a nurs-
ing career into three stages:

• Phase 1: Promise (first 10 years). Initial experiences in the promise phase are
essential building blocks for a long-term, successful career.

• Phase 2: Momentum (11 to 29 years). Continuing to learn and grow, choosing
multiple experiences, and becoming visible in the profession are all important for
continued success.

• Phase 3: Harvest (last years of career). While continuing to grow and learn, nurses
also share their experiences and expertise with younger nurses and leave a legacy
for the next generation. Shirey (2009) further posits that a career does not just hap-
pen: It is planned and cultivated.

Acquiring Your First Position
The first step, after you have completed your basic nursing education, is to select your
first job. The purpose of this job is to learn as much as you can and to perfect your
clinical skills. In addition, you will make contacts among your colleagues and
super visors.

Here are some criteria for choosing your first job:

• You will have opportunities to hone your skills in a clinical area of interest.

• You will learn from more experienced clinicians who are willing to teach you.

368 Chapter 27

• The culture of the organization and, especially, the administration are supportive
of nursing.

• The organization’s mission fits your values (e.g., a teaching hospital that serves
the poor).

• The organization offers opportunities for advancement.

No job is perfect, just as no relationship, home, career, or family is perfect. Use the
preceding criteria to assess the position and the organization. If the position and the
organization fit most of them, especially the criteria most important to you, consider
the following additional criteria:

• The schedule fits your lifestyle.

• The institution is near your home.

The least important criterion for selecting your first job is the salary. A small
amount more in your hourly pay is worth much less than opportunities to help meet
your future goals. Remember, you have a long time to be in your career; do not sacri-
fice opportunities in the future for a slight difference in salary now.

Applying for the Position
Some organizations ask you to fill out an application, either online, by mail, or in per-
son; others request a résumé. A résumé is a written record of your educational achieve-
ments, employment, and accomplishments. (See Box 27-1 for a sample résumé.) Your
résumé might also include your immediate professional goal, such as “gain clinical
experience” and/or your long-term goal, such as “become a manager.”

Education achievements include the following:

• Degrees, institutions, years attended, graduation date (actual or expected)

• Specialty training

• Continuing education

Employment includes the following:

• Positions held

• Names of employers

• Dates of employment

Accomplishments might include the following:

• Volunteer service, such as helping in a homeless shelter

• Organizational service, such as serving as student body president

• Awards won, such as Outstanding Junior Student

Once you have applied for a position and the organization contacts you to say a
representative is interested in meeting you, you will agree on a time and place for an
interview.

The Interview
The interview is your chance (sometimes your only chance) to sell yourself to a poten-
tial employer. Make no mistake: If you cannot sell yourself, no one can. You need to

Advancing Your Career 369

Box 27-1 Sample Résumé
Chloe R. Stevenson, RN, BSN

5625 Summit Lane
Overland Park, KS 66222

913.555.2222
chloestevenson@anyprovider.net

Objective
To obtain a position as a professional registered nurse in a dynamic intensive care unit that will
utilize my strong clinical skills, work ethic, problem-solving ability, and passion for providing
superior patient care.

Work Experience
Registered Nurse
May 2009—Present
Telemetry Unit, Memorial Hospital, Overland Park, KS
• Currently provide direct patient care to a variety of cardiac and postoperative cardiac

patients on a 30-bed telemetry unit
• Clinical duties: assessment, medication administration (including titration of cardiac IV

medications), cardiac monitoring, and all other aspects of nursing care
• Actively develop, implement, and monitor individualized patient plans of care as well as

document patient response and outcomes
• Became Advanced Cardiac Life Support (ACLS)—certified and serve as leader of unit’s

critical response team
• Participate as a member of an evidence-based practice committee for cardiology services

Patient Care Technician
January 2008—May 2009
Telemetry Unit, Memorial Hospital, Overland Park, KS
• Worked under the supervision of an RN to provide direct patient care, including taking vital

signs, dressing changes, bathing, ambulation of patients, and assisting with the admission
and discharge process

• Responsible for appropriate clinical documentation
• Trained to perform 12-lead EKGs as well as cardiac monitoring
• Served on unit’s quality improvement team

Education
• B.S. in Nursing, May 2009, University of Kansas, GPA: 3.7/4.0
• R.N., licensed in Kansas, June 2009
• Advanced Cardiac Life Support (ACLS) certified, August 2009

Awards
• Jane Smith Award for Excellence in Clinical Nursing, May 2009; awarded by faculty to the

senior nursing student who demonstrates excellence in clinical skills and academic course-
work

References available upon request.

prepare for your interview just as you would for any other important meeting. That
includes knowing who you are meeting, learning as much as you can about the orga-
nization, and anticipating questions you might be asked.

mailto:chloestevenson@anyprovider.net

370 Chapter 27

PreParing for tHe interview The purpose of an interview is twofold: for a
potential employer to learn about you and for you to learn about the organization. Ide-
ally, the two of you will discover if there is a role for you in the organization, what is
known as a good “fit.”

To prepare, identify the following:

• What you want to know about the position and the organization

• What questions you might be asked about your education or past experiences (Be
prepared to describe briefly your achievements.)

• What you think your strengths and weaknesses are and how those fit with your
potential employer’s needs

• What you want to know about the organization and the job

Find out who will be interviewing you and ask for the person’s position and role
in the organization. You may interview with someone in the human resources office as
well as with the person who would be your supervisor.

Be especially courteous to office staff; they have the power to smooth your way or
report your behavior to their boss. Try to schedule your interview for a time when you
can be rested and unhurried, not right after a long day at work or when you must be
somewhere else immediately afterward.

You will probably be sent some information about the organization (or you can
request it). A position description is essential—you can compare it with your qualifica-
tions. The materials you receive may include the organization’s mission statement, its
vision for the future, and its goals.

An organizational chart also can be helpful but is not always available. The impor-
tant information for you is where this position fits in the organizational structure. That
will tell you to whom you would report and also explain that person’s reporting rela-
tionship. The most direct line to top administration is the most powerful.

What to Wear to the Interview Most people anguish over what to wear to an
interview—with good reason. The way you dress creates your first impression and can
enhance or detract from your words. Keep it simple and conservative. You want the
interviewer to focus on your qualifications, not your clothing.

Clean, pressed slacks and a tie and jacket for men are appropriate. Women can
wear pants or a skirt with a jacket in neutral colors, low-heeled shoes, simple jewelry,
and carry a handbag or briefcase. Wear something you feel comfortable in. Resist the
urge to buy a new outfit unless you do not have anything suitable in your wardrobe.

At the Interview Take along a copy of your résumé even if you filled out an applica-
tion. (You can refer to it if you are asked to explain an item.) Ask for explicit directions
to the building and office where you will go, and plan to arrive a few minutes early.
Prepare mentally by reminding yourself of the qualifications you bring to the position,
noting items on the position description that fit you. Enter the office with confidence,
smile, and shake hands firmly.

To consider what questions you might be asked in an interview, see examples of
general questions in Table 27-1. In addition, you will be asked questions about your
education and work history. Answer questions honestly, but do not feel you must
explain anything you are not asked. You will have an opportunity to ask your ques-
tions about the position and the organization. Be sure you are prepared to do so. A
candidate who has no questions suggests a lack of interest or expertise.

Advancing Your Career 371

Table 27-1 Examples of Interview Questions

YOUR CURRENT JOB

What do you do in your present job?

What do you like best about your present job?

What do you like least?

Why do you want to leave your present job?

YOUR ACHIEVEMENTS AND GOALS

What are you most proud of accomplishing?

What do you think you do especially well?

What are your areas of weakness?

What are your long-term goals?

What do you plan to do to meet your goals?

YOUR INTEREST IN THE POSITION

Why are you interested in this position?

What do you see yourself doing next?

Why do you think you are right for this position?

Is there anything you would like to add about your qualifications that we haven’t already discussed?

Source: From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Pearson. Used with
permission.

Most interviewers today understand which questions are legal to ask and which
are not—for example, you are not required to answer questions about how many chil-
dren you have, their ages, or your marital status. Simply being asked such questions
indicates an organizational bias, and if you are asked such questions you might want
to reconsider your interest in the organization.

To practice for an interview, role play using the interview script in Box 27-2.

Telephone Interview It is becoming more common for employers to use a telephone
interview to narrow the field of candidates prior to a face-to-face interview (Pagana,
2012). A telephone interview also might be appropriate if you are applying for a posi-
tion out of town, possibly saving unnecessary travel if either you or your potential
employer is no longer interested after the phone interview.

Pagana (2012) suggests preparing for a telephone interview much as you would
for a personal interview:

1. Find out as much as you can about the organization.

2. Be sure you are in a quiet place where you will not be interrupted during the call.

3. Lay out your résumé and paper and pencil for notes.

4. Prepare a list of questions you want to ask.

5. Mirror a personal interview by dressing appropriately.

6. Stand so you sound confident, move around, and smile. (Yes, a smile can be
heard.)

7. Listen carefully so you respond accordingly.

8. Try to end with an invitation for an in-person interview.

After the Interview Send a thank-you letter to everyone who interviewed you within
24 hours of either a telephone or in-person interview. Your letter can be handwritten

372 Chapter 27

on nice quality notepaper or typed on letter-size stationery. It should be brief, thanking
the interviewer for interest in you and saying that you enjoyed the meeting. Include a
few words summing up your qualifications that fit the position. Close the letter by say-
ing that you are looking forward to hearing from her or him soon.

A Second Interview It is not unusual to have a second interview if you have passed
initial scrutiny and appear to be an appropriate candidate for the position. The second
interview usually includes colleagues and managers with whom you would work.
You will probably tour the unit and meet potential coworkers, giving you an opportu-
nity to assess the environment.

Box 27-2 Interview Script
Manager: Hi, I’m Takisha. I’m the nurse manager for the sur-
gical care unit. Thank you for coming in today! I’d like to start
by telling you a little about the surgical care unit, and then
we’ll talk about you and why you would like to work here.

The unit is a thirty-two-bed patient care unit that is
open twenty-four hours a day, seven days a week. We pro-
vide care most typically to patients who have had abdomi-
nal surgeries or orthopedic surgeries. The average length of
stay for a patient here is three days. All rooms are private,
with one patient to a room. We encourage a family member
to stay overnight in the sleeper chair if desired. We work
hard to create a good experience for every patient.

Now, tell me about you and why you’ve chosen to
consider working with us.

IntervIewee: I’m Samuel Jones. I’ve been a nurse for three
years. I went to school at Upstate University. I worked in the
community hospital surgical unit after I graduated from
nursing school—I had clinicals there during my studies.

Now I would like to move on to a larger facility that has
a greater variety of patients. I’ve read a lot about your hos-
pital and was very excited to see the job posting. I think this
organization would be an excellent place for me to work.

Manager: Tell me more about why you think our hospital is
a good fit for you.

IntervIewee: Well, I know you keep adding more floors and
services, and I want to be part of a growing place. I also
know your website says you have just received Magnet
designation. I want to be at a hospital where nursing is val-
ued and growth is encouraged. A member of my family
came here for care and loved it. He said everybody was
very warm and professional.

Manager: That is very good to hear! So, let’s talk about
your work experience at the community hospital. Tell me
about your role there.

IntervIewee: Well, I’m a staff nurse in the surgical unit. I
work the night shift. After working there about a year and a
half, I took a preceptor class and began helping train new
nurses. I am also the charge nurse there. I lead the shift,
help my coworkers with their patients, get patients placed
in a room when they’re admitted, and talk to patients who
have concerns about their care.

Manager: It sounds like you’ve done well in the last three
years. Tell me about being the charge nurse leader. That’s
a large responsibility. Why do you like that responsibility,
and how do you think your peers would describe you in
that role?

IntervIewee: I like working hard and being a role model to
encourage the other staff members to work hard. I also
think that most issues can be fixed with good communica-
tion, so I try to always get people to talk and to share infor-
mation. I think my coworkers would say I’m always asking
them if they need help with their patients. I want them to
know I’m there for them.

Manager: Tell me about your strengths as a nurse.

IntervIewee: I try to keep myself and everybody focused
on the patient. I’m also very dependable. This is the third
year in a row that I’ve had a perfect record of attendance
at work.

Manager: Tell me about your weaknesses.

IntervIewee: I think sometimes I don’t ask for help and
then I get overwhelmed with my work. I always try to help
others but get embarrassed when I need to ask for help. I
need to learn to give and take better.

Manager: We all have strengths and weaknesses. We can
build on your strengths and help you learn to deal with your
weaknesses. Would you like to tour the unit now?

Advancing Your Career 373

Situational questions are often asked at this time. For example, you are given a
scenario and asked how you would handle the situation. Take your time to think
through an answer. Obviously the interviewers think you can handle such a situation
because you have been asked back. Keep your answer short and to the point. Your goal
is to show you are a competent, confident professional.

Interviewing with potential coworkers is also your opportunity to find out what
you want to know about the specific responsibilities and challenges of the position.
You might ask “What are the most pressing problems facing the unit?” or “What do
you need most from a nurse practitioner in this clinic?”

You will probably be asked if you are still interested in the position. If you are, ask
when a hiring decision will be made. Following this interview, again send thank-you
letters, but only to the new people who have interviewed you.

Accepting the Position
When you are offered the position, you have an opportunity to negotiate. Do not
ignore this opportunity in your excitement about getting the job.

Salary is usually the main topic for negotiation. Most employers have some flexi-
bility with salary if they have a justifiable reason for it, but they will seldom tell you
that. It is much more common for an organization to offer the lowest salary in its range
and see if the candidate asks for more. Ask for a number higher than your lowest
acceptable figure, but do not get carried away. Asking for a salary that is a great deal
higher than the offer is unprofessional and makes you appear to be more interested in
the money than the job.

Follow up your verbal agreement with a formal letter of acceptance to the admin-
istrator who hired you. Thank the individual for having confidence in you and your
potential, and state again how pleased you are to be joining the organization.

Declining the Position
Sometimes you will decide not to accept a position offered to you. It might not be the
right job, at the right time, or in the right organization. Be sure to let the appropriate per-
son know your intention as soon as possible. Thank him or her for the offer and the con-
fidence the organization has in you. Explain briefly why you cannot accept the job at this
time and state that you hope the organization will keep you in mind in the future. Follow
up with a letter as well. Even if you are not interested in this position or this organization,
someone there might prove valuable—for example, in referring another organization to
you in the future. Your career will be long; never alienate potential connections.

Progressing in Your Career
Once you have accepted your first position, it is time to think about what you will
need to advance in your career.

The first step is to assess yourself. Identify the following:

• Your personality, values, beliefs, likes, and dislikes

• Your lifestyle

• Your family

• Your friends and social life

374 Chapter 27

• Your hobbies and personal activities

• Your vision of your future

• Your skills

• Your knowledge

• Your nursing preferences

The last item refers to the areas of nursing that suit you best. This may take some
time and experience in practice. Then ask yourself the following:

• Do you like a fast-paced environment, such as an ED, OR, or trauma care?

• Do you prefer to have time with your patients? Rehabilitation nursing, a medical
floor, or long-term care might suit you best.

• Which patient conditions and treatments do you prefer?

• Which patient conditions intrigue you the most (e.g., cardiac problems, psychiatric
conditions, or diagnostics such as the GI lab)?

• Would you like to work in a clinic, medical office, home care, or public health?

• Would you enjoy school nursing? Or occupational health?

This assessment is not done quickly; it involves a period of time in practice, intro-
spection, asking friends and family members for their thoughts about you, and learn-
ing from reading or attending programs. It is also flexible and responsive to ways in
which you grow and change. Your family and social life change also, sometimes mak-
ing adjustments in your plan necessary.

The next step is to assess the environment.
Consider what might change in the healthcare system (today, changes occur rap-

idly). How will the changes in the Affordable Care Act affect your future? Are any new
medications or vaccines pending that might eliminate current jobs or create new
opportunities for you? Are any new educational programs being proposed?

The clinical nurse leader is an example. As advances in transplant technology pro-
liferate, new specialties of nurses and physicians are created. Today’s noninvasive
technology for monitoring and treating patients for a variety of ills and from a distance
suggests that many changes in clinical care may be on the horizon.

There are many ways to learn about the environment. Certainly, paying attention
to popular media reports on scientific breakthroughs and advances in technology is
one way. Reading your professional literature, checking certain professional websites
for updates, and attending programs in your interest area are others. Joining a profes-
sional or specialty organization and receiving its newsletters and journals is especially
useful because those target your interests.

Observing others may prove worthwhile. Many people chose their career path after
watching more experienced members of the profession. Nurses who pursue teaching
and administration often do so after working with an especially competent role model.

Talking with experts, colleagues, and administrators is also valuable. Keep alert to
what you hear, evaluate its credibility, and assess its usefulness to you. Gathering
information is an ongoing process. Your plan will not be fixed; it will change in
response to changes in your life, your goals, and the environment.

Once you have assessed yourself and the environment, determine what your options
are. Include legal constraints or possibilities (e.g., Is the nurse practice law in your state
going to be changed to allow more privileges for nurse practitioners?), new programs
proposed (e.g., a local university is starting an acute care nurse practitioner program),

Advancing Your Career 375

your own desires (e.g., doctoral education to become a nurse researcher), and how
willing you are or might become to relocate, go into debt, or sacrifice the time to reach
your goal. The latter issues are likely to change over time as your family life or lifestyle
changes.

Evaluate what experiences you need and where you might get those from a con-
tinuing education program, on-the-job training, a certificate offered by your institu-
tion’s education department, or a graduate degree. Is there a license or certification
you need? What organizations, such as working at a trauma center or accepting a lead-
ership position in your chapter of Sigma Theta Tau International, could help you
achieve your goals? Are there publications or online resources that would help?

Nursing offers an incredible array of opportunities in clinical areas as diverse as
cardiac surgery and trauma care to home health and rehabilitation nursing. You can be
a clinician or a specialist, a teacher, administrator, or researcher. You can become an
entrepreneur or an information systems specialist; you can branch into pharmaceutical
sales; or, for that matter, you can write books about nursing—all the while being a
nurse. See how one nurse advanced his career in Case Study 27-1.

Create a plan that is long term and flexible. No one knows what will happen in
his or her own life, or in the environment over time, or what opportunities may
emerge. Keep an open mind; talk to other professionals; explore your interests. What
we do know is that we are contributing to our own future by what we do or fail to
do today.

Tracking Your Progress
Keep an activity log to track everything you are doing so when the time comes to apply
for a new position, you are not frantically trying to remember your accomplishments,

CASE STUDY 27-1 | Advancing Your Career
Trevor Briggs, RN, BSN, has worked as the operating room
supervisor for the past 4 years. The department has used a
stand-alone clinical information system for the past 2 years,
and Trevor has been an integral part of the successful
implementation of technology in the OR. In addition to train-
ing staff to use the system, Trevor has worked with the IT
vendor to enhance the system’s capabilities. Recently,
Trevor was appointed by his nurse manager to serve on a
hospital-wide clinical information system selection commit-
tee. Administration has initiated the process of selecting an
integrated clinical information system and is seeking input
from each service line.

Trevor enjoys working with the committee and learning
about the implementation processes. The chief information
officer met with the committee and announced the creation
of a new role: clinical systems team leader. Clinical systems
team leaders will be nurses who are specially trained to
work with the IT department in implementing the new clini-
cal information system. Trevor’s background with the OR
system makes him an excellent candidate for such a

position. After interviewing with the IT department man-
ager, Trevor is selected as a clinical systems team leader.
Trevor also learns that the hospital is willing to pay for spe-
cialized training, including tuition reimbursement for gradu-
ate classes.

To increase his knowledge of information systems,
Trevor enrolls in a master’s of information management sys-
tems program at a local university. After completing the ini-
tial 12 hours of the master’s program, Trevor must decide
whether to pursue a specialty track in software develop-
ment or project management. Trevor reviews market trends
to determine the best option and also considers his per-
sonal preferences. He also takes the time to meet with an
instructor in the master’s program, who is an informatics
nurse specialist and has worked in the IT field for 10 years.
Trevor decides to pursue a track in project management,
which will allow him to utilize his strong leadership and peo-
ple management skills. After completing his master’s
degree, Trevor is promoted to clinical systems nurse man-
ager and is now pursuing certification in nursing informatics.

376 Chapter 27

what continuing education programs you took, or when you completed a course at
your hospital. Note the name of the program, activity, certification, or accom plishments,
add the dates, who sponsored it and where, and note anything special you received or
learned. Include a list of accomplishments on your job, such as teaching a class or pre-
ceptoring students, or skills you have acquired. Include any cross-training as well.
Table 27-2 shows an example of a format you could use.

Every item on your activity log will not go on every résumé. A résumé must be
crafted to meet the purpose you have for submitting it. For example, the résumé you
submit to an organization to be considered for membership differs from one
you would use to apply to graduate school. Having a comprehensive list of all your
activities and accomplishments helps ensure that when you put together an app-
lication or submit your résumé, you will be less likely to forget some of your
achievements.

Keep track of your expenses as well. Note them in your activity log or in a sepa-
rate file organized by year; this information comes in handy at tax time. You can use a
document on your computer or in a notebook. It is helpful to keep continuing educa-
tion (CE) certificates and receipts in a file as well.

Identifying Your Learning Needs
Pursuing a career involves lifelong learning. You can learn in many ways. Online
courses, specialty certification, graduate school, books, journals, websites, and profes-
sional meetings are just a few of the ways you can acquire the knowledge you need. To
develop skills, however, you need experience. Several options are possible.

Baccalaureate education for rns The Institute of Medicine (2010) recom-
mends that 80% of nurses be prepared at the baccalaureate or higher level by 2020. Most
baccalaureate programs in nursing have an option for RNs to complete their degrees
without repeating content from their basic program, and many offer programs online.

Certification Certification is growing in nursing as clinical care becomes more spe-
cialized. certification is a formal recognition that a nurse has acquired specialized
knowledge, skills, and experience that meet identified standards. Nursing certification
programs are accredited by either the National Commission for Certifying Agencies

Table 27-2 Activity Log for Career Progress

Activity Content

Education earned Include names of schools, location, dates attended, degrees

Employment Include all positions, including summer jobs and part-time or full-time work
while in school

Licenses Include license number and state

Certificates/Credentials Include name, date earned, sponsoring organization

Professional Organizations Include name, date joined, any committees or offices held with dates

Publications Include title, name of publication, date

Volunteer Activities Include name of organization and your participation

Accomplishments Include accomplishments from your job, professional activities, volunteer
experiences

Source: From Sullivan, E. J. (2013). Becoming influential: A guide for nurses (2nd ed.). Upper Saddle River, NJ: Pearson. Used with
permission.

Advancing Your Career 377

(NCCA) or the American Board of Nursing Specialties (ABNS). Nursing certifications
are available in a wide range of clinical specialties, including nurse practitioner, clini-
cal nurse specialist, and clinical specialties such as cardiac rehabilitation, gerontologi-
cal nursing, informatics, and primary care.

Nurses may be reluctant to pursue certification for several reasons (Watts, 2010),
including the costs of the examination and study guides, lack of employer support, or
absence of on-the-job rewards. However, the benefits to your long-term career may
offset the immediate disadvantages.

Graduate Education Graduate school, in either a master’s or doctoral program, offers
both didactic content and experience, which might be clinical for a practitioner pro-
gram or research in a doctoral program, depending on your goals. If you want to be a
nurse practitioner, teach nursing, become a nurse researcher, or advance as an admin-
istrator, you will need graduate preparation.

Choosing a graduate program is a difficult and time-consuming endeavor. You
must learn as much as you can about the program, its requirements, and its graduates’
success to determine if the program will meet your needs. Gather literature, meet with
admissions staff and faculty, and talk to students and colleagues. Compare national
rankings of the schools that interest you. Request the names of recent graduates to
contact for references and interview them. Ask your teachers, supervisors, and precep-
tors for advice.

This is one of the most important decisions you will make in your career. It can
also be the most valuable. Take your time, consider your options, and be fully commit-
ted before you enroll.

Many options are available to pay for graduate school education. As with the deci-
sion to select a school and a program, finding sources of funding takes perseverance.
The school’s financial aid office can help you locate loans and scholarships. Service
clubs, such as Rotary International, support nursing scholarships.

It is helpful to know your long-term goal, especially if you are interested in an area
of need. For example, a nursing faculty shortage is increasing as retirements thin the
ranks of today’s instructors. Nurse practitioners are needed to work in disadvantaged
areas; some scholarships exist for nurses who agree to provide care in these areas for a
period of time after graduation. In addition, the military offers scholarships in return
for a service commitment.

Continuing Education Finding continuing education to further your career is not dif-
ficult; determining the quality of the program is not as easy. If you receive information
about a program that interests you and fits with your career goals, evaluate the infor-
mation using the following:

• Is the program sponsored by a known organization, such as a college or profes-
sional association?

• Who are the speakers? Are their credentials appropriate to their presentations?

• Is the content appropriate to you at this stage in your development—neither too
advanced nor too elementary?

• Can you obtain financial assistance to attend? If you do, what will you owe the
organization? Bringing back a report of a program you’ve attended is an excellent
way to reinforce your own learning. This will give you an opportunity to speak in
public as well.

378 Chapter 27

• Consider attending, even if you must pay your own way. You may be able to deduct
the expense on your taxes and, after all, you and your career are the beneficiary.

• Can you arrange to be off work, if necessary, and can you afford the time and
expense?

Professional Associations Membership in professional associations offers many
opportunities for learning. Journals, newsletters, websites, blogs, listservs, meetings,
conventions, and programs are just the beginning. The opportunity to meet and net-
work with your colleagues and senior people in the profession and to learn by serving
on committees, task forces, and boards is immense. Many successful nurses began
their career by participating in a professional association.

Nursing associations cover every specialty and interest. Membership in the Amer-
ican Nurses Association (ANA) is open to all registered nurses through its constituent
member associations. Sigma Theta Tau International has more than 400 chapters affili-
ated with schools of nursing around the world. Specialty organizations exist for nurses
who work in many clinical areas, such as the American Association of Critical Care
Nurses (AACCN) or the American Psychiatric Nurses Association (APNA). Each of
these organizations has divisions, committees, and boards where your time and tal-
ents are welcome.

Finding and Using Mentors
One of the most important tasks in your career is to identify and cultivate mentor rela-
tionships. A mentor is a person who has more experience than you and is willing to
help you progress in your career. A mentor introduces you to key people and tells you
what you need to know and do to move ahead. A mentor provides opportunities for
learning, counsels you on mistakes, and takes pride in your successes.

A mentor may be a senior nurse or someone in another closely aligned profession,
mostly because the mentor must have contacts that can be useful to your career. Often
you work for the same organization, but that is not a requirement. You can have more
than one mentor but, usually, not at one time.

You might identify someone you would like to be your mentor, or the mentor
might select you. The arrangement of mentor and mentee, however, is rarely named
as such. Usually, you find yourself relying more and more on one or two people for
advice, or a mentor singles you out for special opportunities or assignments. If any of
those do not work out especially well, or if the two of you do not seem to be compat-
ible, nothing is lost. You both go on your way without any bad feelings. A person
becomes a mentor when positive experiences accumulate, bringing satisfaction to
you both.

A number of benefits accrue for both you and your mentor. You gain a sense of
accomplishment by working with a mentor, and the mentor acquires fulfillment from
contributing to you and, by extension, to your profession. People who are senior in the
field have a responsibility to pass along what they have learned and to prepare those
who come after them. These are the satisfactions of a career done well.

The time will come, however, when you move away from your mentor. You take a
new job or your mentor does; your relationship changes as a result. You may then
become colleagues and friends, and you may acquire a new mentor in the new organi-
zation. Sometimes you will move ahead of the mentor, a situation that requires tact

Advancing Your Career 379

and commitment from both of you. Accomplished professionals know that they will
always owe a debt to their mentor, and they will continue to show their appreciation in
large and small ways.

Considering Your Next Position
The time to think about your next job is when you accept the first one. Begin to assess
how much you can learn in this job and think about your next step. Take every oppor-
tunity you can to learn.

One new grad had already determined that she wanted to teach nursing and knew that
she needed clinical experience before she went on to graduate school. She used each
clinical experience as a learning opportunity. She made notes on the patients she cared
for and looked up their conditions, treatments, and meds on her time off from work. In
less than a year, she had compiled a study guide of her own notes. She began graduate
school full-time and continued to work part-time, continuing to add notes throughout
her graduate school experience. By the time she graduated, she was an experienced
clinician, although the actual hours she spent in clinical work were fewer than most of
the other new nurse faculty.

Finding Your Next Position
When jobs are plentiful, you have many opportunities for finding the next job in your
career. This move must not be taken lightly, however, no matter how many jobs are
available. This is where self-assessment is essential. You want to be certain you are
ready to leave your current job, that you have learned and accomplished what you set
out to do, that you will not be leaving at a crucial time (e.g., an imminent Joint Com-
mission visit), and that you have selected the job that fits your needs now.

When you are ready, there are many ways to find potential positions. Career fairs,
online ads, nursing websites, and faculty from the school where you graduated are
additional ways to inquire about opportunities and to let others know you are inter-
ested in considering future options. (Also, see Online Resources at end of this chapter.)

Leaving Your Present Position
Just as there is a way to find a job, there is also a way to leave a job. First, check to see
how much notice your employer requires. Tell your supervisor as soon as you have
accepted the new position, and follow up with a formal letter of resignation. Add some
friendly comments, regardless of how you feel about the organization, your cowork-
ers, or the supervisor. Your goal is to leave on good terms.

Resist the urge to just walk out, regardless of the situation. The only reason for
doing this would be that you are in physical danger and the organization is not pro-
viding adequately for your safety. This is a rare, though not unknown, situation.

Always be polite in your interactions with your coworkers and your supervisor.
Resist, also, the urge to belittle the organization or the administration. Negative com-
ments about others reflect mostly on you. Of course, do not say anything that is untrue.
If the situation is difficult, the other employees know it as well. You do not need to say
anything at all, even if you are asked. You never know what the future will bring, and
ending relationships politely is best for your future.

380 Chapter 27

Adapting to Change
Change occurs every day in healthcare, and the pace of change seems to come faster
and faster. In order to pursue the career you want and to find satisfaction in that career,
you must be able to adjust and respond to change. The most important attribute you
can bring to this effort is to remain flexible.

Marika, experienced in psychiatric nursing and home care, entered a master’s program,
intending to work as a mental health clinical specialist for a home healthcare agency.
While she was in graduate school, she learned that the agency would no longer be
reimbursed by insurers for the services of a mental health specialist, and the position had
been eliminated.

Fortunately, Marika had a backup plan. She changed course, continued on in graduate
school, and obtained her doctorate. She became a nursing faculty member and now
researches mental health problems in patients with home care needs.

Other events can change your future. Your spouse is offered a job in another part
of the country. You find you are going to become a parent. Your parents need more care
than you have been providing. When events intrude on your plan, you may need to
adjust your time schedule, taking graduate classes more slowly, for example.

Life is a work in progress. We never know what our future will bring. Allow for
unplanned events, such as illness, pregnancy, or the closing of your hospital. Plan for
contingencies, but keep your eye on your vision. Remain flexible. You might discover
that new opportunities await you, bringing a better future than one you had
imagined.

What You Know Now
• Envisioning your future is an important exercise

to guide your first steps after graduation.

• Your career consists of three phases: promise,
momentum, and harvest.

• Knowing your preferences (e.g., clinical area of
interest, values, lifestyle) can guide you in select-
ing your first position. Take time to create your
résumé, and before an interview learn about a
potential employer and prepare questions. Fol-
low up with thank-you notes. Accept a job offer
after careful negotiations. If you decline an offer,
always do so graciously and on good terms.

• Throughout your career, track your progress and
identify your learning needs.

• Find and use mentors, especially early in your
career.

• When the time is right to find a new job, explore
the many ways (e.g., job fairs, nursing websites,
faculty from your school) to find potential posi-
tions. Submit your resignation in compliance
with your employer’s requirements, and leave on
good terms.

• Flexibility is needed to adapt to change.

Note: This chapter was adapted from content in Sullivan, E. J. (2013). Becoming influential:
A guide for nurses (2nd ed.). Upper Saddle River, NJ: Pearson.

Advancing Your Career 381

Tools for Advancing Your Career
1. Select positions and professional activities that

further your short- and long-term goals.
2. Keep a log of your activities and accomplish-

ments.
3. Keep abreast of the healthcare and policy envi-

ronment, noting possibilities for your future.

4. Evaluate educational opportunities for their
appropriateness for your learning needs and
career advancement.

5. Identify and cultivate mentor relationships.
6. Evaluate your progress periodically and update

with new information or interests.

Questions to Challenge You
1. Answer the questions posed in this chapter about

how you envision your future. Is the study or
work you are currently doing helping you prog-
ress toward that future? If not, what do you need
to do to help yourself?

2. Role play with a colleague the interview in Box 27-2
then reverse roles. How is the experience different if
you are the interviewer versus the candidate being
interviewed?

3. Create or review your résumé. Is it up to date? If
not, add all the missing information. Take a few
moments to ponder your accomplishments.

4. Begin an activity log. Periodically review your
accomplishments.

5. Do you have a mentor? Evaluate that relation-
ship. What more might you want from your inter-
actions with your mentor? How might that occur?

6. What educational needs do you have? Investigate
potential opportunities to acquire the necessary
education or certification.

7. Have you ever had your professional plans fail?
What, if anything, would you do differently in
the future?

Online Resources
American Nurses Association: http://nursingworld.

org/MainMenuCategories/Career-Center
Nurse.com: http://www.nurse.com/jobs

Sigma Theta Tau International: http://jobs.
nursingsociety.org/home/index

References
Institute of Medicine. (2010). The future of nursing:

Leading change, advancing health. Retrieved March 4,
2016, from http://campaignforaction.org/
directory-of-resources/iom-report

Pagana, K. (2012). Ten tips for handling job
interviews by phone. American Nurse
Today, 7(1). Retrieved March 4, 2016, from
http://www.americannursetoday.com/
ten-tips-for-handling-job-interviews-by-phone

Shirey, M. R. (2009). Building an extraordinary career
in nursing: Promise, momentum, and harvest. The
Journal of Continuing Education, 40(9), 394–400.

Sullivan, E. J. (2013). Becoming influential: A guide for
nurses (2nd ed.). Upper Saddle River, NJ: Pearson.

Watts, M. D. (2010). Certification and clinical ladder
as the impetus for professional development.
Critical Care Nursing Quarterly, 33(1), 52–59.

http://nursingworld.org/MainMenuCategories/Career-Center

http://www.nurse.com/jobs

http://jobs.nursingsociety.org/home/index

http://campaignforaction.org/directory-of-resources/iom-report

http://www.americannursetoday.com/ten-tips-for-handling-job-interviews-by-phone

http://jobs.nursingsociety.org/home/index

http://nursingworld.org/MainMenuCategories/Career-Center

http://campaignforaction.org/directory-of-resources/iom-report

382 Chapter 28

Learning Outcomes

After completing this chapter, you will be able to:

1. Examine various ways to think about the future.

2. Evaluate predictions about society’s future.

3. Assess changes affecting the future in healthcare.

4. Critique opportunities for nurses in the future.

Key Terms
plausible future

possible future

preferable future

probable future

wildcards

Introduction
The future is always uncertain, which leads many to believe they cannot do anything
about it. The future, however, is shaped by human decisions and actions, including
our own, made daily. Both individually and collectively, we are affecting the future by
what we do today or what we fail to do.

Ways to Consider the Future
Possible Future

Plausible Future

Probable Future

Preferable Future

Societal Predictions About
the Future

The Future of Healthcare
Technological Innovations

Healthcare Legislation

Demands of Consumerism

The Future of Nursing
Institute of Medicine Recommendations

New Careers in Nursing Project

382

Chapter 28

Imagining the Future

Imagining the Future 383

Ways to Consider the Future
In the past, it was common to believe that the future would be a continuation of the
past. That was not true then, and it is not true today. Rapid changes in healthcare, sci-
ence, technology, and the populace are just a few of the revolutionary circumstances
that are altering the future.

Different ways to think about the future include a possible future, a plausible
future, a probable future, and a preferable future (Bezold, Hancock, & Sullivan, 1999).

Possible Future
The possible future includes anything that could happen, no matter how unlikely. Science
fiction, in its use of the possible future, includes implausible occurrences. The possible
future also includes wildcards, which are unforeseen events that have far-reaching effects.
The World Trade Center attack on 9/11 is an example. Because they are unpredictable,
wildcards are not useful to predict the future.

Plausible Future
The plausible future is narrower in scope and considers events that could happen. The
Institute for Alternative Futures uses a plausible future orientation that considers values
and beliefs to create the futures they prefer (Institute for Alternative Futures, 2016).

Probable Future
The probable future considers the future as an extension of the present. To understand
how unlikely a probable future is, consider how healthcare professionals were paid
only a decade ago: Hospitals and physicians were compensated for the amount of care
they gave—period. If the patient improved, all the better. If not, healthcare providers
were still paid.

Preferable Future
The preferable future, on the other hand, is what we want to have happen in the
future. To create a preferable future, organizations, or individuals, must create a vision
of that future then design strategies to actualize that vision.

Societal Predictions About the Future
Healthcare, including nursing, is embedded in the greater society, so it behooves us to
consider what societal changes may affect nursing. Here is an abbreviated list of pos-
sibilities:

• Science will continue to explore both the minute world within and the expanded
universe with untold possibilities emerging.

• Medical science will perfect targeted and individualized diagnostic tools and spe-
cific treatments to improve healthcare.

• Knowledge will continue to explode as heretofore marginalized peoples gain
access to needed information in such areas as, for example, education, healthcare,
agriculture, and manufacturing.

384 Chapter 28

• Technology will evolve more and more rapidly as innovations are put into practice.

• Mobile devices in the hands of disadvantaged people in developing countries will
provide access to information that in the past was unavailable to them.

• Industries will continue to become computerized, resulting in joblessness or
underemployment for workers without the education, ability, or interest in tech-
nology.

• Education will target specific industries’ emerging needs for employees.

• Education will become more specialized to meet individual interests.

• Online access to education will continue to proliferate, offering information to
diverse populations.

• Learning from such mediums as YouTube videos and TED talks will expand,
enabling anyone with a smartphone to access the expertise of a wide variety of
authorities.

• Structured employment will decrease while fluidity of work will increase with
more and more workers creating their own jobs with one company or several.

• Self-employment and startups will continue to grow.

• Disenfranchised populations are likely to continue their attacks on successful,
Western countries.

• The need for surveillance to target potential threats will persist, and individual
liberties may diminish as a result.

• Entertainment options will expand with print, online, streaming, and audio com-
peting with traditional mediums.

• Entertainment modalities will directly target individuals’ interests (e. g., playlists).

• Competition for scarce resources may force more cooperation, although it may do
the reverse with the powerful dominating access.

• The rights of individuals versus the good of the public will continue to challenge
policies locally, nationally, and worldwide.

None of these predictions may come true, or all of them may. What is known is
that rapid change is occurring today and into the future. The individuals and organi-
zations that prosper in the future will be those who take advantage of the opportuni-
ties in these changes to create their preferred future.

The Future of Healthcare
Rapid changes today can predict possible opportunities in the future. However, allow-
ing today’s trends to morph into the future without finding possibilities in them pre-
vents us from taking advantage of these trends. Only a lack of imagination precludes
us from considering and creating a preferable future in healthcare.

Technological Innovations
It seems as if technology is developing faster than it can be conceived. Mobile devices,
virtual reality, and cloud computing are just three of the technologies changing now
and expected to continue to change into the future. Healthcare technologies are pro-
gressing just as rapidly.

Imagining the Future 385

CommuniCations Only a few years ago, envisioning a mobile device that car-
ried the contents of an entire computer inside was unthinkable. Today it is com-
monplace. In healthcare, patients can access their own records, see the results of
their examinations, read about their treatments, and delve into the purpose and
side effects of their medications through a portal into their health record. As a
result, patients are able to become partners with their healthcare providers in plan-
ning and implementing their care. In addition, electronic communication speeds
answers to patients’ questions, schedules tests, and returns lab results, among other
uses. In addition, cloud computing shifts data from devices to services and enables
real-time data to be shared among healthcare providers as well as with patients
(Sensmeier, 2013).

Examination and monitoring Bedside x-ray and scanning devices are com-
monplace. Distance exams, too, can be conducted via Skype, and mobile devices can
monitor changes in a patient’s condition from afar. Paperless prescriptions sent elec-
tronically to the pharmacy prevent costly mistakes (Woodard, 2009).

automatEd tEChnology Automated technology makes medication adminis-
tration safer and more convenient. Barcode scanning sends a medication order to the
pharmacy. After the medication is verified, it is entered into the patient’s record. Then
bedside barcodes verify patient identification to match patient to medication and at
the same time the codes enter the medication delivery into the patient’s record. Invis-
ible to the nursing staff but equally important is an inventory management system that
replenishes medications automatically as they are removed.

Healthcare Legislation
Healthcare legislation known as the Affordable Care Act (ACA) was enacted in 2010 and
mandated that individuals acquire insurance coverage or face penalties; it also changed
how care is reimbursed. As a result, healthcare organizations are paid for the value of their
care, rather than the amount of care. Patient satisfaction is assessed after discharge, and
Medicare reimbursement is based on the results (Dempsey, Reilly, & Buhlman, 2014).
However, the ACA may be repealed and what plan will replace it is unknown at this time.

Patient satisfaction efforts have spawned efforts for improvement. One such
endeavor is to improve relationships between patients and nurses (Prescott, 2015). By
introducing themselves by name and role when they first meet a patient, nurses
encourage a positive connection between them. Wearing a visible “RN” nametag rein-
forces their importance to the patient’s well-being.

Demands of Consumerism
Consumerism has grown simultaneously as products and services have become easily
accessible and personalized. Amazon’s algorithms allow the company to target individ-
ual consumers and to suggest additional items of interest based on their searches and
purchases. Reviews of local or national products and services enable consumers to
choose from an array of possibilities and then to make informed decisions before buying.

Savvy, educated consumers expect their healthcare to be as easily accessed as other
products and services, especially their individual needs (Squires, 2012). Younger con-
sumers, in particular, want to access information and interact with healthcare provid-
ers via their mobile devices (Morrison, 2015). Healthcare clinics are located in retail
stores (e. g., Target, Walmart, CVS, Walgreens) to meet urgent care needs and consumers’

386 Chapter 28

desire for quick, available service. Even the growth of the right-to-die movement is
consumer driven (Childress, 2012).

What this means for those who work in healthcare is that we must continue to
keep the patient (our customer) at the forefront of our considerations. What does the
patient need at this moment? A medication? Information? Suggestions for discharge?
Reassurance? Furthermore, we must make certain to follow up. Such a system is satis-
fying for patients and rewarding for nurses. In addition, healthcare organizations ben-
efit economically.

The Future of Nursing
The nursing profession is perfectly poised to take advantage of opportunities to create
its preferred future. Nurses are the frontline of contact and care of patients. It is the
actions of nurses, more than any other healthcare providers, that affect patients’ satis-
faction with their care, which, in turn, affects healthcare organizations’ reimburse-
ment. Nothing could be more valuable to the healthcare organization.

Determined to improve nursing, and thus healthcare, the Robert Wood Johnson
Foundation funded two projects: the Institute of Medicine (2011a) study to examine
the nursing profession and make recommendations for its future, and a collaborative
effort with the American Association of Colleges of Nursing to increase diversity in
nursing’s ranks (Krol, in press).

Institute of Medicine Recommendations
The Institute of Medicine (IOM) report entitled The Future of Nursing, released in 2011,
recommended major changes in nursing education and practice that would transform
healthcare (Hassmiller & Reinhard, 2015). Included in the IOM recommendations
were demands for nurses to expand their education and to be full partners in the
healthcare delivery system. Nurses must help shape and lead healthcare change,
according to the report. (See Table 28-1 for IOM’s recommendations.)

New Careers in Nursing Project
In response to nursing shortages and a nursing population lacking in diversity, the
Robert Wood Johnson Foundation funded the New Careers in Nursing program (Krol,
in press). It was designed to support individuals with degrees in other fields to enter
accelerated baccalaureate or master’s programs in nursing. In that way, numbers of
new nurses could be educated in a relatively short time. Underrepresented groups and
those from disadvantaged backgrounds were targeted for recruitment.

The program offered scholarships for entering students and numerous resources
for schools involved. These resources include the following:

• Leadership Development Toolkit

• Pre-Entry Immersion Program Toolkit

• Mentoring Toolkit

• Recruitment Toolkit

• Doctoral Advancement in Nursing Toolkit

• New Careers in Nursing Scholar Alumni Toolkit (Krol, in press)

Imagining the Future 387

Table 28-1 Institute of Medicine’s Recommendations for Nursing

Recommendations Explanations

1. Remove scope-of-practice barriers. 1. Advanced practice RNs should be able to practice to the full extent of their
education and training.

2. Expand opportunities for nurses to lead and diffuse
collaborative improvement efforts.

2. Private and public funders, healthcare organizations, nursing education
programs, and nursing associations should expand opportunities for nurses to
lead and manage collaborative efforts with physicians and other members of the
healthcare team to conduct research and to redesign and improve practice
environments and health systems. These entities should also provide
opportunities for nurses to diffuse successful practices.

3. Implement nurse residency programs. 3. State boards of nursing, accrediting bodies, the federal government, and
healthcare organizations should take action to support nurses’ completion of a
transition-to-practice program (nurse residency) after they have completed a
prelicensure or advanced practice degree program or when they are transitioning
into new clinical practice areas.

4. Increase the proportion of nurses with a baccalaureate
to 80% by 2020.

4. Academic nurse leaders across all schools of nursing should work together to
increase the proportion of nurses with a baccalaureate from 50% to 80% by
2020. These leaders should partner with education accrediting bodies, private
and public funders, and employers to ensure funding, monitor progress, and
increase the diversity of students to create a workforce prepared to meet the
demands of diverse populations across the lifespan.

5. Double the number of nurses with a doctorate by 2020. 5. Schools of nursing, with support from private and public funders, academic
administrators and university trustees, and accrediting bodies, should double the
number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty
and researchers, with attention to increasing diversity.

6. Ensure nurses engage in lifelong learning. 6. Accrediting bodies, schools of nursing, healthcare organizations, and continuing
competency educators from multiple health professions should collaborate to
ensure that nurses and nursing students and faculty continue their education and
engage in lifelong learning to gain the competencies needed to provide care for
diverse populations across the lifespan.

7. Prepare and enable nurses to lead change to advance
health.

7. Nurses, nursing education programs, and nursing associations should prepare
the nursing workforce to assume leadership positions across all levels, while
public, private, and governmental healthcare decision makers should ensure that
leadership positions are available to and filled by nurses.

8. Build an infrastructure for the collection and analysis of
interprofessional healthcare workforce data.

8. The National Health Care Workforce Commission, with oversight from the
Government Accountability Office and the Health Resources and Services
Administration, should lead a collaborative effort to improve research and the
collection and analysis of data on healthcare workforce requirements. The
Workforce Commission and the Health Resources and Services Administration
should collaborate with state licensing boards, state nursing workforce centers,
and the Department of Labor in this effort to ensure that the data are timely and
publicly accessible.

Source: Institute of Medicine. (2011b). The future of nursing: Campaign for action. Retrieved April 1, 2016 from http://campaignforaction.org/directory-of-resources/iom-report.
Used with permission.

As of June 2015, 130 schools in 41 states and the District of Columbia had par-
ticipated in the program, and more than 3,500 students had earned baccalaureate or
master’s degrees (Krol, in press). Participating institutions reported that their orga-
nizations had become more diverse and inclusive as a result of the program (Krol).

For the nursing profession to create its preferred future, individual nurses, nurs-
ing education, practice settings, and nursing science must contribute their expertise.
Individual nurses must have educational opportunities to advance and be willing to
take advantage of them. Furthermore, they must be able to practice at the highest level
of their education. The practice setting must use nurses’ expertise and make them full
partners with other healthcare professionals to shape the healthcare system of the
future. In order to meet the healthcare needs of an increasingly diverse population,

http://campaignforaction.org/directory-of-resources/iom-report

388 Chapter 28

nursing education must continue to attract disadvantaged populations and men to the
profession. Nursing science must continue to delve into ways that nursing care
improves health and expands wellness. Nursing has the potential to enhance the
health of the nation in ways only imagined today.

Leading at the Bedside: Imagining the Future
This chapter, more than any others, is for you. You are the
future of nursing. What you do today has the potential to
improve nursing care to patients, to enhance your practice,
and to enrich the profession. Conversely, if you assume
what has happened in the past will continue into the

future—or if you ignore opportunities to change yourself,
your practice, and your profession—you are unlikely to
improve nursing care or its environment.

Which nurse do you want to be?

What You Know Now
• The future is unknown, but a preferred future can

be created with vision and strategies.

• Science, knowledge, technology, education, employ-
ment, and entertainment are just a few of the areas
that will experience considerable change in the
future.

• Technology, healthcare legislation, and consumers’
demands will continue to evolve and impact
healthcare in multiple ways.

• Nursing’s future will involve demands for higher
levels of education, advances in nurses’ practice
opportunities, nurses’ increased participation in
workforce planning and creating healthcare’s
future, and more diversity in nursing’s ranks.

• Nurses have exceptional opportunities to take
advantage of changes in today’s healthcare envi-
ronment.

Questions to Challenge You
1. If you could design a brand-new healthcare sys-

tem, what would it look like?
2. Can you add any societal predictions to the list in

this chapter?
3. What other changes are occurring in healthcare

that are not included in this chapter?

4. Have you seen any of the Institute of Medicine’s
recommendations in your practice or educational
setting?

5. What specific changes could you imagine in your
area of practice? If they occurred, would they
improve or diminish your patients’ care?

References
Bezold, C., Hancock, T., & Sullivan, E. J. (1999).

Examining nursing from a futures perspective. In
E. J. Sullivan (Ed.) Creating nursing’s future: Issues,
opportunities, and challenges. St. Louis, MO: Mosby.

Childress, S. (ed.). (2012). The suicide plan: The
evolution of America’s right-to-die movement. PBS:
Frontline. Retrieved March 29, 2016, from http://
www.pbs.org/wgbh/frontline/film/suicide-plan

http://www.pbs.org/wgbh/frontline/film/suicide-plan

http://www.pbs.org/wgbh/frontline/film/suicide-plan

Imagining the Future 389

Dempsey, C., Reilly, B., & Buhlman, N. (2014).
Improving the patient experience. Journal of
Nursing Administration, 44(3), 142–151.

Hassmiller, S. B., & Reinhard, S. C. (2015). A bold
new vision for America’s healthcare system.
American Journal of Nursing, 115(2), 49–55.

Institute for Alternative Futures. (2016). About us.
Retrieved March 28, 2016, from www.
altfutures.org

Institute of Medicine. (2011a). The future of nursing:
Leading change, advancing health: Campaign for
action. Retrieved April 1, 2016, from http://
campaignforaction.org/directory-of-resources/
iom-report

Institute of Medicine. (2011b). The future of nursing:
Campaign for action – overview. Retrieved April 1,
2016, from http://campaignforaction.org/directory-
of-resources/iom-report. Used with permission.

Krol, D. M. (in press). The new career in nursing
program: A strong investment in the future of
nursing. Journal of Professional Nursing, 0(0), 1–3.

Morrison, I. (2015). The American healthcare
consumer. The Health Care Blog.
Retrieved March 29, 2016, from http://
thehealthcareblog.com/blog/2015/01/16/
the-american-healthcare-consumer

Prescott, C. (2015). Increasing staff pride and patient
connection. Journal of Nursing Administration,
45(11), 529–530.

Sensmeier, J. (2013). Technology’s future now.
Nursing Management, 44(12), 6.

Squires, S. (2012). Patient satisfaction: How to get it and
how to keep it. Nursing Management, 43(4), 26–32.

Woodard, C. (2009). Digital Rx: Obama pushing
for paperless prescriptions. Canadian Medical
Association Journal, 180(8), 806.

http://www.altfutures.org

http://www.altfutures.org

http://campaignforaction.org/directory-of-resources/iom-report

http://campaignforaction.org/directory-of-resources/iom-report

http://campaignforaction.org/directory-of-resources/iom-report

http://campaignforaction.org/directory-of-resources/iom-report

http://campaignforaction.org/directory-of-resources/iom-report

The American Healthcare Consumer

The American Healthcare Consumer

390

A
absence culture The informal norms within a work unit that

determine how employees of that unit view absenteeism.

absence frequency The total number of distinct absence peri-
ods, regardless of their duration.

accommodating An unassertive, cooperative tactic used in con-
flict management when individuals neglect their own concerns
in favor of others’ concerns.

accountability The act of accepting ownership for results or the
lack thereof.

accountable care organization (ACO) A group of healthcare
providers who provide care to a specified group of patients.

activity log An ongoing record of professional progress, includ-
ing educational programs, training, certifications, and
accomplishments.

adaptive decisions The type of decisions made when problems
and alternative solutions are somewhat unusual and only par-
tially understood.

additive task A task in which group performance depends on
the sum of individual performance.

adjourning The final stage of group development, when a
group dissolves after achieving its objectives.

administrative law Public law made by administrative agen-
cies that are granted authority to enact rules and regulations to
carry out specific intentions of a statute.

advance directive A document that allows a competent patient
to make choices prior to the need for medical treatment.

Affordable Care Act (ACA) Legislation implemented in 2010
that radically changed how healthcare is delivered and com-
pensated in the United States.

Age Discrimination Act A law prohibiting discrimination
against applicants and employees over the age of 40.

all-hazards approach Determining and acting upon a commu-
nity’s vulnerability to specific threats for emergency prepared-
ness planning.

allocation A decision that society makes regarding how many
of its resources will be devoted to a particular effort; also called
macroallocation.

Americans with Disabilities Act A law prohibiting discrimina-
tion against qualified individuals who have physical or mental
impairments that substantially limit one or more of the major
life activities.

artificial intelligence Computer technology that can diagnose
problems and make limited decisions.

assignment Allocating tasks appropriate to the individual’s job
description.

attendance barriers The events that affect an employee’s ability
to attend (e.g., illness, family responsibilities).

authority The right to act or empower.

autonomy The right of individuals to take action for
themselves.

avoiding A conflict management technique in which the par-
ticipants deny that conflict exists.

B
behavior-oriented performance evaluation A system for

appraising employee performance based on organizational val-
ues, position descriptions, cluster behaviors, specific examples,
and developmental goals.

behavioral interviewing Interview questions that use the can-
didate’s past performance and behaviors to predict behavior on
the job.

benchmarking A method of comparing performance using
identified quality indicators across institutions or disciplines.

beneficence The duty to help others by doing what is best for
them.

benefit time Paid time, such as vacation, holidays, and sick
days, for which there is no work output.

block staffing Scheduling a set staff mix for every shift so that
adequate staff are available at all times.

bona fide occupational qualification (BFOQ) A characteristic
that excludes certain groups from consideration for
employment.

brainstorming A decision-making method in which group
members meet and generate diverse ideas about the nature of,
cause of, definition of, or solution to a problem.

budget A quantitative statement, usually in monetary terms, of
the expectations of a defined area of an organization over a
specified period of time in order to manage its financial
performance.

budgeting The process of planning and controlling future
operations by comparing actual results with planned
expectations.

bullying Aggressive behavior as mild as innocuously irritating
or as extreme as dangerously violent.

bureaucracy A term proposed by Max Weber to define the
ideal, intentionally rational, most efficient form of organization.

burnout The perception that an individual has used up all
available energy to perform the job and feels that he or she
does not have enough energy to complete the task.

business necessity Discrimination or exclusion that is allowed
if it is necessary to ensure the safety of workers or customers.

C
capital budget A component of the budget plan that includes

equipment and renovations needed by an organization in order
to meet long-term goals.

Glossary

Glossary 391

capitation A fixed monthly fee for providing services to
enrollees.

Centers for Medicare & Medicaid Services (CMS) The U.S.
agency that oversees government payments for healthcare.

certification Formal recognition that the nurse has acquired
specialized knowledge, skills, and experience that meet identi-
fied standards.

chain of command The hierarchy of authority and
responsibility within an organization.

change agent One who works to bring about change.

change The process of making something different from what
it was.

channels of communication Pathways for exchanging infor-
mation that employ synchronous or asynchronous methods.

charge nurse An expanded staff nurse role with increased
responsibility and the function of liaison to the nurse
manager.

clinical nurse leader (CNL) A lateral integrator of care respon-
sible for a specified group of patients within a microsystem of
the healthcare setting.

closed shop A business in which union membership (often of a
specific union and no other) is a precondition to employment.

coaching The day-to-day process of helping employees
improve their performance.

coercive power Power based on penalties that a manager
might impose if the individual or group does not comply with
authority.

cohesiveness The degree to which the members are attracted to
the group and wish to retain membership in it.

collaboration All parties working together to solve a problem.

collective bargaining Collective action taken by workers to
secure better wages or working conditions.

committees Groups that deal with specific issues involving
several service areas.

common law Type of law derived from earlier decisions made
by courts; also referred to as legal precedent.

communication A complex, ongoing, dynamic process in
which the participants simultaneously create shared meaning
in an interaction.

compassion fatigue Secondary traumatic stress experienced by
caregivers.

competing An all-out effort to win, regardless of the cost.

compromise A conflict management technique in which the
rewards are divided between both parties.

confidentiality The right to privacy of records and information.

conflict The consequence of real or perceived differences in
mutually exclusive goals, values, ideas, attitudes, beliefs, feel-
ings, or actions.

confrontation The most effective means of resolving conflict, in
which the conflict is brought out in the open and attempts are
made to resolve it through knowledge and reason.

conjunctive task A task in which the group succeeds only if all
members succeed.

connection power Power based on an individual’s formal and
informal links to influential or prestigious persons inside and
outside an organization.

consensus A conflict strategy in which a solution that meets
everyone’s needs is agreed upon.

content theories Motivational theories that emphasize individ-
ual needs or the rewards that may satisfy those needs.

continuous quality improvement (CQI) The process used to
improve quality and performance.

controlling The process of comparing actual results with pro-
jected results.

corporate liability An organization’s responsibility for its own
wrongful conduct.

cost center The smallest area of activity within an organization
for which costs are accumulated.

creativity The ability to develop and implement new and better
solutions.

critical pathways Tools or guidelines that direct care by identi-
fying expected outcomes.

critical thinking A process of examining underlying assump-
tions, interpreting and evaluating arguments, imagining and
exploring alternatives, and developing reflective criticism for
the purpose of reaching a reasoned, justifiable conclusion.

D
decision making A process whereby appropriate alternatives

are weighed and one is ultimately selected.

delegation The process by which responsibility and authority
are transferred to another individual.

demand management A system that uses best-practices proto-
cols to predict the demand for nursing expertise several days in
advance.

descriptive rationality model A decision-making process that
emphasizes the limitations of the rationality of the decision
maker and the situation.

developmental plan A staff member’s goals for the coming
year against which performance will be judged.

diagonal communication Communication involving individu-
als at different hierarchical levels.

direct costs Expenses that directly affect patient care.

directing The process of getting the work within an organiza-
tion done.

disjunctive task A task in which the group succeeds if one
member succeeds.

distributive justice The concept of giving a person that which
he or she deserves regardless of race, gender, religion, or socio-
economic status so no one bears a disproportionate share of
benefits or burdens.

diversification The expansion of an organization into new are-
nas of service.

divisible task Tasks that can be divided into subtasks with
division of labor.

DMAIC A Six Sigma process improvement method.

392 Glossary

downward communication Communication, generally direc-
tive, given from an authority figure or manager to staff.

driving forces Behaviors that facilitate change by pushing par-
ticipants in the desired direction.

durable power of attorney A legal document made by a
competent adult that appoints a surrogate or proxy to make
decisions in the event that the individual becomes unable to
do so.

E
efficiency variance The difference between budgeted and

actual nursing care hours provided.

electronic health records (EHRs) Integrated records that
include information from all medical sources and can be
accessed from multiple locations by sanctioned providers.

emergency operations plan (EOP) The EOP includes prepara-
tion, education and training, and implementation of the hospi-
tal’s response to emergency situations.

emotional intelligence Personal competence (self-awareness
and self-management) and social competence (social aware-
ness and relationship management) that begin with
authenticity.

empirical-rational model A change agent strategy based on the
assumption that people are rational and follow self-interest if
that self-interest is made clear.

engagement When an employee is inspired by an organization,
willing to invest effort, likely to recommend the organization,
and planning to remain in the organization.

equity theory The motivational theory that suggests effort and
job satisfaction depend on the degree of equity or perceived
fairness in the work situation.

ethics A science that deals with principles of right and wrong,
good and bad; it governs our relationship with others.

evidence-based practice (EBP) Applying the best scientific evi-
dence to a patient’s unique diagnosis, condition, and situation
to make clinical decisions.

expectancy theory The motivational theory that emphasizes
the role of rewards and their relationship to the performance of
desired behaviors.

expense budget A comprehensive budget that lists salary and
nonsalary items that reflect patient care objectives and activity
parameters for the nursing unit.

experimentation A type of problem solving in which a theory
is tested to enhance knowledge, understanding, or prediction.

expert power Power based on the manager’s possession of
unique skills, knowledge, and competence.

expert systems Computer programs that provide complex data
processing, reasoning, and decision making.

extinction The technique used to eliminate negative behavior,
in which a positive reinforcer is removed and the undesired
behavior is extinguished.

F
feedback The day-to-day process of helping employees evalu-

ate and improve their performance.

felt conflict The negative feelings between two or more parties.

first-level manager The manager responsible for supervising
nonmanagerial personnel and day-to-day activities of specific
work units.

fiscal year A specified 12-month period during which opera-
tional performance and financial performance are measured.

fixed budget A budget in which amounts are set regardless of
changes that occur during the year.

fixed costs Expenses that remain the same for the budget
period regardless of the activity level of the organization.

followership An interactive and complementary relationship
to leadership.

forcing A conflict management technique that forces an imme-
diate end to conflict but leaves the cause unresolved.

formal committees Committees in an organization with
authority and a specific role.

formal groups Clusters of individuals designated by an organi-
zation to perform specified organizational tasks.

formal leadership Leadership that is exercised by an individ-
ual with legitimate authority conferred by position within an
organization.

forming The initial stage of group development, in which indi-
viduals assemble into a well-defined cluster.

four Ps of marketing Four strategies included in marketing
plans: product, place, price, and promotion.

full-time equivalent (FTE) The percentage of time an
employee works that is based on a 40-hour workweek.

G
goal setting The relating of current behavior, activities, or oper-

ations to an organization’s or individual’s long-range goals.

goal-setting theory The motivational theory that suggests that
the goal itself is the motivating force.

grievances Formal expressions of complaints, generally classi-
fied as misunderstandings, contract violations, or an inade-
quate labor agreement.

group An aggregate of individuals who interact and mutually
influence each other.

groupthink A negative phenomenon occurring in highly cohe-
sive, isolated groups in which group members come to think
alike, which interferes with critical thinking.

H
Hawthorne effect The tendency for people to perform as

expected because of special attention.

health home With this arrangement, primary care providers
facilitate access to specialty care when needed and monitor that
care using electronic health records; also called medical home.

hidden agendas A group member’s individual, unspoken
objectives that interfere with commitment or enthusiasm.

horizontal integration Arrangements between or among
organizations that provide the same or similar services.

horizontal promotion A program to reward a high-performing
employee without promoting the employee to a management
position.

horizontal violence Harassment between or among employees
of equal rank.

Glossary 393

Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) A 32-item instrument to measure patient
satisfaction across institutions after discharge.

I
incident reports Accurate and comprehensive reports on

unplanned or unexpected occurrences that could potentially
affect a patient, family member, or staff.

incivility Aggressive behavior; also called bullying.

incremental (line-by-line) budget A budget worksheet listing
expense items on separate lines that is usually divided into sal-
ary and nonsalary expenses.

indicator A tool used to measure the performance of structure,
process, and outcome standards.

indirect costs Necessary expenditures that do not affect patient
care directly.

informal committees Committees with no delegated authority
that are organized for discussion.

informal groups Groups that evolve from social interactions
that are not defined by an organizational structure.

informal leadership Leadership that is exercised by an individ-
ual who does not have a specified management role.

information power Power based on an individual’s access to
valued data.

informed consent A statutory law that provides for patients to
agree to treatment only when certain conditions are met.

innovation A strategy to bridge the gap between an existing
state and a desired state.

innovative decisions The type of decisions made when prob-
lems are unusual and unclear and creative solutions are
necessary.

integrated healthcare networks Organizational healthcare
structures that deliver a continuum of care, provide coverage
for a group of individuals, and accept fixed payments for that
group.

intentional torts The type of tort law that applies when the
intent to harm is present.

interrater reliability An agreement between two measures by
several interviewers.

interruption log A journal of specific information regarding
interruptions, analysis of which may help identify ways to
reduce interruptions.

interview guide A written document containing questions,
interviewer directions, and other pertinent information so the
same process is followed and the same basic information is
gathered from each applicant.

intrarater reliability An agreement between two measures by
the same interviewer.

invasion of privacy The violation of a person’s right to be left
alone without being subjected to unwarranted or uninvited
publicity and to make personal choices without interference.

involuntary absenteeism Absenteeism that is not under the
employee’s control.

involuntary turnover When an employee is terminated by his
or her employers.

J
job reassignment The process of pulling nurses from one area

of the hospital to another; also called floating.

just culture An environment for reporting of errors without
fear of undue retribution.

L
lateral communication Communication that occurs between or

among individuals at the same hierarchical level.

laws Rules of conduct, established and enforced by authority,
that prohibit extremes in behavior so that one can live without
fear for oneself or one’s property.

leader Someone who uses interpersonal skills to influence oth-
ers to accomplish specific goals.

Lean Six Sigma A quality program that focuses on improving
process flow and eliminating waste.

Leapfrog Group A coalition of public and private employers
organized to bring attention to consumers about quality indica-
tors in healthcare and mobilize employers to reward healthcare
organizations that demonstrate quality outcome measures.

legitimate power A manager’s right to make requests because
of authority within an organizational hierarchy.

licensure A credential provided for by state statutes that author-
izes qualified individuals to perform designated skills and services.

line authority The linear hierarchy of supervisory responsibil-
ity and authority.

living will A form signed by a competent adult indicating
what healthcare the person does and does not want in the
event of terminal illness.

M
Magnet Recognition Program Recognition by the American

Nurses Credentialing Center that an organization provides
quality nursing care.

malpractice Professional negligence; evolved from negligence
law; refers to any misconduct or lack of skill in carrying out
professional responsibilities.

manager An individual employed by an organization who is
responsible for efficiently accomplishing its goals.

marginal employees Employees who never reach the expected
level of competence.

mass casualty events (MCE) Natural or man-made disasters
that result in multiple injuries.

mediation Use of a third-party mediator to help settle disputes.

medical errors Preventable mistakes, including falls, wrong
site surgeries, avoidable infections, pressure ulcers, and
adverse drug events.

medical home A patient-centered model in which all services
are provided by a group of healthcare professionals; also called
health home.

mentor A more experienced person who guides, supports, and
nurtures a less experienced person.

mindfulness The ability to attend to whatever is happening in
the present moment and to accept the situation as it is without
judgment.

394 Glossary

mission A general statement of the purpose of an organization.

motivation The factors that initiate and direct behavior.

N
negative inquiry A communication technique used to clarify

objections and feelings (e.g., I don’t understand. . . .).

negligence The failure of an individual not to perform an act
(omission) or to perform an act (commission) that a reasonable,
prudent person would or would not perform in a similar set of
circumstances.

negligent hiring Failure of an organization, responsible for the
character and actions of all employees, to ascertain the back-
ground of an employee.

negotiation A conflict management technique in which the
conflicting parties give and take on various issues.

nonmaleficence The principle of not to inflict harm or to risk
harm to others.

nonsalary expenditure variances Deviation from the budget as
a result of changes in patient volume, supply quantities, or
prices paid.

normative-reeducative strategy A change agent strategy based
on the assumption that people act in accordance with social
norms and values.

norming The third stage of group development, in which
group members define goals and rules of behavior.

norms Informal rules of behavior shared and enforced by
group members.

nurse practice act A state’s rules and regulations for the prac-
tice of nursing set into statutes and enforced by the state’s
board of nursing.

nursing care hours (NCHs) The number of hours of patient
care provided per unit of time.

O
objective probability The likelihood that an event will or will

not occur based on facts and reliable information.

on-the-job instruction An educational method using observa-
tion and practice by which employees learn new skills after
being employed.

open shop A business in which union membership is not a
component in hiring decisions and union members do not
receive any preference in hiring.

operating budget An organization’s statement of expected rev-
enues and expenses for the upcoming year.

ordinary interacting groups Common types of groups; gener-
ally have a formal leader and are run according to an informal
structure with the purpose of solving a problem or making a
decision.

organization A collection of people working together under a
defined structure to achieve predetermined outcomes.

organizational culture The basic assumptions and values held
by members of an organization.

organizational environment The system-wide conditions that
contribute to a positive or negative work setting.

organizing The process of coordinating the work to be done
within an organization.

orientation A process by which staff development personnel
and managers ease a new employee into an organization by
providing relevant information.

outcome standards Standards that reflect the desired result or
outcome of care.

overdelegation A common form of ineffective delegation that
occurs when the delegator loses control over a situation by giv-
ing too much authority or responsibility to the delegate.

P
patient-centered care A nursing care delivery system that is

unit based and consists of patient care coordinators, patient care
associates, unit support assistants, administrative support per-
sonnel, and a nurse manager.

patient-centered medical home (PCMH) A model for deliver-
ing primary care to ensure that adequate and appropriate care
is provided to a population of patients across all settings; also
called patient-centered medical home.

patient classification systems (PCSs) Systems developed to
objectively determine workload requirements and staffing
needs.

pay for performance (P4P) Medicare reimbursement linked to
hospitals’ scores on HCAHPS; also called value-based purchas-
ing (VBP).

peer review A process by which other employees assess and
judge the performance of professional peers against predeter-
mined standards.

perceived conflict One’s perception of another’s position in a
conflict.

performance evaluation The process of interaction, written
documentation, formal interview, and follow-up that occurs
between managers and their employees to give feedback, make
decisions, and cover fair employment practice law.

performance management Systems, policies, procedures, posi-
tion descriptions, and evaluation components essential to pro-
viding consistent, high-quality nursing practice.

performing The fourth stage of group development, in which
group members agree on basic purposes and activities and
carry out the work.

personal liability The responsibility and accountability nurses
have for their own actions or inactions.

personal power Power based on an individual’s credibility,
reputation, expertise, experience, control of resources or infor-
mation, and ability to build trust.

philosophy The mission, values, and vision of an organization.

planning A four-stage process to establish goals, evaluate the
present situation and predict future trends and events, formu-
late a planning statement, and convert the plan into an action
statement.

plausible future An orientation for envisioning the future that
takes into account values and beliefs.

policy Decisions that govern action and determine an organiza-
tion’s relationships, activities, and goals.

political decision-making model A decision-making process in
which the particular interests and objectives of powerful stake-
holders influence how problems and objectives are defined.

Glossary 395

politics A means of influencing the allocation of scarce
resources, events, and the decisions of others.

pooled interdependence A type of interdependence in which
each individual contributes to the group but no one contribu-
tion is dependent on any other.

pools Internal or external groups of workers that are used as
supplemental staff by an organization.

position control A monitoring tool used to compare actual
numbers of employees to the number of budgeted FTEs for the
nursing unit.

position description Describes the skills, abilities, and knowl-
edge required to perform the job.

position power Power of an individual that is determined by
the job description, assigned responsibilities, recognition,
advancement, authority, the ability to withhold money, and
decision making.

possible future A vision of the future that includes anything
that could possible happen, no matter how unlikely.

posttraumatic stress disorders (PTSD) Disorders resulting
from being present at a scary, shocking, or dangerous event.

power plays Attempts by others to diminish or demolish their
opponents.

power The potential ability to influence in order to achieve goals.

power-coercive strategies Change-agent strategies based on
the application of power by legitimate authority, economic
sanctions, or political clout.

practice partnership A nursing care delivery system in which
senior and junior staff members share patient care
responsibilities.

preceptors An experienced individual who assists new
employees in acquiring the necessary knowledge and skills to
function effectively in a new environment.

preferable future A vision of the future built on what one
desires to occur.

private law Civil law; further classified into tort law, contract
law, and protecting and reporting law.

probability The likelihood that an event will or will not occur.

probability analysis A calculation of the expected risk made to
accurately determine the probabilities of each alternative.

probable future A vision of the future built solely on what has
occurred in the past or is occurring in the present.

problem solving A process whereby a dilemma is identified
and corrected.

process standards Standards connected with the actual deliv-
ery of care.

process theories Motivational theories that emphasize how the
motivation process works to direct an individual’s effort into
performance.

productivity A measure of how well the work group or team
uses the resources available to achieve its goals and produce its
services.

profit The difference between revenues and expenses.

progressive discipline The process of increasingly severe
warnings for repeated violations that can result in termination.

public law Constitutional law, administrative law, and criminal
law.

punishment A process used to inhibit an undesired behavior
by applying a negative reinforcer.

Q
Quality and Safety Education for Nurses (QSEN) Quality and

safety competencies, based on the recommendation of the Insti-
tute of Medicine and developed by a national advisory board
of experts, designating targets of knowledge, skills, and atti-
tudes (KSAs) for nursing education.

quality management A preventive approach designed to
address problems efficiently and quickly.

quantum leadership A leadership style based on the concepts
of chaos theory.

R
rate variances The difference between budgeted and actual

hourly rates paid.

rational decision-making model A decision-making process
based on logical, well-grounded, rational choices that maxi-
mize the achievement of objectives.

rationing A decision society makes regarding who gets a ser-
vice or supply and who does not; also called microallocation.

real (command) groups Groups that accomplish tasks in an
organization and are recognized as legitimate organizational
entities.

reality shock The stress, surprise, and disequilibrium experi-
enced when shifting from a familiar culture into one whose val-
ues, rewards, and sanctions are different (e.g., from a school
culture to a work culture).

reciprocal interdependence A type of interdependence in
which members must coordinate their activities with every
other individual in the group.

redesign A technique that examines the tasks within each job
with the goal of combining appropriate tasks to improve
efficiency.

referent power Power based on admiration and respect for an
individual.

re-forming A stage of group development in which the group
reassembles after a major change in the environment or in
which the goals of the group require the group to refocus its
activities.

reinforcement theory (behavior modification) The motiva-
tional theory that views motivation as learning and proposes
that behavior is learned through a process called operant
conditioning.

reportable incident Any unexpected or unplanned occurrence
that affects or could potentially affect a patient, family member,
or staff.

resistance A behavior that can be positive or negative and may
mean opposition to change or disobedience; at times, an effec-
tive approach to handling power differences.

resolution The stage of conflict that occurs when a mutually
agreed-upon solution is arrived at and both parties commit
themselves to carrying out the agreement.

396 Glossary

respondeat superior A legal principle that allows the courts to
hold the employer responsible for the actions of the employee
when the employee is performing services for the organization.
Literally means “let the master speak.”

responsibility An obligation to accomplish a task.

restraining forces Behaviors that impede change by
discouraging participants from making specified changes.

résumé A written record of an individual’s educational
achievements, employment, and accomplishments.

retail medicine Walk-in clinics that provide convenient
services for low-acuity illnesses without scheduled
appointments.

retention An organization’s ability to hold onto employees and
prevent them from leaving.

revenue budget A projection of expected income for a budget
period based on volume and mix of patients, rates, and
discounts.

reverse delegation A common form of ineffective delegation
that occurs when someone with a lower rank delegates to
someone with more authority.

reward power Power based on inducements offered by the
manager in exchange for contributions that advance the
manager’s objectives.

right-to-work state A state in which no person can be denied
the right to work because of membership or nonmembership in
a labor union.

risk management A program directed toward identifying, eval-
uating, and taking corrective action against potential risks that
could lead to injury.

robotics Using robots to deliver supplies and remote care.

role A set of expectations about behavior ascribed to a specific
position.

role ambiguity The frustrations that result from unclear expec-
tations for one’s performance.

role conflict The incompatibility between an individual’s per-
ception of the role and its actual requirements.

role redefinition The clarification of roles and an attempt to
integrate or tie together the various roles that individuals play.

root cause analysis A method to work backward through an
event to examine every action that led to the error or event that
occurred.

routine decisions The type of decisions made when problems
are relatively well-defined and common and when established
rules, policies, and procedures can be used to solve them.

S
salary (personnel) budget A budget that projects salary costs to

be paid and charged to the cost center during the budget
period.

salary compression The effect of a higher starting pay for new
nurses, or rewarding those with fewer years of experience with
higher increases, that results in the salaries of long-term
employees being at or below those of less-experienced nurses.

satisficing A decision-making strategy whereby the individual
chooses a less-than-ideal alternative that meets minimum
standards of acceptance.

self-evaluation A critical component of performance evalua-
tion that fosters reflection—the deliberate process of critically
thinking about one’s performance.

self-scheduling A staffing model in which managers and their
staff completely manage staffing and schedules.

sequential interdependence A type of interdependence in
which members must coordinate their activities with others in
some designated order.

servant leadership The premise that leadership originates from
a desire to serve; a leader emerges when others’ needs take pri-
ority over one’s own needs.

service-line structures Organizational structures in which clinical
services are organized around patients with specific conditions.

shaping The selective reinforcement of behaviors that are suc-
cessively closer approximations to the desired behavior.

shared governance An organizational paradigm based on the
values of interdependence and accountability that allows
nurses to make decisions in a decentralized environment.

shared leadership An organizational structure in which several
individuals share the responsibility for achieving an organiza-
tion’s goals.

shared visioning An interactive process in which both leaders
and followers commit to an organization’s goals.

Six Sigma A quality management program that uses measures,
goals, and management involvement to monitor performance
and ensure progress.

skill competency The ability to perform a skill knowledgeably
and safely.

smoothing Managing conflict by complimenting one’s oppo-
nent, downplaying differences, and focusing on minor areas of
agreement.

spaghetti diagram A drawing of the actual work flow in a
specified area at a point in time.

span of control The number of employees that can be effec-
tively supervised by a single manager.

staff authority The advisory relationship in which responsibil-
ity for actual work is assigned to others.

staff nurse A nurse who supervises LPNs, other professionals,
and assistive personnel and thus is also a manager who needs
management and leadership skills.

staffing mix The type of staff necessary to perform the work of
an organization.

staffing The process of balancing the quantity of staff available
with the quantity and mix of staff needed by an organization.

stakeholders People or groups with a direct interest in the
work of an organization.

status The social ranking of individuals relative to others in a
group based on the position they occupy.

status incongruence The disruptive impact that occurs when
factors associated with group status are not congruent.

statutory law Law enacted by the legislative branch of govern-
ment; designed to declare, command, or prohibit something.

storming The second stage of group development, in which
group members develop roles and relationships; competition
and conflict generally occur.

Glossary 397

stress The nonspecific reaction that people have to threatening
demands from the environment.

strike The organized stoppage of work by employees within
the union.

structure standards Standards that relate to the physical envi-
ronment, organization, and management of an organization.

subjective probability The likelihood that an event will or will
not occur based on a manager’s personal judgment and beliefs.

suppression The stage of conflict that occurs when one person
or group defeats the other.

surge capacity An institution’s ability to mobilize when sud-
denly confronted with a vast increase in patient demand.

synchronous and asynchronous channels Channels of com-
munication that allow communication between two or more
parties at the same time (synchronous) or at different times
(asynchronous).

synergy model of care An organizational model that matches
patients’ needs to nurses’ competencies.

T
task forces Ad hoc committees appointed for a specific purpose

and a limited time.

task group Several individuals who work together to accom-
plish specific time-limited assignments.

team building A group development technique that focuses on
the task and relationship aspects of a group’s functioning in
order to build team cohesiveness.

teams Real groups in which people work cooperatively with
each other in order to achieve some goal.

telehealth Technologies used to assess, intervene, and monitor
patients from remote locations.

termination The firing of an employee.

throughput A performance measure related to moving patients
into and out of the healthcare system.

time logs Journals of activities that are useful in analyzing
actual time spent on specific activities.

time-waster Something that prevents a person from accom-
plishing a job or achieving a goal.

to-do list A list of responsibilities to be accomplished within a
specific time frame.

tort law A type of private law that covers unintentional and
intentional events.

total quality management (TQM) A management philosophy
that emphasizes a commitment to excellence throughout an
organization.

total time lost The number of scheduled days an employee
misses.

transactional leadership A leadership style based on principles
of social exchange theory in which social interaction between
leaders and followers is essentially economic, and success is
achieved when needs are met, loyalty is enhanced, and work
performance is enhanced.

transformational leadership A leadership style focused on
effecting revolutionary change in an organization through a
commitment to its vision.

transition The period of time between the current situation and
when change is implemented.

trial-and-error method A method whereby one solution after
another is tried until the problem is solved or appears to be
improving.

turnover The number of staff members who vacate a position.

U
underdelegation A common form of ineffective delegation that

occurs when full authority is not transferred, responsibility is
taken back, or there is a failure to equip and direct the delegate.

upward communication Communication that occurs from staff
to management.

V
validity The ability to predict outcomes with some accuracy.

value-based purchasing (VBP) Medicare reimbursement
linked to hospitals’ scores on HCAHPS; also called pay for
performance (P4P).

values The beliefs or attitudes one has about people, ideas,
objects, or actions that form a basis for behavior.

variable budget A budget developed with the understanding
that adjustments to the budget may be made during the year.

variable costs Expenses that depend on and change in direct
proportion to patient volume and acuity.

variance The difference between the amount that was budgeted
for a specific cost and the actual cost.

vertical integration An arrangement between or among dissimi-
lar but related organizations to provide a continuum of services.

vicarious liability Negligence that is ascribed to a person who
is not negligent himself or herself but who is assumed to be
negligent because of association with the negligent person.

vision A mental model of a possible future.

vision statement A description of the goal to which an organi-
zation aspires.

volume variances Differences in the budget as a result of
increases or decreases in patient volume.

voluntary absenteeism Absenteeism that is under the
employee’s control.

voluntary turnover When an employee chooses to leave an
organization.

W
wildcards Unforeseen events that have far-reaching effects.

withdrawal The removal of at least one party from the conflict,
making it impossible to resolve the situation.

work sample questions Questions that are asked to determine
an applicant’s knowledge about work tasks and the ability to
perform a job.

workplace violence Any violent act, including physical assaults
and threats of assault, directed toward persons at work or on duty.

Z
zero-based budget A budgetary approach that assumes the base

for projecting next year’s budget is zero; managers are required
to justify all activities and every proposed expenditure.

398

Chapter 1: Page 4: Hader, R. (2010). The evidence that isn’t . . .
interpreting research. Nursing Management, 41(9), 23–26; Page 5:
From Competencies. Published by Case Western Reserve
University, © 2015; Page 5: American Nurses Credentialing
Center. (2015). National recognition of Magnet®. Retrieved
April 9, 2015, from http://www.nursecredentialing.org/
Magnet/ ProgramOverview; Page 9: From The Future of Nursing:
Leading Change, Advancing Health. Published by The National
Academies Press, © 2010.

Chapter 2: Page 16 (Figure 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 17 (Figure 2): Longest, B. B.,
Rakich, J. S., & Darr, K. (2000). Managing health services organiza-
tions and systems (4th ed.). Baltimore, MD: Health Professions
Press, p. 124. © 2000; Page 20 (Figure 3): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing (9th ed.).
New York, NY: Pearson Education, Inc.; Page 25 (Figure 4):
Sullivan, E. J. (2013). Becoming influential: A guide for nurses
(2nd ed.). Upper Saddle River, NJ: Prentice Hall Health.
Reprinted and electronically reproduced by permission of
Pearson Education.; Page 26 (Figure 5): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing
(9th ed.). New York, NY: Pearson Education, Inc.; Page 26
(Figure 6): Sullivan, E. J. (2017). REVEL for effective leadership and
management in nursing (9th ed.). New York, NY: Pearson Educa-
tion, Inc.; Page 26 (Figure 7): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 29: From AACN Standards for
Establishing and Sustaining Healthy Work Environments. Published
by American Association of Critical-Care Nurses, © 2016.

Chapter 3: Page 34 (Box 1): From 1887 Nursing Job Description.
Published by Cleveland Lutheran Hospital; Page 36 (Figure 1):
Sullivan, E. J. (2017). REVEL for effective leadership and manage-
ment in nursing (9th ed.). New York, NY: Pearson Education,
Inc.; Page 37 (Figure 2): Sullivan, E. J. (2017). REVEL for effective
leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 39: From The AACN Synergy Model
for Patient Care. Published by American Association of Critical-
Care Nurses, © 2011; Page 40: Agency for Healthcare Research
& Quality. (2015). Defining the PCMH. Retrieved April 28, 2015,
from http://pcmh.ahrq.gov/page/ defining-pcmh; Page 40:
Henderson, S., Princell, C. O., & Martin, S. D. (2012). The
patient-centered medical home. American Journal of Nursing,
112(12), 54–59.

Chapter 4: Page 48 (Table 1): Goleman, D., Boyatzis, R., &
McKee, A. (2013). Emotional Intelligence Domains and Associ-
ated Competencies. Primal leadership: Unleashing the power of
emotional intelligence. Copyright © 2013 by Harvard Business
Publishing (HBP); Page 50 (Box 1): Yukl, G. A. (2013). Leadership
in organizations (8th ed.), p. 239. Reprinted and electronically
reproduced by permission of Pearson Education, Inc., New York,
NY © 2013; Page 53 (Box 2): Nurse Executive Competencies. By the
American Organization of Nurse Executives (AONE). © 2005. All
rights reserved.

Page 53 (Figure 1): Nurse Executive Competencies. By the American
Organization of Nurse Executives (AONE). © 2005. All rights
reserved; Page 55 (Box 3): Sullivan, E. J. (2017). REVEL for effective
leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 57 (Box 4): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing (9th ed.).
New York, NY: Pearson Education, Inc.

Chapter 5: Page 61 (Box 1): From The Future of Nursing: Leading
Change, Advancing Health. Published by The National Academies
Press, © 2010; Page 62 (Table 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 63 (Figure 1): By the American
Psychological Association. Copyright © 1997. Adapted with
permission. The official citation that should be used in referenc-
ing this material is from Resolving Social Conflicts and Field Theory
in Social Science by K. Lewin. The Use of APA information does
not imply endorsement by APA; Page 64 (Box 2): Sullivan, E. J.
(2017). REVEL for effective leadership and management in nurs-
ing (9th ed.). New York, NY: Pearson Education, Inc.; Page 71:
Bridges, W. (2009). Managing transitions: Making the most of change.
Cambridge, MA: Da Capo Press.

Chapter 6: Page 77 (Figure 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 79 (Figure 2): Six Sigma training.
Retrieved March 4, 2016, from http://www.dmaictools.com/six-
sigma-training; Page 79: DMAICTools.com. (n.d.). Six Sigma train-
ing. Retrieved March 4, 2016, from http://www.dmaictools.com/
six-sigma-training; Page 80 (Figure 3): Sullivan, E. J. (2017). REVEL
for effective leadership and management in nursing (9th ed.). New
York, NY: Pearson Education, Inc.; Page 81: Chassin, M. R., Loeb,
J. M., Schmaltz, S. P., & Wachter, R. M. (2010). Accountability meas-
ures: Using measurement to promote quality improvement. The
New England Journal of Medicine, 363(7), 683–688; Page 81: Institute
for Healthcare Improvement. (2010). “No Needless List.”; Page 87:
Weiss, A. P. (2009). Quality improvement in healthcare: The six
Ps of root-cause analysis. (Letter to the editor). American Journal of
Psychiatry, 166(3), 372; Page 87: Fujita, L. Y., Harris, M., Johnson,
K. G., Irvine, N. P., & Latimer, R. W. (2009). Nursing peer review:
Integrating a model in a shared governance environment. Journal
of Nursing Administration, 39(12), 524–530. Published by Wolters
Kluwer Health, Inc., © 2009; Page 90: Khatri, N., Brown, G. D., &
Hicks, L. L. (2009). From a blame culture to a just culture in health
care. Health Care Management Review, 34(4), 312–322. Published by
Wolters Kluwer Health, Inc., © 2009.

Chapter 7: Page 96 (Box 1): By American Nurses Association.
© 2015. Reprinted with permission. All rights reserved.

Chapter 8: Page 113 (Box 1): Yukl, G. A. (2013). Leadership in
organizations (6th ed.). Reprinted and electronically reproduced
by permission of Pearson Education, Inc., Upper Saddle River,
NJ © 2006; Page 116 (Box 2): Sullivan, E. J. (2013). Becoming
influential: A guide for nurses (2nd ed.). Reprinted and electroni-
cally reproduced by permission of Pearson Education , Inc.,
Upper Saddle River, NJ. © 2013; Page 120: Reardon, K. K. (2011).

Credits

http://www.nursecredentialing.org/Magnet/ProgramOverview

http://www.nursecredentialing.org/�Magnet/398

http://pcmh.ahrq.gov/page/�defining-pcmh

Six Sigma Training

Six Sigma Training

Six Sigma Training

Six Sigma Training

Credits 399

It’s all politics: Winning in a world where hard work and talent aren’t
enough. New York, NY: Crown Business © 2011; Page 120 (Box 3):
Sullivan, E. J. (2013). Becoming influential: A guide for nurses
(2nd ed.). Reprinted and electronically reproduced by permis-
sion of Pearson Education, Inc., Upper Saddle River, NJ. © 2013;
Page 121 (Box 4): Sullivan, E. J. (2013). Becoming influential: A
guide for nurses (2nd ed.). Reprinted and electronically repro-
duced by permission of Pearson Education, Inc., Upper Saddle
River, NJ. © 2013.

Chapter 9: Page 127 (Figure 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 128 (Table 1): Wilkinson, J.
(1992). Nursing process in action: A critical thinking approach
(1st ed.). © 1992. Reprinted and electronically reproduced by
permission of Pearson Education, Inc. Upper Saddle River, NJ;
Page 129 (Figure 2): Sullivan, E. J. (2017). REVEL for effective
leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 132 (Table 2): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing (9th ed.).
New York, NY: Pearson Education, Inc.; Page 134 (Box 1):
Sullivan, E. J. (2017). REVEL for effective leadership and manage-
ment in nursing (9th ed.). New York, NY: Pearson Education,
Inc.; Page 134 (Figure 3): Sullivan, E. J. (2017). REVEL for effective
leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 137 (Box 2): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing (9th ed.).
New York, NY: Pearson Education, Inc.; Page 142: Lachman,
V. D., Glasgow, M. E. S., & Donnelly, G. F. (2009). Teaching
innovation. Nursing Administration Quarterly, 33(3), 205–211.
Published by Wolters Kluwer Health, Inc., © 2009.

Chapter 10: Page 147 (Figure 1): Shockley, P. (1988). Funda-
mentals of organizational communication (1st ed.). Reprinted and
electronically reproduced by permission of Pearson Educa-
tion, Inc., New York, NY © 1988; Page 151 (Table 1): Sullivan,
E. J. (2013). Becoming influential: A guide for nurses (2nd ed.).
Reprinted and electronically reproduced by permission of Pear-
son Education, Inc., Upper Saddle River, NJ. © 2013; Page 152
(Table 2): Sullivan, E. J. (2013). Becoming influential: A guide for
nurses (2nd ed.). Reprinted and electronically reproduced by
permission of Pearson Education, Inc., Upper Saddle River, NJ.
© 2013; Page 154 (Box 1): Sullivan, E. J. (2017). REVEL for effective
leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 159 (Table 3): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing (9th ed.).
New York, NY: Pearson Education, Inc.

Chapter 11: Page 165 (Box 1): Based on American Nurses
Association. (2012). ANA’s principles for practice. Retrieved
August 20, 2015, from http://www.nursingworld.org/
MainMenuCategories/ThePracticeofProfessionalNursing/
NursingStandards/ANAPRinciples/PrinciplesofDelegation.
pdf; Page 167 (Box 2): From American Nurses Association
(ANA) and the National Council of State Boards of Nursing
(NCSBN). (2015). Joint statement on delegation. Used by Permis-
sion of National Council of State Boards of Nursing © 2015;
Page 167: Knox, C. (2013). The five rights of delegation. Essentials
of correctional nursing. Retrieved August 20, 2015, from http://
essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-
the-five-rights-of-delegation; Page 167 (Box 3): Sullivan, E. J.
(2017). REVEL for effective leadership and management in nursing (9th
ed.). New York, NY: Pearson Education, Inc.; Page 168 ( Figure 1):
Adapted from National Council of State Boards of Nursing. (2006).

Joint statement on delegation. Retrieved December 2007, from www.
ncsbn.org/Joint_statement ; Page 171 (Box 4): Sullivan, E. J.
(2017). REVEL for effective leadership and management in nursing
(9th ed.). New York, NY: Pearson Education, Inc.

Chapter 12: Page 183 (Figure 1): Adapted from Homans, G.
(1950). The human group. New York: Harcourt Brace Jovanovich;
and Homans, G. (1961). Social behavior: Its elementary forms. New
York: Harcourt Brace. By permission of Transaction Publishers;
Page 192 (Box 1): Sullivan, E. J. (2017). REVEL for effective leader-
ship and management in nursing (9th ed.). New York, NY: Pearson
Education, Inc.

Chapter 13: Page 199: Oetzel, J. G., & Ting-Toomey, S. (2013). The
SAGE handbook of conflict communication (2nd ed.). Los Angeles,
CA: Sage; Page 200: From Pocket Guide: TeamSTEPPS: Team Strate-
gies & Tools to Enhance Performance and Patient Safety. Published
by U.S. Department of Health & Human Services; Page 201
( Figure 1): Sullivan, E. J. (2017). REVEL for effective leadership and
management in nursing (9th ed.). New York, NY: Pearson Educa-
tion, Inc.; Page 205: Runde, C., & Flanagan, T. (2013). Becoming a
conflict competent leader: How you and your organization can manage
conflict effectively (2nd ed.). San Francisco, CA: John Wiley &
Sons, Inc; Page 205 (Box 1): Runde, C., & Flanagan, T. (2013).
Becoming a conflict competent leader: How you and your organization
can manage conflict effectively (2nd ed.). San Francisco, CA: John
Wiley & Sons, Inc; Page 207: Littlejohn, S. W., & Domenici, K.
(2007). Communication, conflict, and the management of difference.
Long Grove, IL: Waveland Press, Inc.

Chapter 14: Page 212 (Box 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 213 (Figure 1): Sullivan, E. J.
(2017). REVEL for effective leadership and management in nursing
(9th ed.). New York, NY: Pearson Education, Inc.; Page 215: Jones,
L., & Loftus, P. (2009). Time well spent: Getting things done through
effective time management. Philadelphia, PA: Kogan Page; Page 215
(Figure 2): Sullivan, E. J. (2017). REVEL for effective leadership and
management in nursing (9th ed.). New York, NY: Pearson Educa-
tion, Inc.; Page 219 (Figure 3): Sullivan, E. J. (2017). REVEL for effec-
tive leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 221: Raso, R. (2010). Tackling time
management and performance evaluation. Nursing Management,
41(10), 56; Pages 221–222: Merritt, C. (2009). Too busy for your own
good. NewYork, NY: McGraw Hill.

Chapter 15: Page 231 (Figure 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.

Chapter 16: Pages 242–243 (Box 1): Sullivan, E. J. (2017). REVEL
for effective leadership and management in nursing (9th ed.). New
York, NY: Pearson Education, Inc.; Page 247 (Box 2): Sullivan,
E. J. (2017). REVEL for effective leadership and management in nurs-
ing (9th ed.). New York, NY: Pearson Education, Inc.; Page 249
(Figure 1): Sullivan, E. J. (2017). REVEL for effective leadership
and management in nursing (9th ed.). New York, NY: Pearson
Education, Inc.; Page 249 (Box 3): Sullivan, E. J. (2017). REVEL
for effective leadership and management in nursing (9th ed.). New
York, NY: Pearson Education, Inc.; Page 250 (Box 4): Sullivan,
E. J. (2017). REVEL for effective leadership and management in nurs-
ing (9th ed.). New York, NY: Pearson Education, Inc.; Page 257
(Figure 2): Sullivan, E. J. (2017). REVEL for effective leadership
and management in nursing (9th ed.). New York, NY: Pearson
Education, Inc.

http://www.nursingworld.org/�MainMenuCategories/ThePracticeofProfessionalNursing/�NursingStandards/ANAPRinciples/PrinciplesofDelegation

http://�essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-the-five-rights-of-delegation

http://�essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-the-five-rights-of-delegation

http://�essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-the-five-rights-of-delegation

http://�essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-the-five-rights-of-delegation

http://�essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-the-five-rights-of-delegation

http://www.ncsbn.org/Joint_statement

http://www.ncsbn.org/Joint_statement

400 Credits

Chapter 17: Page 262 (Box 1): Dent, B. (2015). Nine principles for
improved nurse staffing. Nursing Economics, 33(1), 41–66.

Chapter 18: Page 272 (Figure 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 279: Benner, P. (2000). Novice
to expert: Excellence and power in clinical nursing practice (1st ed.).
Published by Pearson Education Inc, Upper Saddle River, NJ
© 2000.

Chapter 19: Page 289 (Box 1): By Healthcom Media. Copyright ©
2011. All rights reserved. American Nurse Today, September 2011.
www.AmericanNurseToday.com; Pages 288–289: Haag-Heitman,
B., & George, V. (2011). Nursing peer review: Principles and prac-
tice. American Nurse Today, 6(9). Published by HealthCom Media,
© 2011; Page 285–286 (Table 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 292 (Table 2): Sullivan, E. J.
(2017). REVEL for effective leadership and management in nursing (9th
ed.). New York, NY: Pearson Education, Inc.; Page 291 (Box 2):
Sullivan, E. J. (2017). REVEL for effective leadership and management
in nursing (9th ed.). New York, NY: Pearson Education, Inc.

Chapter 20: Pages 297–298 (Box 1): Wiggins, G. (2012). Seven
keys to effective feedback. Educational Leadership, 70(1), 10–16;
Page 298: Staples, S. (2012). Bringing coaching into your nursing
career. Retrieved May 1, 2015, from http://www.nursetogether.
com/bringing-coaching-into-your-nursing-career; Page 299
( Figure 1): Sullivan, E. J. (2017). REVEL for effective leadership
and management in nursing (9th ed.). New York, NY: Pearson
Education, Inc.; Page 299 (Figure 2): Sullivan, E. J. (2017). REVEL
for effective leadership and management in nursing (9th ed.). New
York, NY: Pearson Education, Inc.; Page 300 (Box 2): Sullivan,
E. J. (2017). REVEL for effective leadership and management in nurs-
ing (9th ed.). New York, NY: Pearson Education, Inc.; Page 301
(Box 3): Sullivan, E. J. (2017). REVEL for effective leadership and
management in nursing (9th ed.). New York, NY: Pearson Educa-
tion, Inc.; Page 302 (Box 4): Sullivan, E. J. (2017). REVEL for effec-
tive leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 304 (Box 5): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing (9th ed.).
New York, NY: Pearson Education, Inc.

Chapter 21: Page 309 (Figure 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 317: American Association
of Critical Care Nurses. (2016). AACN’s standards for establishing
and sustaining healthy work environments: A journey to excellence
(2nd ed.). Retrieved March 28, 2016, from http://www.aacn.org/
wd/hwe/docs/hwestandards ; Page 318 (Box 1): Sullivan,
E. J. (2017). REVEL for effective leadership and management in nurs-
ing (9th ed.). New York, NY: Pearson Education, Inc.; Page 318:
Hinson, T. D., & Spatz, D. L. (2011). Improving nurse retention in
a large tertiary acute-care hospital. Journal of Nursing Administra-
tion, 41(3), 103–108.

Chapter 22: Page 328 (Box 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 328 (Box 2): Sullivan, E. J.

(2017). REVEL for effective leadership and management in nurs-
ing (9th ed.). New York, NY: Pearson Education, Inc.; Page 329
(Box 3): Sullivan, E. J. (2017). REVEL for effective leadership
and management in nursing (9th ed.). New York, NY: Pearson
Education, Inc.

Chapter 23: Page 333 (Box 1): Sullivan, E. J. (2017). REVEL for
effective leadership and management in nursing (9th ed.). New York,
NY: Pearson Education, Inc.; Page 334: Smeltzer, S., Bare, B.,
Hinkel, J., & Cheever, K. (2010). Brunner and Suddarth’s textbook of
medical–surgical nursing (12th ed.). Philadelphia, PA: Lippincott
Williams & Wilkins; Pages 334–335: Smeltzer, S., Bare, B., Hinkel,
J., & Cheever, K. (2010). Brunner and Suddarth’s textbook of medical–
surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams
& Wilkins.

Chapter 24: Page 345: Sullivan, E. J. (2013). Becoming influential: A
guide for nurses (2nd ed.). Reprinted and electronically reproduced
by permission of Pearson Education, Inc., Upper Saddle River,
NJ. © 2013; Page 341: Sullivan, E. J. (2013). Becoming influential: A
guide for nurses (2nd ed.). Reprinted and electronically reproduced
by permission of Pearson Education, Inc., Upper Saddle River, NJ.
© 2013; Page 344 (Box 1): Sullivan, E. J. (2017). REVEL for effective
leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 345 (Box 2): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing (9th ed.).
New York, NY: Pearson Education, Inc.; Page 346 (Box 3):
Sullivan, E. J. (2017). REVEL for effective leadership and management
in nursing (9th ed.). New York, NY: Pearson Education, Inc.

Chapter 25: Page 353: National Labor Relations Board. (2006).
Golden Crest Healthcare Center, 348 NLRB No. 39.

Chapter 27: Page 369 (Box 1): Sullivan, E. J. (2017). REVEL for effec-
tive leadership and management in nursing (9th ed.). New York, NY:
Pearson Education, Inc.; Page 372 (Box 2): Sullivan, E. J. (2017).
REVEL for effective leadership and management in nursing (9th ed.).
New York, NY: Pearson Education, Inc.; Page 367: Shirey, M. R.
(2009). Building an extraordinary career in nursing: Promise,
momentum, and harvest. The Journal of Continuing Education,
40(9), 394–400; Page 371 (Figure 1): Sullivan, E. J. (2013). Becoming
influential: A guide for nurses (2nd ed.). Reprinted and electroni-
cally reproduced by permission of Pearson Education, Inc., Upper
Saddle River, NJ. © 2013; Page 372: Pagana, K. (2012). Ten tips
for handling job interviews by phone. American Nurse Today, 7(1).
Retrieved March 4, 2016, from http://www.americannursetoday.
com/ ten-tips-for- handling-job-interviews-by-phone; Page 376
(Figure 2): Sullivan, E. J. (2013). Becoming influential: A guide for
nurses (2nd ed.). Reprinted and electronically reproduced by
permission of Pearson Education, Inc., Upper Saddle River, NJ.
© 2013.

Chapter 28: Page 386: Krol, D. M. (in press). The new career in
nursing program: A strong investment in the future of nurs-
ing. Journal of Professional Nursing. Published by Elsevier Inc.,
© 2016; Page 387 (Figure 1): Reprinted with permission from The
Future of Nursing: Leading Change, Advancing Health, 2011 by the
National Academy of Sciences, Courtesy of the National Acad-
emies Press, Washington, D.C.

http://www.AmericanNurseToday.com

http://www.nursetogether.com/bringing-coaching-into-your-nursing-career

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http://www.aacn.org/wd/hwe/docs/hwestandards

http://www.americannursetoday.com/ ten-tips-for-handling-job-interviews-by-phone

401

A
ABC model, 284
Absence culture, 310. See also Employee attendance model
Absence frequency, 308
Absenteeism, 308

employee attendance model. See Employee attendance model
involuntary, 308
managing, 311–12
monitoring, 313
policies, 312–13
stress and, 361
voluntary, 308

Accommodating, in conflict management, 207
Accountability, 164
Accountable care organization (ACO), 3, 27, 40
Activity log, 375–76, 376t
Acute care hospitals, 23
Adaptive decisions, 130
Adaptive organizational theories

chaos theory, 19
contingency theory, 18–19
systems theory, 18

Additive task, 187
Adjourning, 184
Administrative law, 98
Administrators, communication with, 154–56
Advance directive, 103
Affordable Care Act (ACA), 2–3, 40, 67, 80, 81, 385
Age Discrimination Act, 256
Age Discrimination in Employment Act (ADEA) in 1967, 107, 255
Agency for Healthcare Research and Quality (AHRQ), 81, 187
Agendas, hidden, 186
Alcohol/drug dependency

physical symptoms of, 328b
signs of, 328b

All-hazards approach, 334
Allocation, 97
Alternative dispute resolution (ADR), 208–9
American Academy of Family Physicians, 40
American Academy of Nursing, 142
American Academy of Pediatrics, 40
American Association of Critical-Care Nurses (AACN), 29, 39,

317, 378
American Board of Nursing Specialties (ABNS), 377. See also

Nursing certification
American College of Physicians, 40
American Medical Association, 23
American Nurses Association (ANA), 78, 164, 166, 288, 289, 324, 378

Code of Ethics, 95, 96b
American Nurses Credentialing Center (ANCC), 5
American Organization of Nurse Executives (AONE), 53, 53b
American Psychiatric Nurses Association (APNA), 378
Americans with Disabilities Act (ADA) of 1990

and substance abuse, 330
Title I of, 107, 255

Annual budget, 229–30

Annual performance evaluation
components of, 287–88
conducting, 292–94

Assertive communication strategies, 159t
Assignment, 165
Asynchronous channels, of communication, 148
Attendance barriers, 309
AT&T’s language line service, 157
Authority, 165
Automated scheduling, 268
Automated technology, 385
Autonomy, 96
Avoiding, in conflict management, 207

B
Baby boomers, 152, 310
Baccalaureate degree for RNs, 376
Bargaining agent, 351
Behavioral interviewing, 248, 249t
Behavior-oriented performance evaluation, 288
Beliefs, values and, 202
Benchmarking, 4
Beneficence, 97
Benefit time, 231
Blame-free environment, 90
Block staffing, 265
Bona fide occupational qualifications (BFOQ), 107, 255, 256
Brainstorming, 134f, 135
Budgeting

approaches to, 227–29
case study, 238
process, 225–27
timetable for, 227

Budget(s), 225–26
capital, 234
expense, 230
fixed, 229
improvement, 237–39
incremental/line-by-line, 228
operating/annual, 229–30
performance, monitoring and controlling, 234–37
personnel, 230–33, 231t
revenue, 229–30
staff impact on, 237–39
supply and nonsalary expense, 233–34
variable, 229
zero-based, 228

Bullying, 341
examples of, 324
in healthcare, 324

Bureaucracy, 16
Burnout, 360–61. See also Stress
Business necessity, 255

C
California Critical Thinking Disposition Inventory, 127
Capacity, as informed consent element, 102

Index
Note: Page numbers followed by f, t, or b represent figures, tables, or boxes respectively.

402 Index

Capital budget, 234
Capitation, 27
Career development/advancement, 279

adapting to change and, 380
case study, 375
envisioning future, 367
first position, 367–73

accepting, 373
applying for, 368–69
criteria for, 376–77
declining, 373
interviewing for. See Interview
second interview for, 372–73

learning needs, identifying, 376–78
mentors for, 378–79
next position, 379
requirements for, 373–79
tracking progress, 375–76, 376t

Care maps. See Critical pathways
Caring attitude, 89–90
Case management, 36–37, 37f
Case studies

budget management, 238
career advancement, 375
collective bargaining, 354
communication, 159
conflict management, 208
delegation, 171
emergencies, 337
encouraging change, 71–72
legal issues, nursing, 103–4
motivation, 280
politics, 121
problem solving, 130
progressive discipline, 303
risk management, 89
scheduling, 267
staff, 327–28
staff retention, 319
staff selection, 258
stress management, 363
team building, 191
time management, 218
workplace violence, 346

Centers for Medicare & Medicaid Services
(CMS), 3, 81

Certification, 376–77. See also Nursing certification
Certification to contract, 351. See also Unionization
Chain of command, 16, 16f
Change, 61

constant, 72–73
encouraging (case study), 71–72
implementing, 71
initiating, 69–71
nurse’s role in, 69–73
process. See Change process
resistance to, 68–69
strategies. See Change strategies
unplanned, 72

Change agent, nurse as, 62
Change process, 64–66

case study, 71–72
data analysis and selection, 65

data and information, collection of, 65
interventions, 66
planning, 65–66
problem/opportunity, identification of, 64–65
steps in, 64b
supporters/opposers, identification of, 66

Change strategies
empirical–rational, 67
normative-reeducative, 67–68
power–coercive, 67

Change theories, 62–64, 62t, 63f
Channels, of communication, 148–49
Chaos theory, 19, 46
Charge nurse, 54, 55–56
Civil Rights Act (CRA), Title VII of, 107, 255
Civil Service Reform Act of 1978, 350
Classical theory. See Reductive/classical theory
Clinical advancement program, 279
Clinical information systems, 76
Clinical ladder system, 181, 279
Clinical nurse leader (CNL), 56
Clinical nurse specialist (CNS), 56
Closed shop, 350
Coaching, 278–79, 297, 298–99

feedback vs., 299, 299t
success, essentials for, 298

Code of Ethics, 95, 96b
Coercive power, 112
Cohesiveness, 189
Co-leadership, 47
Collaboration, in conflict management, 206
Collaborative communication, 157–58. See also Communication
Collective bargaining. See also Unionization

case study, 354
laws governing, 350
for nurses, 352–54
private sector vs. public sector, 350

Committees, 180, 192. See also Task forces
formal, 192
informal, 192
leading, 192–95

Common law, 98
Communication

with administrators, 154–56
assertive communication strategies, 159t
case study, 159
channels of, 148–49
collaborative, 157–58
with coworkers, 156
defined, 146
directions of, 150
effective listening, 150–51
with employees, 153–54
gender differences in, 151, 151t, 152t
generational and cultural differences in, 152
goals of, 146
in group, 190–91
with medical staff, 156
nonverbal, 149
organizational culture and, 152–53
with other healthcare personnel, 156–57
with patients and families, 157
role in leadership, 153–57

Index 403

technological innovations in, 385
transactional model of, 147, 147f

Communication skills, steps to improve, 158, 160
Communication technology, 6

social media, 6
Compassion fatigue, 361. See also Stress
Competency-based interviewing. See Behavioral interviewing
Competing, in conflict management, 207
Competition, for scarce resources, 202
Complaint handling, 88–89
Comprehensive quality management plan, 77
Compromise, in conflict management, 206
Computerized prescriber order entry (CPOE), 83
Concentric diversification, 26
Confidentiality, patients, 101–2
Conflict

behaviors, 203
defined, 199
felt, 202–3
intergroup, 199
interpersonal, 199
interprofessional, 199–200
intragroup, 199
intrapersonal, 199
managing. See Conflict management
navigating, guidelines for, 205
outcomes of, 203
perceived, 202–3
process model, 200–203, 201f
resolution, 203
responses, 206–8
role, 201
structural, 202
suppression, 203

Conflict management, 204–9
accommodating in, 207
avoiding in, 207
case study, 208
collaboration in, 206
competing in, 207
compromise in, 206
confrontation in, 206
forcing in, 207
negotiation in, 206
resisting in, 207
smoothing in, 207
suppressing in, 207
withdrawing in, 207

Confrontation
in conflict management, 206
steps in, 299, 300t

Conglomerate diversification, 27
Conjunctive task, 188
Connection power, 112
Consensus, 202
Consumerism, 385–86
Contemporary theories, 46–49

emotional leadership, 48. See also Emotional intelligence
quantum leadership, 46
servant leadership, 48
shared leadership, 47
transactional leadership, 46. See also Social exchange theory
transformational leadership, 46–47

Content theories, motivation, 273
Contingency planning, 51
Contingency theory, 18–19, 45
Continuing education, 377–78
Continuous quality improvement (CQI), 77
Controlling, 51–52
Corporate healthcare network, 26f
Corporate liability, 99
Cost center, 230
Cost centers, 227
Costs

direct, 230
fixed, 230
indirect, 230
variable, 230

Covey, Stephen, 111
Creativity, 128–29, 129f

defined, 128
incubation, 129, 129f
insight, 129, 129f
preparation, 129, 129f
stages of, 129, 129f
verification, 129, 129f

Critical pathways, 37–38, 77
Critical thinking

creativity in. See Creativity
defined, 126
model, 127f
in nursing, 127
and problem solving, 139
using, 127–28, 128t

Critical-thinking skills, 126, 127, 128
Crossing the Quality Chasm report (IOM), 28
Cross-training, 246–47
Cultural differences

in communication, 152
in nursing, 7

D
Decision making, 130

under certainty, 131
conditions, 131–32
group, 135
obstacles to, 141
problem solving vs., 130
process, 132–33
steps in, 133–34b
stumbling blocks, 141
techniques, 134–35, 134f
types of decisions, 130
under uncertainty and risk, 131–32, 132t

Delegation, 215
accepting, 171
accountability in, 164
assignment vs., 165
authority and, 165
benefits of, 165–66
case study, 171
decision tree, 168f
defined, 164
five rights of, 166–67, 167b, 168f
ineffective. See Ineffective delegation
key behaviors for successful, 170, 171b

404 Index

liability and, 166
principles for, 165b
process, 167–71, 167b
responsibility in, 164

Demand management, 262
Deming, W. Edwards, 76
Department of Health and Human Services (DHHS), 81
Depression, 360. See also Stress
Descriptive rationality model, 132
DESC script, 200
Developmental plan, 290

sample, 291b
Diagnostic procedure incident, 86
Diagonal communication, 150. See also Communication
Direct costs, 230
Directing, 51
Disasters. See also Emergencies

examples of, 333b
human-caused, 8
levels of, 334
man-made, 333–34
natural, 8, 333

Discipline, 299, 300
guidelines for effective, 300b
progressive, 301

Disgruntled employees, 327. See also Staff
Disjunctive task, 188
Distributive justice, 97
Diversification

concentric, 26
conglomerate, 27
defined, 26
joint venture, 27

Divisible task, 188
DMAIC (define, measure, analyze, improve, and control)

method, 79–80, 79f
Downward communication, 150. See also Communication
Drexel University’s College of Nursing, 142
Driving forces, 62
Drug abuse, workplace indications of, 329b. See also Substance

abuse
“Due care” standard, 106
Durable power of attorney, 104
Dynamic Network Analysis Decision Support (DyNADS)

project, 135

E
Efficiency variance, 236
Electronic health records (EHRs), 6, 82, 262. See also Healthcare
Electronic medication administration record (eMAR), 83
Email, 148–49

managing, 220
Emergencies

case study, 337
man-made disasters, 333–34
natural disasters, 333
staff utilization in, 336–37
types of, 333–34

Emergency operations plan (EOP), 334–35
planning, 335
practicing, 335
preparing, 335

Emergency preparedness
continuation of services during, 336
hospitals, 334–36
triage system, 336

Emotional intelligence, 48–49, 48t
Empirical–rational model, 67
Employee assistance program (EAP), 363. See also Stress
Employee attendance model, 308–11, 309f. See also

Absenteeism
absence culture, 310
generational differences, 310
job, nature of, 309
labor market, 311
organizational practices, 310
personal characteristics, 311

Employment issues, 107–8
Engagement, 316
Equal Employment Opportunity Commission (EEOC),

107, 256
Equal Pay Act of 1963, 255
Equity theory, 275
Ethical decision making

autonomy, 96
beneficence, 97
distributive justice, 97
nonmaleficence, 97

Ethics, 95
Evidence-based practice (EBP), 4, 82. See also Healthcare
Evolving models, nursing care delivery, 38–40

patient-centered care, 38–39
patient-centered medical home, 39–40
synergy model of care, 39

Expectancy theory, 275
Expense budget, 230
Experimentation, 136
Expert power, 112
Extinction, 274

F
Family

communication with, 157
dissatisfaction with care, 86

Family and Medical Leave Act (FMLA) of 1993, 108, 313
Fayol, Henri, 50
Federal Emergency Management Agency (FEMA), 333
Federal Mediation and Conciliation Service (FMCS), 352
Feedback, 297

vs. coaching, 299, 299t
successful, keys to, 298b

Felt conflict, 202–3
First-level manager, 54, 55b
Fiscal year, 229
Fixed budget, 229
Fixed costs, 230
Floor nurse, job description of, 34b
Followers, guidelines for, 50b
Followership, 49. See also Leadership
Forcing, in conflict management, 207
Formal committees, 192
Formal groups, 179
Formal leadership, 45. See also Leadership
Forming, 183
Four Ps of marketing, 245–46

Delegation (continued)

Index 405

place, 246
price, 246
product, 246
promotion, 246

Full-time equivalent (FTE), 231, 263–65
example of, 263–64
and position control, 237

Functional nursing, 35
Functional structure, organizations, 19
Future, 382

plausible, 383
possible, 383
preferable, 383
probable, 383
societal predictions about, 383–84

G
Gender differences

in communication, 151, 151t, 152t
in nursing, 7

Generational differences
in absenteeism, 310
in communication, 152
management, 310–11
in nursing, 7–8

Generation X, 152, 310
Generation Y, 7, 310
Generation Z, 7, 310
Goals

of communication, 146
incompatible, 200–201
Six Sigma as, 78
of staffing, 261

Goal setting, 214–17
Goal-setting theory, 275
Graduate education, 377
Grapevine communication, 150. See also Communication
Greenleaf, Robert, 48
Grievances

classification of, 352
defined, 351
process, 352
unfair labor practices and, 351–52

Group problem solving, 140–41
advantages of, 140
disadvantages of, 140–41

Group(s)
cohesiveness, 189
communication, 190–91
composition, 188
defined, 179
formal, 179
informal, 180
interaction, 182
leadership, 182
manager, 180
meetings, 192–93, 194b
members, 180
norms, 184
ordinary interacting, 181–82
problem solving. See Group problem solving
process, 182–86, 183f
productivity, 188

real (command), 180
roles in, 185–86
size, 188
status, 185–86
task, 180. See also Task forces
workplace teams and, 180

Groupthink, 140

H
Havelock’s change theory, 63
Hawthorne effect, 18
Healthcare

changes in, 2–6
disasters in, 8
electronic health records, 6
evidence-based practice, 4
future of, 384–86
home, 23
legislation, 385
networks, 24–25
pandemics in, 8
paying for, 2–6
quality improvement, 3–5, 80–82
robotics and, 6
societal change, 7–8
technological innovations, 384–85
telehealth, 6
violence in, 8, 341–43

Healthcare organizations, 180
diversification, 26–27
goals, 201
interorganizational relationships, 26, 26f
managed, 27
nursing care expenditures in, 239
ownership of, 24, 25f
redesigning, 28–30
types of, 22–24

Health home, 3, 28
Health Information Technology for Economic and Clinical

Health Act (HITECH), 83
Health Insurance Portability and Accountability Act (HIPAA), 101
Health maintenance organizations (HMOs), 27
Health Resources and Services Administration (HRSA), 8
Hidden agendas, 186
Hire decision, 253–55

education and experience requirements, 253–54
information integration, 254–55
licensure requirements, 254
offer making, 255

H1N1 virus, 8
Homans’ framework, 182–86, 183f
Home healthcare, 23
Horizontal integration, 26, 26f
Horizontal promotion, 279
Horizontal violence, 325–26, 341
Hospital Consumer Assessment of Healthcare Providers and Sys-

tems (HCAHPS), 82
Hospitalists, 23
Hospitals

acute care, 23
emergency preparedness, 334–36

Human-caused disasters, 8
Humanistic organizational theory, 17–18

406 Index

I
Image, as power, 114–16
Incident reports, 84–85
Incivility, 341
Incoming messages, 220
Incremental budget, 228
Indicator, 78
Indirect costs, 230
Ineffective delegation, 172–76

insecure delegation and, 172–74
lack of resources and, 172
organizational culture and, 172
overdelegation, 175–76
reasons for, 172
reverse delegation, 175
underdelegation, 174–75
unwilling delegate and, 174

Inflation rate index, 233
Informal committees, 192
Informal groups, 180
Informal leadership, 45. See also Leadership
Information, as informed consent element, 102
Information power, 112
Informed consent, 102
Innovation, 142
Innovative decisions, 130
In-person interruptions, 220
Inputs, 18
Institute for Healthcare Improvement (IHI), 38, 81
Institute of Medicine (IOM), 3, 5, 61, 289

Crossing the Quality Chasm report, 28
The Future of Nursing report, 386
recommendations for nursing, 9, 386, 387t

Integrated healthcare networks, 24
Integrated models, nursing care delivery, 36–38

case management, 36–37, 37f
critical pathways, 37–38
practice partnerships, 36, 36f

Intentional torts, 99
Interdependence

pooled, 188
reciprocal, 188
sequential, 188

Intergroup conflict, 199
Interpersonal conflict, 199
Interprofessional conflict, 199–200
Interrater reliability, 253
Interruption log, 218, 219t
Interruptions, controlling, 217–21
Interview, 248, 369–73

closing, 252
information-giving part of, 252
job-related questions, 249b
legal considerations in, 255–58, 257t
opening, 251–52
preparation for, 250–51, 370
principles for effective, 248–52
questions, examples of, 371t
reliability, 253
salary negotiation, 373
script, 250b, 371–72b
script for hiring, 250b
staff involvement in, 252

structured guides for, 248, 250
telephone, 372
validity, 253

Interview guide, 248
Intragroup conflict, 199
Intrapersonal conflict, 199
Intrarater reliability, 253
Investment centers, 227
Involuntary absenteeism, 308. See also Absenteeism
Involuntary turnover, 315. See also Turnover

J
Job enlargement, 211
Job performance

consequence of stress on, 361
data collection methods, 288–91
model, 272–75, 272t
motivation in, 273–75
self-evaluation, 289–90

Job reassignment, 105–6
Job satisfaction, 316–17
Joint Commission on Accreditation of Healthcare Organizations,

80, 81
Joint venture, 27
Just culture, 90

K
Kansas Nurses Assistance Program (KNAP), 329
Kentucky River trilogy, 353
Knowledge, skills, and attitudes (KSAs), 5
Kotter’s change theory, 62t, 63–64

L
Lack of civility, 324–25
Laser-guided robots, 6
Lateral communication, 150. See also Communication
Laws, 95

administrative, 98
common, 98
sources of, 97–98
statutory, 98
types of, 98–99

Leaders, 44
clinical nurse, 56
functions of, 44
role of, 57
servant, 48
transformational, 47

Leadership, 45
competencies, 53f
emotional, 48
followership and, 49
formal, 45
group, 182
informal, 45
power and, 111–13
quantum, 46
role of communication in, 153–57
servant, 48
shared, 47
theories. See Leadership theories
transactional, 46
transformational, 46–47

Index 407

Leadership development, 280
Leadership theories, 45–49

contemporary. See Contemporary theories
traditional, 45

Lean Six Sigma, 79
Leapfrog Group, 4
Legal issues, nursing, 100–108

case study, 103–4
employment issues, 107–8
nursing licensure, 100
patient care rights, 100–105

Legitimate power, 112
Length of stay (LOS), 265
Lewin’s force-field model of change, 62–64,

62t, 63f
Liability, 99–100

and delegation, 166
Licensed Practical Nurses (LPN), 35
Licensure

multistate, 100
requirements, 254
uniform requirement, 100

Line authority, 16, 16f
Line-by-line budget, 228
Listening, barriers to effective, 150–51

defensiveness, 150–51
flagging energy, 150
habit, 151
lack of self-confidence, 150
preconceived beliefs, 150

Living will, 103
Long-term care facilities, 23–24

M
Macroallocation, 97
Magnet-certified hospitals, 238, 239
Magnet Recognition Program, 4–5, 289
Malpractice, 98–99
Managed healthcare organization

health maintenance organizations, 27
point-of-service plans, 27
preferred provider organizations, 27

Management, functions of, 50–52
controlling, 51–52
directing, 51
organizing, 51
planning, 50–51

Management, issues of
delegation, 105
job reassignment, 105–6
policies and procedures, 106
staffing, 105
supervision, 105

Managers, 44–45
evaluation of, 291
responsibilities of, 287

Managing teams, 187–90
development and growth, 190
group size and composition, 188
productivity and cohesiveness, 188–89
shared governance, 190
task

additive, 187
conjunctive, 188

disjunctive, 188
divisible, 188

Man-made disasters, 333–34
Manthey, Marie, 35, 36
Marginal employees, 327. See also Staff
Marketing, four Ps of, 245–46
Mass casualty events (MCE), 334
Matrix structure, 21
Mediation, 208
Medical errors, 3
Medical home, 3, 28
Medical-legal incident, 86
Medical technologies, 5–6

communication technology, 6
electronic health records, 6
robotics, 6. See also Robotics
telehealth, 6

Medicare, 229–30
Medication errors, 83, 85–86
Meeting

conducting, 192–93, 194b
participation, 192
patient care conferences, 195
place and time, 192–93
preparation of, 192
task forces, 194–95

Meeting management, 221–22
Memos, 149
Mentoring, 278
Mentors, 378–79
Microallocation, 97
Midland Memorial Hospital, principles of nurse staffing at, 262b
Mindfulness, 362
Mission, organizations, 15
Model nursing practice act, 100
Motivation, 272, 273

case study, 280
succession planning in, 280

Motivational theories
content, 273
process, 273
reinforcement, 274–75

Multidisciplinary teams, 191
Multistate licensure, 100

N
National Commission for Certifying Agencies (NCCA), 376–77.

See also Nursing certification
National Council of State Boards of Nursing (NCSBN), 100, 166
National Institute of Nursing Research, 119
National Institutes of Health (NIH), 119
National Labor Relations Act in 1935, 350
National Labor Relations Board (NLRB), 350–51, 353
National Practitioner Date Bank (NPDB), 106
National Quality Forum, 80, 81
Natural disasters, 8, 333
Negative inquiry, 155
Negligence, 98
Negotiations, 206, 350
Nightingale, Florence, 118
Nonmaleficence, 97
Nonsalary expenditure variance, 236
Nonverbal communication, 149. See also Communication
Normative–reeducative strategies, 67–68

408 Index

Norms, 184
Novice-to-expert concepts, 279, 280
Nurse managers, 2, 44, 45, 117, 126, 154, 182

as change agent, 62, 69. See also Change
charge nurse, 54, 55–56
clinical nurse leader, 56
communication style, 190–91
competencies of, 53, 53b, 53f
first-level manager, 54, 55b
interruption log, 218, 219t
in practice, 52–56
staff nurse, 52, 54
stress factors for, 358–60
as team leader, 190–91
time analysis log, 213t

Nurse practice acts, 100
Nursing

certification. See Nursing certification
changes in, adaptation to, 9
critical thinking in, 127
cultural differences in, 7
current status of, 8
future of, 8–9, 61b, 386–88
gender differences in, 7
generational differences in, 7–8
IOM’s recommendations for, 9, 386, 387t
legal issues in. See Legal issues, nursing
licensure, 100
new careers in, 386, 387–88
political history, 118–19
primary, 35–36
team, 35

Nursing care delivery
evolving models, 38–40

patient-centered care, 38–39
patient-centered medical home, 39–40
synergy model of care, 39

integrated models, 36–38
case management, 36–37, 37f
critical pathways, 37–38
practice partnerships, 36, 36f

traditional models, 34
functional nursing, 35
primary nursing, 35–36
team nursing, 35
total patient care, 35

Nursing care hours (NCHs), 263
Nursing certification

American Board of Nursing Specialties (ABNS), 377
National Commission for Certifying Agencies (NCCA), 376–77
programs, 376–77

Nursing hours per patient per day (NHPPD), 263

O
Objective probability, 132
Occupational Safety and Health Act of 1970, 108
Occupational Safety and Health Administration (OSHA), 108
Omnibus Budget Reconciliation Act (OBRA) of 1987, 104
On-call hours, 232
On-the-job instruction, 276–77
Open shift management, 267
Open shop, 350
Operant conditioning, 274

Operating budget, 229–30
Ordinary interacting groups, 181–82
Organizational culture, 29–30

and communication, 152–53
and ineffective delegation, 172

Organizational environment, 29
Organizational structures, 16

functional structure, 19
matrix structure, 21
parallel structure, 21–22
service-line structure, 20–21, 20f
and shared governance, 22

Organizational theories
adaptive, 18–19
contingency theory, 18–19
humanistic theory, 17–18
reductive/classical theory, 15–17, 16f, 17f
systems theory, 18

Organization-level plans, 50
Organizations, 14. See also Healthcare organizations

home care, 14
mission of, 15
values, 14–15
vision statement, 15

Organizing, 51
Orientation, 276
Outcome standards, 78
Outgoing messages, 220
Outputs, 18
Overdelegation, 175–76. See also Ineffective delegation
Overtime, 232

P
Pandemics, 8
Paperwork, managing, 220–21
Parallel structure, 21–22
Patient care, rights, 100–105
Patient care conferences, 195
Patient-centered medical home (PCMH), 39–40
Patient classification systems (PCSs), 262–63
Patients

communication with, 157
confidentiality, 101–2
dissatisfaction with care, 86
privacy rights, 101
right to refuse treatment, 102–3
satisfaction, 316

Patient Self-Determination Act, 1990, 103
Pay for performance (P4P), 82
PDCA (Plan, Do, Check, Act) cycle, 77, 77f
Peer review, 87, 288–89, 289b
Perceived conflict, 202–3
Perfectionism, 360
Performance evaluation, 191, 284

challenges, 291–92
components of, 287–88
conducting, 292–94
dos and don’ts, 292t
manager’s evaluation, 291
process, 284–88, 285–86t
self-evaluation, 289–90
tools, 288

Performance management, 284

Index 409

Performing, 184
Personal liability, 99
Personnel budget, 230–33, 231t
Philosophy, organizational, 14
Phone calls, managing, 218, 219–20
Planning, 50–51, 226, 281

contingency, 51
strategic, 51

Plausible future, 383
Point-of-service plans (POS), 27
Policy, 119

public, 121–22
Political decision-making model, 133
Politics, 118–20

case study, 121
Pooled interdependence, 188
Pools

external, 269
internal, 268

Position control, 237
Position description, 242, 243b
Position power, 112–13
Possible future, 383
Posttraumatic stress disorders (PTSD), 361.

See also Stress
Power

coercive, 112
connection, 112
defined, 111
expert, 112
guidelines for usage, 113b
image as, 114–16
information, 112
and leadership, 111–13
legitimate, 112
position, 112–13
principle-centered, 111
referent, 112
reward, 111–12
types of, 111–12
use of, 114–17, 116b

Power–coercive strategies, 67
Power plays, 117
Practice partnerships, 36, 36f
Preceptors, 277–78
Preferable future, 383
Preferred provider organizations (PPOs), 27
Premiums, 232
Primary care, 23
Primary nursing, 35–36
Principle-centered power, 111
Priorities, determining, 215, 215t
Private law, 98
Probability analysis, 132, 132t
Probable future, 383
Problem solving

case study, 130
critical thinking and, 139
decision making vs., 130
group, 140–41
methods, 135–37
obstacles to, 141. See also Stumbling blocks
process of, 137–39, 137b

Process standards, 78
Process theories, motivation, 273
Productivity, group, 188
Product-line structure. See Service-line structure
Professional associations, 378
Profit, 230
Profit centers, 227
Progressive discipline, 301, 302

case study, 303
Public law, 98
Public officials, working with, 121b
Punishment, in reinforcement theory, 274

Q
Quality and Safety Education for Nurses (QSEN), 5
Quality improvement, health care, 80–82

dashboards, use of, 82
electronic health records, 82
evidence-based practice, 82
medication errors and, 83
national initiatives for, 81–82
peer review and, 87
rounding, 82

Quality management, 3–4, 76–80
components of, 77–78
continuous quality improvement, 77
DMAIC method, 79–80, 79f
Lean Six Sigma, 79
Six Sigma, 78–79
total quality management, 76–77, 77f

Quantity variance, 236
Quantum leadership, 46

R
Rate variances, 236
Rational decision-making model, 132–33
Rationing, 97
Real (command) groups, 180
Reality shock, 360
Reciprocal interdependence, 188
Recruitment. See Staff, recruitment and selection
Redesign, 28
Reductive/classical theory, 15–17, 16f, 17f

chain of command, 16, 16f
division and specialization of labor, 15
organizational structures, 16
span of control, 16–17, 17f

Referent power, 112
Re-forming, 184
Registered nurses (RNs), 35, 36, 164, 172

baccalaureate degree for, 376
medical intensive care unit, 243b

Reinforcement theory (behavior modification), 274–75
Reliability, interview, 253
Reportable incident, 85
Residency programs, nurse, 279
Resistance, to change, 68–69

management, 68–69
Resisting, in conflict management, 207
Resolution, 203, 204
Respondeat superior, 99
Responsibility, 164
Restraining forces, 62

410 Index

Résumé, 368
sample, 368–69b
writing

accomplishments, 369
education achievements, 369
employment, 369

Retail medicine, 23
Retention, generational differences and, 310
Revenue budget, 229–30
Revenue centers, 227
Reverse delegation, 175. See also Ineffective delegation
Reward power, 111–12
Rewards, for employees, 319b
Right-to-work state, 350
Risk management, 83–90

blame-free environment and, 90
case study, 89
incident examples, 85–86
incident reports, 84–85
nurse manager’s role, 87–90
nursing’s role in, 84
root-cause analysis, 87

Robert Wood Johnson Foundation, 38
Robotics, 6

laser-guided, 6
Rogers’change theory, 62t, 63
Role ambiguity

role underload, 360
underutilization, 360

Role conflict, 360. See also Conflict
Role redefinition, 361. See also Stress
Roles, 185–86

conflicts, 201
nurturing, 185
task, 185

Root-cause analysis, 87
Rounding, 82
Routine decisions, 130

S
Salary compression, 317
Salary increases, 233
Salary (personnel) budget, 230–33, 231t
Satisficing, 133
“Scatter-gun” approach, 246
Scheduling

automated, 268
case study, 267
self-scheduling, 266

Self-directed work teams, 47
Self-evaluation, 289–90

developmental plan, 290
Self-scheduling, 266
Sequential interdependence, 188
Servant leadership, 48
Service-line structure, 20–21, 20f
Sexual harasment, 107
Shaping, 274
Shared governance, 47, 190

organizational structures and, 22
Shared leadership, 47
Shared schedule, 267
Shared visioning, 117–18

Shift differentials, 232
Six Sigma, 78–79

as goal, 78
as management system, 78
as measure, 78
themes of, 79

Smoothing, in conflict management, 207
Social exchange theory, 46
Social system, 182–83, 183f
Societal change, 7–8
Spaghetti diagram, 79–80, 80f
Span of control, 16–17, 17f
Spending variances, 236
Staff

attendance model. See Employee attendance model
case study, 327–28
coaching, 278–79, 297, 298–99
confronting behavior, 299, 300t
development. See Staff development
discipline. See Discipline
distribution of, 264–65
impact on budget, 237–39
involvement in interview process, 252
problematic behaviors, 324–26

bullying, 324
disgruntled employees, 327
handling, 326–27
horizontal violence, 325–26
lack of civility, 324–25
marginal employees, 327

recruitment and selection
case study, 258
education and experience requirements, 253–54
interviews for. See Interview
legal considerations in, 255–58, 257t
licensure requirements, 254
process, 242, 244–47, 247b
purpose of, 242
strategy, 243–47

retaining. See Staff retention
substance abuse, 328–30, 328b, 329b
supplementing, 268–69
termination, 303–4, 304b
utilization in emergencies, 336–37

Staff authority, 16, 16f
Staff development, 275

coaching and, 278–79
mentoring in, 278
on-the-job instruction and, 276–77
orientation in, 276
preceptors, 277–78
residency programs and, 279

Staffing, 261–62. See also Scheduling
block, 265
combined

advantages of, 266
problems of, 266

distribution of staff and, 264–65
flexible patterns, 266
full-time equivalents in, 263–65
goal of, 261
as management issues, 105
mix, 264

Index 411

nurse, principles of, 262b
nursing care hours, determination of, 263
patient classification systems, 262–63
weekend plan, 267–68

Staffing mix, 264
Staff nurse, 52, 54
Staff retention, 316–20

case study, 319
employee engagement and, 316
healthy work environment and, 317
job satisfaction and, 316–17
salaries and, 317
strategies, 318–20

intraorganizational mobility, 318, 319
turnover rate, 320

Stakeholders, 120
Status, 185–86

incongruence, 186
Statutory law, 98
Storming, 183
Strategic planning, 51
Stress

causes of, 358–60
individual, 359–60
interpersonal, 358–59
organizational, 358

consequences of, 360–61
absenteeism, 361
burnout, 360–61
compassion fatigue, 361
depression, 360
perfectionism, 360
physical illnesses, 360
posttraumatic stress disorders, 361

defined, 357
management, 361–64

case study, 363
employee assistance programs, 363
mindfulness, 362
role redefinition, 361
time management, 362

nature of, 357–58
Strike, 352
Structural conflict, 202
Structure standards, 78
Stumbling blocks

personality, 141
preconceived ideas, 141
rigidity, 141

Subjective probability, 132
Substance abuse

Americans with Disabilities Act and, 330
intervention strategies, 329–30
nursing and, 328–30
reentry to workplace, 330
state boards of nursing, 329

Succession planning, in motivation, 281
Superiors, communication with, 154–56, 154b
Supply and nonsalary expense budget, 233–34
Suppression, conflict, 203, 207
Surge capacity, 335–36
Synchronous channels, of communication, 148
Systems theory, 18

T
Task forces, 180, 192

managing of, 193, 194–95
meeting, 194–95
reports, 195

Task group, 180
Task interdependence, 201
Teaching hospital, 23
Team building, 186

activities, 187
assessment, 186–87
case study, 191

Team nursing, 35
Team(s). See also Group(s)

defined, 181
managing. See Managing teams
multidisciplinary, 191
norms, 184
performance evaluation, 191
process, 182–86, 183f

Team Strategies and Tools to Enhance Performance and Patient
Safety (TeamSTEPPS), 187

Technology, and healthcare, 384–85
Telehealth, 6
Telephone interview, 372
Termination, staff, 303–4, 304b
Text messages, 220
Thomas-Kilmann Conflict Mode Instrument, 200
Throughputs, 18
Time logs, 213, 213t
Time management, 211–12, 362. See also Stress

case study, 218
controlling interruptions in, 217–21
goal setting in, 214–17
grouping activities for, 216
ineffective, 212b
minimizing routine work for, 216
personal organization and self-discipline in, 217
planning and scheduling, 216
priorities, determining, 215, 215t
respecting time in, 222

Time-wasters, 212–13
Title I of Americans with Disabilities Act (ADA)

of 1990, 107, 255
Title VII of Civil Rights Act, 107, 255
To-do list, 216
Total patient care, 35
Total quality management (TQM), 76–77, 77f

characteristics of, 77
description of, 76

Total time lost, 308
Traditional leadership theories, 45
Traditional models, nursing care delivery, 34

functional nursing, 35
primary nursing, 35–36
team nursing, 35
total patient care, 35

Transactional communication model,
147, 147f

Transactional leadership, 46
Transformational leadership, 46–47
Transitions, 71
Trial-and-error method, 135–36

412 Index

Turnover, 314–16
causes of, 315
involuntary, 315
nursing, cost of, 314
voluntary, 315–16

U
Underdelegation, 174–75. See also Ineffective delegation
Unionization. See also Collective bargaining

certification to contract, 351
contract administration, 351
and grievances. See Grievances
process of, 350–51
selection of bargaining agent, 351

Unlicensed assistive personnel (UAP), 35, 166, 172
Unplanned change, 72
Upward communication, 150. See also Communication
U.S. Census Bureau, 7
U.S. Supreme Court, 350

V
Validity, interview, 253
Value-based purchasing (VBP), 82
Values, and beliefs, 202
Variable budget, 229
Variable costs, 230
Variance, 234

analysis of, 235–36
efficiency, 236
nonsalary expenditure, 236
rate, 236
salary, 236
volume, 236

Verbal warning, 301, 301b
Vertical integration, 26, 26f

Vicarious liability, 99
Violence

horizontal, 325–26, 341
workplace. See Workplace violence

Vision statement, 15
Voice mail, 148, 219
Volume variances, 236
Voluntarily, as informed consent element, 102
Voluntary absenteeism, 308. See also Absenteeism
Voluntary turnover, 315–16. See also Turnover

W
Weekend staffing plan, 267–68
Western Electric Company, 17
Wildcards, 383
Withdrawal, in conflict management, 207
Work environment, and job satisfaction, 317
Workplace violence, 8

case study, 346
consequences of, 342
defined, 341
factors contributing to, 341–43
handling incident, 344–46, 345b

verbal intervention, 344, 344b
incidence of, 341
post-incident follow-up, 346–47, 347b
prevention strategies, 343–44

employee education, 343
environmental controls, 343–44
zero-tolerance policies, 343

Work sample questions, 252
Written warning, 301, 302b

Z
Zero-based budget, 228

Cover

Title Page

Copyright Page

About the Author

Thank You

Preface

Brief Contents

Acknowledgments

Contents

Part 1 Understanding Nursing Management and Organizations����������������������������������������������������������������

1 Introducing Nursing Management���������������������������������������

Introduction�������������������

Changes in Healthcare����������������������������

Paying for Healthcare����������������������������

Changes in Society�������������������������

Cultural, Gender, and Generational Differences�����������������������������������������������������

Violence, Pandemics, and Disasters�����������������������������������������

Changes in Nursing’s Future����������������������������������

Current Status of Nursing��������������������������������

Institute of Medicine’s Recommendations for Nursing����������������������������������������������������������

Adapting to Constant Change����������������������������������

What You Know Now������������������������

Questions to Challenge You���������������������������������

References�����������������

2 Designing Organizations��������������������������������

Introduction�������������������

Reductive and Adaptive Organizational Theories�����������������������������������������������������

Reductive Theory�����������������������

Humanistic Theory as a Bridge������������������������������������

Adaptive Theories������������������������

Organizational Structures and Shared Governance������������������������������������������������������

Functional Structure���������������������������

Service-line Structure�����������������������������

Matrix Structure�����������������������

Parallel Structure�������������������������

Shared Governance������������������������

Healthcare Settings��������������������������

Primary Care�������������������

Acute Care Hospitals���������������������������

Home Healthcare����������������������

Long-term Care���������������������

Ownership and Complex Healthcare Arrangements����������������������������������������������������

Ownership of Healthcare Organizations��������������������������������������������

Healthcare Networks��������������������������

Interorganizational Relationships����������������������������������������

Diversification����������������������

Managed Healthcare Organizations���������������������������������������

Accountable Care Organizations�������������������������������������

Redesigning Healthcare�����������������������������

Organizational Environment and Culture���������������������������������������������

What You Know Now������������������������

Questions to Challenge You���������������������������������

References�����������������

3 Delivering Nursing Care��������������������������������

Introduction�������������������

Traditional Models of Care���������������������������������

Total Patient Care�������������������������

Functional Nursing�������������������������

Team Nursing�������������������

Primary Nursing����������������������

Integrated Models of Care��������������������������������

Practice Partnerships����������������������������

Case Management����������������������

Critical Pathways������������������������

Evolving Models of Care������������������������������

Patient-centered Care����������������������������

Synergy Model of Care����������������������������

Patient-centered Medical Home������������������������������������

What You Know Now������������������������

Questions to Challenge You���������������������������������

References�����������������

4 Leading, Managing, Following�������������������������������������

Introduction�������������������

Leaders and Managers���������������������������

Leadership�����������������

Leadership Theories��������������������������

Traditional Leadership Theories��������������������������������������

Contemporary Leadership Theories���������������������������������������

Followership: An Essential Component of Leadership���������������������������������������������������������

Traditional Management Functions���������������������������������������

Planning���������������

Organizing�����������������

Directing����������������

Controlling������������������

Nurse Managers in Practice���������������������������������

Nurse Manager Competencies���������������������������������

Staff Nurse������������������

First-level Management�����������������������������

Charge Nurse�������������������

Clinical Nurse Leader����������������������������

What You Know Now������������������������

Tools for Leading, Managing, and Following�������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

5 Initiating and Managing Change���������������������������������������

Introduction�������������������

The Nurse as Change Agent��������������������������������

Change Theories����������������������

The Change Process�������������������������

Step 1: Identify the Problem or Opportunity��������������������������������������������������

Step 2: Collect Necessary Data and Information�����������������������������������������������������

Step 3: Select and Analyze Data��������������������������������������

Step 4: Develop a Plan for Change, Including Time Frame and Resource���������������������������������������������������������������������������

Step 5: Identify Supporters and Opposers�����������������������������������������������

Step 6: Implement Interventions to Achieve Desired Change����������������������������������������������������������������

Step 7: Evaluate Effectiveness of the Change and, if Successful, Stabilize the Change��������������������������������������������������������������������������������������������

Change Strategies������������������������

Power–Coercive Strategies��������������������������������

Empirical–Rational Model Strategies������������������������������������������

Normative–Reeducative Strategies���������������������������������������

Resistance to Change���������������������������

The Nurse’s Role�����������������������

Initiating Change������������������������

Implementing Change��������������������������

Unplanned Change�����������������������

Handling Constant Change�������������������������������

What You Know Now������������������������

Tools for Initiating and Managing Change�����������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

6 Managing and Improving Quality���������������������������������������

Introduction�������������������

Quality Management�������������������������

Total Quality Management�������������������������������

Continuous Quality Improvement�������������������������������������

Components of Quality Management���������������������������������������

Six Sigma����������������

Lean Six Sigma���������������������

DMAIC Method�������������������

Improving the Quality of Care������������������������������������

National Initiatives���������������������������

Evidence-based Practice������������������������������

Electronic Health Records��������������������������������

Dashboards�����������������

Rounding���������������

Reducing Medication Errors���������������������������������

Risk Management����������������������

Nursing’s Role in Risk Management����������������������������������������

Incident Reports�����������������������

Examples of Risk�����������������������

Root-cause Analysis��������������������������

Peer Review������������������

Role of the Nurse Manager��������������������������������

Creating a Blame-free Environment����������������������������������������

What You Know Now������������������������

Tools for Managing and Improving Quality�����������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

7 Understanding Legal and Ethical Issues�����������������������������������������������

Introduction�������������������

Law and Ethics���������������������

Ethical Decision Making������������������������������

Autonomy���������������

Beneficence and Nonmaleficence�������������������������������������

Distributive Justice���������������������������

The Legal System�����������������������

Sources of Law���������������������

Types of Law�������������������

Liability����������������

Legal Issues in Nursing������������������������������

Nursing Licensure������������������������

Patient Care Rights��������������������������

Management Issues������������������������

Employment Issues������������������������

What You Know Now������������������������

Questions to Challenge You���������������������������������

References�����������������

8 Understanding Power and Politics�����������������������������������������

Introduction�������������������

Power and Leadership���������������������������

Power: How Managers and Leaders Get Things Done������������������������������������������������������

Using Power������������������

Image as Power���������������������

Using Power Appropriately��������������������������������

Shared Visioning as a Power Tool���������������������������������������

Power, Politics, and Policy����������������������������������

Nursing’s Political History����������������������������������

Using Political Skills to Influence Policies���������������������������������������������������

Influencing Public Policies����������������������������������

How Nurses Can Influence the Future������������������������������������������

What You Know Now������������������������

Tools for Using Power and Politics�����������������������������������������

Questions to Challenge You���������������������������������

References�����������������

Part 2 Learning Key Skills in Nursing Management�������������������������������������������������������

9 Thinking Critically, Making Decisions, Solving Problems����������������������������������������������������������������

Introduction�������������������

Critical Thinking������������������������

Critical Thinking in Nursing�����������������������������������

Using Critical Thinking������������������������������

Creativity�����������������

Decision Making����������������������

Types of Decisions�������������������������

Decision-making Conditions���������������������������������

The Decision-making Process����������������������������������

Decision-making Techniques���������������������������������

Group Decision Making����������������������������

Problem Solving����������������������

Problem-solving Methods������������������������������

The Problem-solving Process����������������������������������

Group Problem Solving����������������������������

Stumbling Blocks�����������������������

Personality������������������

Rigidity���������������

Preconceived Ideas�������������������������

Innovation�����������������

What You Know Now������������������������

Tools for Making Decisions and Solving Problems������������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

10 Communicating Effectively�����������������������������������

Introduction�������������������

Communication��������������������

Transactional Model of Communication�������������������������������������������

Channels of Communication��������������������������������

Nonverbal Messages�������������������������

Directions of Communication����������������������������������

Effective Listening��������������������������

Effects of Differences in Communication����������������������������������������������

Gender Differences in Communication������������������������������������������

Generational and Cultural Differences in Communication�������������������������������������������������������������

Differences in Organizational Culture��������������������������������������������

The Role of Communication in Leadership����������������������������������������������

Employees����������������

Administrators���������������������

Coworkers����������������

Medical Staff��������������������

Other Healthcare Personnel���������������������������������

Patients and Families����������������������������

Collaborative Communication����������������������������������

Enhancing Your Communication Skills������������������������������������������

What You Know Now������������������������

Tools for Communicating Effectively������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

11 Delegating Successfully���������������������������������

Introduction�������������������

Delegation�����������������

Benefits of Delegation�����������������������������

Benefits to the Nurse����������������������������

Benefits to the Delegate�������������������������������

Benefits to the Manager������������������������������

Benefits to the Organization�����������������������������������

The Five Rights of Delegation������������������������������������

The Delegation Process�����������������������������

Steps in the Delegation Process��������������������������������������

Key Behaviors for Successful Delegation����������������������������������������������

Accepting Delegation���������������������������

Ineffective Delegation�����������������������������

Organizational Culture�����������������������������

Lack of Resources������������������������

An Insecure Delegator����������������������������

An Unwilling Delegate����������������������������

Underdelegation����������������������

Reverse Delegation�������������������������

Overdelegation���������������������

What You Know Now������������������������

Tools for Delegating Successfully����������������������������������������

Questions to Challenge You���������������������������������

References�����������������

12 Building and Managing Teams�������������������������������������

Introduction�������������������

Groups and Teams�����������������������

Group Interaction������������������������

Group Leadership�����������������������

Group and Team Processes: Homans Framework�������������������������������������������������

Norms������������

Roles������������

Building Teams���������������������

Assessment�����������������

Team-building Activities�������������������������������

Managing Teams���������������������

Task�����������

Group Size and Composition���������������������������������

Productivity and Cohesiveness������������������������������������

Development and Growth�����������������������������

Shared Governance������������������������

The Nurse Manager as Team Leader���������������������������������������

Communication��������������������

Evaluating Team Performance����������������������������������

Leading Committees and Task Forces�����������������������������������������

Guidelines for Conducting Meetings�����������������������������������������

Managing Task Forces���������������������������

Patient Care Conferences�������������������������������

What You Know Now������������������������

Tools for Building and Managing Teams��������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

13 Handling Conflict���������������������������

Introduction�������������������

Conflict���������������

Interprofessional Conflict���������������������������������

Conflict Process Model�����������������������������

Antecedent Conditions����������������������������

Perceived and Felt Conflict����������������������������������

Conflict Behaviors�������������������������

Conflict Resolved or Suppressed��������������������������������������

Outcomes���������������

Managing Conflict������������������������

Conflict Responses�������������������������

Alternative Dispute Strategies�������������������������������������

What You Know Now������������������������

Tools for Handling Conflict����������������������������������

Questions to Challenge You���������������������������������

Resources����������������

References�����������������

14 Managing Time�����������������������

Introduction�������������������

Time-wasters�������������������

Setting Goals��������������������

Determining Priorities�����������������������������

Daily Planning and Scheduling������������������������������������

Grouping Activities and Minimizing Routine Work������������������������������������������������������

Personal Organization and Self-discipline������������������������������������������������

Controlling Interruptions��������������������������������

Phone Calls, Voice Mail, Email, and Text Messages��������������������������������������������������������

In-person Interruptions������������������������������

Paperwork����������������

Controlling Time in Meetings�����������������������������������

Respecting Time����������������������

What You Know Now������������������������

Tools for Managing Time������������������������������

Questions to Challenge You���������������������������������

References�����������������

Part 3 Managing Resources��������������������������������

15 Budgeting and Managing Fiscal Resources�������������������������������������������������

Introduction�������������������

The Budgeting Process����������������������������

Timetable for the Budgeting Process������������������������������������������

Approaches to Budgeting������������������������������

Incremental Budget�������������������������

Zero-based Budget������������������������

Fixed or Variable Budgets��������������������������������

The Operating Budget���������������������������

The Revenue Budget�������������������������

The Expense Budget�������������������������

Determining the Salary and Nonsalary Budget��������������������������������������������������

The Salary Budget������������������������

The Supply and Nonsalary Expense Budget����������������������������������������������

The Capital Budget�������������������������

Monitoring and Controlling Budgetary Performance During the Year�����������������������������������������������������������������������

Variance Analysis������������������������

Position Control�����������������������

Staff Impact on Budget�����������������������������

Improving Performance����������������������������

What You Know Now������������������������

Tools for Budgeting and Managing Resources�������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

16 Recruiting and Selecting Staff����������������������������������������

Introduction�������������������

The Recruitment and Selection Process��������������������������������������������

Recruiting Applicants����������������������������

Where to Look��������������������

How to Look������������������

When to Look�������������������

How to Promote the Organization��������������������������������������

Cross-training as a Recruitment Strategy�����������������������������������������������

Selecting Candidates���������������������������

Interviewing Candidates������������������������������

Principles for Effective Interviewing��������������������������������������������

Involving Staff in the Interview Process�����������������������������������������������

Interview Reliability and Validity�����������������������������������������

Making a Hire Decision�����������������������������

Education, Experience, and Licensure�������������������������������������������

Integrating the Information����������������������������������

Making an Offer����������������������

Legality in Hiring�������������������������

What You Know Now������������������������

Tools for Recruiting and Selecting Staff�����������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

17 Staffing and Scheduling���������������������������������

Introduction�������������������

Staffing���������������

Patient Classification Systems�������������������������������������

Determining Nursing Care Hours�������������������������������������

Planning FTE Workforce�����������������������������

Determining Staffing Mix�������������������������������

Determining Distribution of Staff����������������������������������������

Scheduling�����������������

Self-staffing and Scheduling�����������������������������������

Shared Schedule����������������������

Open Shift Management����������������������������

Weekend Staffing Plan����������������������������

Automated Scheduling���������������������������

Supplementing Staff��������������������������

Internal Pools���������������������

External Pools���������������������

What You Know Now������������������������

Tools for Handling Staffing and Scheduling�������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

18 Motivating and Developing Staff�����������������������������������������

Introduction�������������������

A Model of Job Performance���������������������������������

Employee Motivation��������������������������

Motivational Theories����������������������������

Staff Development������������������������

Orientation������������������

On-the-job Instruction�����������������������������

Preceptors�����������������

Mentoring����������������

Coaching���������������

Nurse Residency Programs�������������������������������

Career Advancement�������������������������

Leadership Development�����������������������������

Succession Planning��������������������������

What You Know Now������������������������

Tools for Motivating and Developing Staff������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

19 Evaluating Staff Performance��������������������������������������

Introduction�������������������

Performance Management�����������������������������

The Performance Evaluation Process�����������������������������������������

Management Responsibilities����������������������������������

Components of the Annual Performance Evaluation������������������������������������������������������

Developing Evaluation Tools����������������������������������

Methods for Collecting Performance Data����������������������������������������������

Peer Review������������������

Self-evaluation����������������������

Skill Competency�����������������������

Manager’s Evaluation���������������������������

Facing the Challenges of Performance Review��������������������������������������������������

Conducting the Annual Performance Review�����������������������������������������������

What You Know Now������������������������

Tools for Evaluating Staff Performance���������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

20 Feedback and Coaching, Disciplining, and Terminating Staff��������������������������������������������������������������������

Introduction�������������������

Feedback���������������

Coaching���������������

Feedback versus Coaching�������������������������������

Confronting Behavior���������������������������

Discipline�����������������

Termination������������������

What You Know Now������������������������

Tools for Feedback and Coaching, Disciplining and Terminating Staff��������������������������������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

21 Managing Absenteeism, Reducing Turnover, Retaining Staff

Introduction�������������������

Absenteeism������������������

A Model of Employee Attendance�������������������������������������

Managing Employee Absenteeism������������������������������������

Absenteeism Policies���������������������������

Selecting Employees and Monitoring Absenteeism�����������������������������������������������������

Family and Medical Leave�������������������������������

Reducing Turnover������������������������

Cost of Nursing Turnover�������������������������������

Causes of Turnover�������������������������

Understanding Voluntary Turnover���������������������������������������

Retaining Staff����������������������

Job Satisfaction�����������������������

Improving Salaries�������������������������

Retention Strategies���������������������������

What You Know Now������������������������

Tools for Reducing Turnover, Retaining Staff���������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

22 Dealing with Disruptive Staff Problems������������������������������������������������

Introduction�������������������

Harassing Behaviors��������������������������

Bullying���������������

Lack of Civility�����������������������

Horizontal Violence��������������������������

How to Handle Problem Behaviors��������������������������������������

Marginal Employees�������������������������

Disgruntled Employees����������������������������

The Employee with a Substance Abuse Problem��������������������������������������������������

State Board of Nursing�����������������������������

Strategies for Intervention����������������������������������

Reentry��������������

The Americans with Disabilities Act and Substance Abuse��������������������������������������������������������������

What You Know Now������������������������

Tools for Managing Staff Problems����������������������������������������

Questions to Challenge You���������������������������������

References�����������������

23 Preparing for Emergencies�����������������������������������

Introduction�������������������

Types of Emergencies���������������������������

Natural Disasters������������������������

Man-made Disasters�������������������������

Levels of Disasters��������������������������

Hospital Preparedness for Emergencies��������������������������������������������

All-hazards Approach���������������������������

Emergency Operations Plan��������������������������������

Surge Capacity���������������������

Disaster Triage����������������������

Continuation of Services�������������������������������

Staff Utilization in Emergencies���������������������������������������

What You Know Now������������������������

Tools for Preparing for Emergencies and Preventing Violence������������������������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

24 Preventing Workplace Violence���������������������������������������

Introduction�������������������

Violence in Healthcare�����������������������������

Incidence of Workplace Violence��������������������������������������

Horizontal Violence��������������������������

Consequences of Workplace Violence�����������������������������������������

Factors Contributing to Violence in Healthcare�����������������������������������������������������

Preventing Violence��������������������������

Zero-tolerance Policies������������������������������

Reporting and Education������������������������������

Environmental Controls�����������������������������

Dealing with Violence����������������������������

Verbal Intervention��������������������������

A Violent Incident�������������������������

Other Dangerous Incidents��������������������������������

Post-incident Follow-up������������������������������

What You Know Now������������������������

Tools for Preventing Violence������������������������������������

Questions to Challenge You���������������������������������

References�����������������

25 Handling Collective Bargaining Issues�����������������������������������������������

Introduction�������������������

Laws Governing Unions����������������������������

Process of Unionization������������������������������

Handling Grievances��������������������������

Unfair Labor Practices�����������������������������

The Grievance Process����������������������������

Collective Bargaining and Nurses���������������������������������������

Legal Issues of Supervision����������������������������������

The Future of Collective Bargaining for Nurses�����������������������������������������������������

What You Know Now������������������������

Tools for Handling Collective Bargaining Issues������������������������������������������������������

Questions to Challenge You���������������������������������

References�����������������

Part 4 Taking Care of Yourself�������������������������������������

26 Managing Stress�������������������������

Introduction�������������������

The Nature of Stress���������������������������

Causes of Stress�����������������������

Organizational Factors�����������������������������

Interpersonal Factors����������������������������

Individual Factors�������������������������

Consequences of Stress�����������������������������

Managing Stress����������������������

Personal Methods�����������������������

Organizational Methods�����������������������������

What You Know Now������������������������

Tools for Managing Stress��������������������������������

Questions to Challenge You���������������������������������

References�����������������

27 Advancing Your Career�������������������������������

Introduction�������������������

Envisioning Your Future������������������������������

Acquiring Your First Position������������������������������������

Applying for the Position��������������������������������

The Interview��������������������

Accepting the Position�����������������������������

Declining the Position�����������������������������

Progressing in Your Career���������������������������������

Tracking Your Progress�����������������������������

Identifying Your Learning Needs��������������������������������������

Finding and Using Mentors��������������������������������

Considering Your Next Position�������������������������������������

Finding Your Next Position���������������������������������

Leaving Your Present Position������������������������������������

Adapting to Change�������������������������

What You Know Now������������������������

Tools for Advancing Your Career��������������������������������������

Questions to Challenge You���������������������������������

Online Resources�����������������������

References�����������������

Part 5 Looking to the Future�����������������������������������

28 Imagining the Future������������������������������

Introduction�������������������

Ways to Consider the Future����������������������������������

Possible Future����������������������

Plausible Future�����������������������

Probable Future����������������������

Preferable Future������������������������

Societal Predictions About the Future��������������������������������������������

The Future of Healthcare�������������������������������

Technological Innovations��������������������������������

Healthcare Legislation�����������������������������

Demands of Consumerism�����������������������������

The Future of Nursing����������������������������

Institute of Medicine Recommendations��������������������������������������������

New Careers in Nursing Project�������������������������������������

What You Know Now������������������������

Questions to Challenge You���������������������������������

References�����������������

Glossary���������������

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Credits��������������

Index������������

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2017-04-08T08:42:51+0000

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Leadership Roles and
Management Functions
in Nursing
Theory and Application
Bessie L. Marquis, RN, MSN
Professor Emeritus of Nursing
California State University
Chico, California
Carol J. Huston, RN, MSN, DPA, FAAN
Director, School of Nursing
California State University
Chico, California
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8th edition
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Library of Congress Cataloging-in-Publication Data
Marquis, Bessie L., author.
Leadership roles and management functions in nursing: theory and application/Bessie L. Marquis, Carol
J. Huston.—8th edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4511-9281-0 — ISBN 1-4511-9281-9
I. Huston, Carol Jorgensen, author. II. Title.
[DNLM: 1. Leadership. 2. Nursing, Supervisory. 3. Nurse Administrators. 4. Nursing—organization
& administration. WY 105]
RT89
362.17′3068—dc23
2013036678
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted
practices. However, the author(s), editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this
information in a particular situation remains the professional responsibility of the practitioner; the clinical
treatments described and recommended may not be considered absolute and universal recommendations.
The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage
set forth in this text are in accordance with the current recommendations and practice at the time of
publication. However, in view of ongoing research, changes in government regulations, and the constant
flow of information relating to drug therapy and drug reactions, the reader is urged to check the package
insert for each drug for any change in indications and dosage and for added warnings and precautions. This is
particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of the health-care provider to
ascertain the FDA status of each drug or device planned for use in his or her clinical practice.
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I dedicate this book to the two most important
partnerships in my life: my husband, Don Marquis,
and my colleague, Carol Huston.
BESSIE L. MARQUIS
I dedicate this book to my mother Marilyn Jorgensen.
You are one of the reasons
I have become the capable woman I am today.
CAROL JORGENSEN HUSTON
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Reviewers
Carol Amann, MSN, RN-BC, CDP
Instructor
Gannon University
Erie, Pennsylvania
Joanne Casatelli, DNP
Molloy College
Rockville Centre, New York
Joanne Clements, MS, RN, ACNP
Assistant Professor of Clinical Nursing
University of Rochester
Rochester, New York
Margaret Decker, MS, RN, CNE
Clinical Assistant Professor
Binghamton University
Binghamton, New York
Hobie Feagai, EdD, MSN, FNP-BC, APRN-Rx
Chair
Department of Baccalaureate Nursing Program
Hawaii Pacific University
Kaneohe, Hawaii
Lisa Marie Greenwood, MSN, RN, APRN-BC, CWOCN, CNS
Nursing Instructor
Madison Area Technical College
Reedsburg, Wisconsin
Vonna Henry, BSN, MPH, RN
Assistant Professor
St. Cloud State University
St. Cloud, Minnesota
Debora Kirsch, RN, MS, CNS
Director of Undergraduate Nursing Studies
SUNY Upstate Medical University
Syracuse, New York
v
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vi reviewers
Carole McCue, RN, MS, CNE
Instructor
Cochran School of Nursing
Yonkers, New York
Jennifer Douglas Pearce, MSN, RN, CNE
Professor and Chairperson
University of Cincinnati
Blue Ash, Ohio
Tawna Pounders, RN, MNSc
Coordinator and Medical-Surgical Theory Faculty
Baton Rouge Community College
Baton Rouge, Louisiana
Loretta Quigley, MSN
Academic Dean
St. Joseph’s College of Nursing
Syracuse, New York
Elaine Rose, RN, BN, MHS, DM(c)
Assistant Professor
Mount Royal University
Calgary, Alberta, Canada
Charlotte Sortedahl, DNP, MPH, MS, RN
Assistant Professor
University of Wisconsin
Eau Claire, Wisconsin
Patricia Varga, MSN, RN
Assistant Professor
Alverno College
Milwaukee, Wisconsin

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Preface
This book’s philosophy has evolved over the past 30+ years of teaching leadership and
management. We entered academe from the acute care sector of the health-care industry,
where we held nursing management positions. In our first effort as authors, Management
Decision Making for Nurses: 101 Case Studies, published in 1987, we used an experiential
approach and emphasized management functions appropriate for first- and middle-level
managers. The primary audience for this text was undergraduate nursing students.
Our second book, Retention and Productivity Strategies for Nurse Managers, focused
on leadership skills necessary for managers to decrease attrition and increase productivity.
This book was directed at the nurse-manager rather than the student. The experience of
completing research for the second book, coupled with our clinical observations, compelled
us to incorporate more leadership content in our teaching and to write this book.
Leadership Roles and Management Functions in Nursing was also influenced by national
events in business and finance that led many to believe that a lack of leadership in management
was widespread. It became apparent that if managers are to function effectively in the rapidly
changing health-care industry, enhanced leadership and management skills are needed.
What we attempted to do, then, was to combine these two very necessary elements:
leadership and management. We do not see leadership as merely one role of management
nor management as only one role of leadership. We view the two as equally important and
necessarily integrated. We have attempted to show this interdependence by defining the
leadership components and management functions inherent in all phases of the management
process. Undoubtedly, a few readers will find fault with our divisions of management
functions and leadership roles; however, we felt it was necessary to first artificially separate
the two components for the reader, and then to reiterate the roles and functions. We do believe
strongly, however, that adoption of this integrated role is critical for success in management.
The second concept that shaped this book was our commitment to developing critical-
thinking skills through the use of experiential learning exercises and the promotion of whole-
brain thinking. We propose that integrating leadership and management and using whole-brain
thinking can be accomplished through the use of learning exercises. The majority of academic
instruction continues to be conducted in a teacher-lecturer–student-listener format, which
is one of the least effective teaching strategies. Few individuals learn best using this style.
Instead, most people learn best by methods that utilize concrete, experiential, self-initiated,
and real-world learning experiences.
In nursing, theoretical teaching is almost always accompanied by concurrent clinical
practice that allows concrete and real-world learning experience. However, the exploration of
leadership and management theory may have only limited practicum experience, so learners
often have little first-hand opportunity to observe middle- and top-level managers in nursing
practice. As a result, novice managers frequently have little chance to practice their skills before
assuming their first management position, and their decision making thus reflects trial-and-
error methodologies. For us, then, there is little question that vicarious learning, or learning
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viii Preface
through mock experience, provides students the opportunity to make significant leadership and
management decisions in a safe environment and to learn from the decisions they make.
Having moved away from the lecturer–listener format in our classes, we lecture for only a small
portion of class time. A Socratic approach, case study debate, and problem solving are emphasized.
Our students, once resistant to the experiential approach, are now our most enthusiastic supporters.
We also find this enthusiasm for experiential learning apparent in the workshops and seminars we
provide for registered nurses. Experiential learning enables management and leadership theory to
be fun and exciting, but most important, it facilitates retention of didactic material. The research
we have completed on this teaching approach supports these findings.
Although many leadership and management texts are available, our book meets the need
for an emphasis on both leadership and management and the use of an experiential approach.
Two hundred and fifty-nine learning exercises, taken from various health-care settings and
a wide variety of learning modes, are included to give readers many opportunities to apply
theory, resulting in internalized learning. In Chapter 1, we provide guidelines for using the
experiential learning exercises. We strongly urge readers to use them to supplement the text.
We also provide guidelines for instructors on thePoint, Wolters Kluwer Health’s
trademarked web-based course and content management system that is available to
instructors who adopt the text. We recommend its use. The Web site includes a test bank, an
image collection, suggestions for using the learning exercises, a glossary, and a large number
of PowerPoint slides with images.
TEXT ORGANIZATION
The first edition of Leadership Roles and Management Functions in Nursing presented the
symbiotic elements of leadership and management, with an emphasis on problem solving and
critical thinking. This eighth edition maintains this precedent with a balanced presentation
of a strong theory component along with a variety of real-world scenarios in the experiential
learning exercises. Nineteen new learning exercises have been added to this edition, further
strengthening the problem-based element of this text. Almost 200 displays, figures, and tables
(46 of which are new) help readers to visualize important concepts.
Responding to reviewer recommendations, we have added and deleted content. In
particular, we have attempted to strengthen the leadership component of the book while
maintaining a balance of management content. We have also added a chapter crosswalk
(pp. 15–22) of content based on the American Association of Colleges of Nursing (AACN)
Essentials of Baccalaureate Education for Professional Nursing Practice (2008); the AACN
Essentials of Master’s Education in Nursing (2011); the American Organization of Nurse
Executive (AONE) Competencies; and the Quality and Safety Education for Nurses (QSEN)
Competencies. This crosswalk shows how content in each chapter draws from or contributes
to content identified as essential for baccalaureate and graduate education, for practice as a
nurse administrator, and for safety and quality in clinical practice.
We have also retained the strengths of earlier editions, reflecting content and application
exercises appropriate to the issues faced by nurse-leader-managers as they practice in an era
increasingly characterized by limited resources and emerging technologies. The eighth edition
also includes contemporary research and theory to ensure accuracy of the didactic material.
Unit I provides a foundation for the decision-making, problem-solving, and critical-
thinking skills, as well as management and leadership skills needed to address the
management–leadership problems presented in the text. Unit II covers ethics, legal concepts,
and advocacy, which we see as core components of leadership and management decision
making. The remaining units are organized using the management processes of planning,
organizing, staffing, directing, and controlling.

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Preface ix
LEARNING TOOLS
The eighth edition contains many pedagogical features designed to benefit both the student
and the instructor:
Examining the Evidence, appearing in each chapter, depicts new research findings,
evidence-based practice, and best practices in leadership and management.
Learning Exercises interspersed throughout each chapter foster readers’ critical-thinking
skills and promote interactive discussions. Additional learning exercises are also presented
at the end of each chapter for further study and discussion.
Breakout Comments are highlighted throughout each chapter, visually reinforcing key ideas.
Tables, displays, figures, and illustrations are liberally supplied throughout the text to
reinforce learning as well as to help clarify complex information.
Key Concepts summarize important information within every chapter.
NEW AND EXPANDED CONTENT
Additional content that has been added or expanded in this edition includes:
• Increased focus on evidence-driven leadership and management decision making
• New models for ethical problem solving and an increased emphasis on patient,
professional, and subordinate advocacy
• Expanded discussion of full-range leadership theory, transformational leadership, and
leadership competency identification
• Emerging leadership theories such as Strengths-Based Leadership and the Positive
Psychology Movement, Level 5 leadership, thought leadership, authentic leadership, and
servant leadership
• Introduction to Affordable Care Act in 2010, and the new Patient’s Bill of Rights
• Key components of the Patient Protection and Affordable Care Act (PPACA) as well as its
implementation plan between 2010 and 2014
• Health-care reform and financing mechanisms, including bundled payments, accountable
care organizations, value-based purchasing, medical homes, and health insurance
marketplaces
• The shifting in health-care reimbursement from volume to value
• Reflective practice and the professional portfolio
• Transition-to-practice programs/residencies for new graduate nurses
• Civility, incivility, bullying, mobbing, and workplace violence
• Visioning of health care’s future
• A broad discussion of social media as a communication tool and cause for work distraction
and the ethical issues encompassed in the topic
• Continuing competence, lifelong learning, nurse residencies, reflective practice, and the
professional portfolio
• Interprofessional collaboration including the Multidisciplinary Team Leader,
Interprofessional Primary Healthcare Teams, and Interprofessional Primary Health Care
Teams (PHCTs)
• The unique needs of a culturally diverse workforce as well as a workforce representing up
to four generations at the same time
• Nurse navigators
• Patient- and family-centered care
• Importance of self-care for nurses
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x Preface
• The use of ISBAR (Introduction, Situation, Background, Assessment, Recommendation) as
a tool to promote communication between care providers or between care providers and
patients/families
• Social media and organizational communication
• New mergers of collective bargaining agents to form super unions for nurses
• Leapfrog initiatives including electronic health records, computerized provider order
entry, evidence-based hospital staffing, and ICU physician staffing
• New Joint Commission core measures and National Patient Safety Goals
• The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
survey
• Patient safety and quality of care
thePoint (http://thepoint.lww.com), a trademark of Wolters Kluwer Health, is a web-based
course and content management system providing every resource that instructors and students
need in one easy-to-use site.
Instructor Resources
Advanced technology and superior content combine at thePoint to allow instructors to design
and deliver online and off-line courses, maintain grades and class rosters, and communicate
with students.
In addition, instructors will find the following content designed specifically for this
edition:
• Test bank
• Image bank
• Instructor’s guide, including guidelines for using the experiential learning exercises in
the text
• PowerPoint slides with images
Student Resources
Students can visit thePoint to access supplemental multimedia resources to enhance their
learning experience, download content, upload assignments, and join an online study group.
Students will also find a glossary that defines the italicized terms in the text.
THE CROSSWALK
New to this edition is a chapter crosswalk of content based on the AACN Essentials of
Baccalaureate Education for Professional Nursing Practice (2008); the AACN Essentials of
Master’s Education in Nursing (2011); the AONE Competencies; and the QSEN Competencies.
A crosswalk is a table that shows elements from different databases or criteria that interface.
This edition then attempts to show how content in each chapter draws from or contributes
to content identified as essential for baccalaureate and graduate education, for practice as a
nurse administrator, and for safety and quality in clinical practice.
Without doubt, some readers will disagree with the author’s determinations of which
Essential or Competency has been addressed in each chapter, and certainly, an argument
could be made that most chapters address many, if not all, of the Essentials or Competencies
in some way. The crosswalks in this book then are intended to note the primary content focus
in each chapter although additional Essentials or Competencies may well be a part of the
learning experience with each chapter.

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The American Association of Colleges of Nursing Essentials of
Baccalaureate Education for Professional Nursing Practice
The AACN Essentials of Baccalaureate Education for Professional Nursing Practice
(commonly called the BSN Essentials) were released in 2008 and identified the following
nine outcomes expected of graduates of baccalaureate nursing programs (Table 1). Essential
IX describes generalist nursing practice at the completion of baccalaureate nursing education
and includes practice-focused outcomes that integrate the knowledge, skills, and attitudes
delineated in Essentials I to VIII. Achievement of the outcomes identified in the BSN
Essentials will enable graduates to practice within complex health-care systems and to
assume the roles of provider of care; designer/manager/coordinator of care’; and member of
a profession (AACN, 2008) (Table 1).
TABLe 1 American Association of Colleges of Nursing Essentials of Baccalaureate Education for Professional Nursing Practice
Essential I: Liberal education for baccalaureate generalist nursing practice
• A solid base in liberal education provides the cornerstone for the practice and education of nurses
Essential II: Basic organizational and systems leadership for quality care and patient safety
• Knowledge and skills in leadership, quality improvement, and patient safety are necessary to provide high-quality health care.
Essential III: Scholarship for evidence-based practice
• Professional nursing practice is grounded in the translation of current evidence into one’s practice.
Essential IV: Information management and application of patient-care technology
• Knowledge and skills in information management and patient-care technology are critical in the delivery of quality patient care
Essential V: Health-care policy, finance, and regulatory environments
• Health-care policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the
health-care system and thereby are important considerations in professional nursing practice.
Essential VI: Interprofessional communication and collaboration for improving patient health outcomes
• Communication and collaboration among health-care professionals are critical to delivering high quality and safe patient care.
Essential VII: Clinical prevention and population health
• Health promotion and disease prevention at the individual and population level are necessary to improve population health and
are important components of baccalaureate generalist nursing practice.
Essential VIII: Professionalism and professional values
• Professionalism and the inherent values of altruism, autonomy, human dignity, integrity, and social justice are fundamental to
the discipline of nursing.
Essential IX: Baccalaureate generalist nursing practice
• The baccalaureate graduate nurse is prepared to practice with patients, including individuals, families, groups, communities,
and populations across the lifespan and across the continuum of health-care environments.
• The baccalaureate graduate understands and respects the variations of care, the increased complexity, and the increased use
of health-care resources inherent in caring for patients.
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xii Preface
The American Association of Colleges of Nursing Essentials of Master’s
Education in Nursing
The AACN Essentials of Master’s Education in Nursing (commonly called the MSN
Essentials) were published in March 2011 and identified the following nine outcomes
expected of graduates of master’s nursing programs, regardless of focus, major, or intended
practice setting (Table 2). Achievement of these outcomes will prepare graduate nurses to
lead change to improve quality outcomes, advance a culture of excellence through lifelong
learning, build and lead collaborative interprofessional care teams, navigate and integrate
care services across the health-care system, design innovative nursing practices, and translate
evidence into practice (AACN, 2011).
Essential I: Background for practice from sciences and humanities
• Recognizes that the master’s-prepared nurse integrates scientific findings from nursing, biopsychosocial fields, genetics, public
health, quality improvement, and organizational sciences for the continual improvement of nursing care across diverse settings.
Essential II: Organizational and systems leadership
• Recognizes that organizational and systems leadership are critical to the promotion of high quality and safe patient care.
Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a
systems perspective.
Essential III: Quality improvement and safety
• Recognizes that a master’s-prepared nurse must be articulate in the methods, tools, performance measures, and standards
related to quality, as well as prepared to apply quality principles within an organization.
Essential IV: Translating and integrating scholarship into practice
• Recognizes that the master’s-prepared nurse applies research outcomes within the practice setting, resolves practice
problems, works as a change agent, and disseminates results.
Essential V: Informatics and health-care technologies
• Recognizes that the master’s-prepared nurse uses patient-care technologies to deliver and enhance care and uses
communication technologies to integrate and coordinate care
Essential VI: Health policy and advocacy
• Recognizes that the master’s-prepared nurse is able to intervene at the system level through the policy development
process and to employ advocacy strategies to influence health and health care.
Essential VII: Interprofessional collaboration for improving patient and population health outcomes
• Recognizes that the master’s-prepared nurse, as a member and leader of interprofessional teams, communicates,
collaborates, and consults with other health professionals to manage and coordinate care.
Essential VIII: Clinical prevention and population health for improving health
• Recognizes that the master’s-prepared nurse applies and integrates broad, organizational, client-centered, and culturally
appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and
population care and services to individuals, families, and aggregates/identified populations.
Essential IX: Advanced generalist nursing practice
• Recognizes that nursing practice, at the master’s level, is broadly defined as any form of nursing intervention that
influences health-care outcomes for individuals, populations, or systems. Master’s-level nursing graduates must have an
advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into
practice. Nursing practice interventions include both direct and indirect care components.
TABLe 2 American Association of Colleges of Nursing Essentials of Master’s Education in Nursing

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The Quality and Safety Education for Nurses Competencies
Using the Institute of Medicine (2003) competencies for nursing, the QSEN Institute defined
six pre-licensure and graduate quality and safety competencies for nursing (Table 3) and
proposed targets for the knowledge, skills, and attitudes to be developed in nursing programs
for each of these competencies. Led by a national advisory board and distinguished faculty,
QSEN pursues strategies to develop effective teaching approaches to assure that future
graduates develop competencies in patient-centered care, teamwork and collaboration,
evidence-based practice, quality improvement, safety, and informatics.
TABLe 3 Quality and Safety Education for Nurses Competencies
Patient-centered care
• Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and
coordinated care based on respect for patient’s preferences, values, and needs.
Teamwork and collaboration
• Definition: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect,
and shared decision making to achieve quality patient care.
Evidence-based practice
• Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of
optimal health care.
Quality improvement
• Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes
to continuously improve the quality and safety of health-care systems.
Safety
• Definition: Minimizes the risk of harm to patients and providers through both system effectiveness and individual
performance.
Informatics
• Definition: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.
The American Organization of Nurse Executives – Nurse Executive
Competencies
In 2004, the AONE published a paper describing skills common to nurses in executive
practice regardless of their educational level or titles in different organizations. While these
Nurse Executive Competencies differed depending on the leader’s specific position in the
organization, the AONE suggested that managers at all levels must be competent in the five
areas noted in Table 4 (AONE, 2011). These competencies suggest that nursing leadership/
management is as much a specialty as any other clinical nursing specialty and as such, it
requires proficiency and competent practice specific to the executive role (AONE).
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xiv Preface
REFERENCES
TABLe 4 American Organization of Nurse Executive Competencies
I. Communication and relationship building
• Communication and relationship building includes effective communication; relationship management; influence of
behaviors; ability to work with diversity; shared decision making; community involvement; medical staff relationships; and
academic relationships.
II. A knowledge of the health-care environment
• Knowledge of the health-care environment includes clinical practice knowledge; patient-care delivery models and work
design knowledge; health-care economics knowledge; health-care policy knowledge; understanding of governance;
understanding of evidence-based practice; outcome measurement; knowledge of, and dedication to patient safety;
understanding of utilization/case management; knowledge of quality improvement and metrics; and knowledge of risk
management.
III. Leadership
• Leadership skills include foundational thinking skills; personal journey disciplines; the ability to use systems thinking;
succession planning; and change management.
IV. Professionalism
• Professionalism includes personal and professional accountability; career planning; ethics; evidence-based clinical and
management practice; advocacy for the clinical enterprise and for nursing practice; and active membership in professional
organizations.
V. Business skills
• Business skills include understanding of health-care financing; human resource management and development; strategic
management; marketing; and information management and technology.
American Association of Colleges of Nursing (AACN).
(2008, October 20). The essentials of baccalaureate
education for professional nursing practice.
Retrieved June 20, 2013, from http://www.aacn.nche
.edu/education-resources/baccessentials08
American Association of Colleges of Nursing (AACN).
(2011, March 21) The essentials of master’s
education in nursing. Retrieved June 20, 2013, from
http://www.aacn.nche.edu/education-resources/
MastersEssentials11
American Organization of Nurse Executives (2011). The
AONE nurse executive competencies. Retrieved
June 20, 2013, from http://www.aone.org/resources/
leadership%20tools/nursecomp.shtml
Institute of Medicine. (2003). Health professions education:
A bridge to quality. Washington, DC: National
Academies Press.
Quality and Safety Education for Nurses Institute (2013).
Competencies. Retrieved June 20, 2013, from http://
qsen.org/competencies/

http://www.aacn.nche.edu/education-resources/baccessentials08

http://www.aacn.nche.edu/education-resources/baccessentials08

http://www.aacn.nche.edu/education-resources/MastersEssentials11

http://www.aacn.nche.edu/education-resources/MastersEssentials11

http://www.aone.org/resources/leadership%20tools/nursecomp.shtml

http://qsen.org/competencies/

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Contents
UNIT I
The Critical Triad: Decision Making, Management, and Leadership 1
1 Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning:
Requisites for Successful Leadership and Management 2
Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning 3
Vicarious Learning to Increase Problem-Solving and Decision-Making Skills 4
Theoretical Approaches to Problem Solving and Decision Making 7
Critical Elements in Problem Solving and Decision Making 11
Individual Variations in Decision Making 15
Overcoming Individual Vulnerability in Decision Making 18
Decision Making in Organizations 19
Decision-Making Tools 20
Pitfalls in Using Decision-Making Tools 24
Summary 24
Key Concepts 25
Additional Learning Exercises and Applications 25
2 Classical Views of Leadership and Management 32
Managers 33
Leaders 34
Historical Development of Management Theory 35
Historical Development of Leadership Theory (1900 to Present) 39
Interactional Leadership Theories (1970 to Present) 42
Integrating Leadership and Management 47
Key Concepts 48
Additional Learning Exercises 49
3 Twenty-First-Century Thinking about Leadership and Management 53
New Thinking about Leadership and Management 54
Transition from Industrial Age Leadership to Relationship Age Leadership 63
Leadership and Management for Nursing’s Future 65
Key Concepts 66
Additional Learning Exercises and Applications 66
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xvi CoNtENtS
UNIT II
Foundation for Effective Leadership and Management Ethics, Law,
and Advocacy 69
4 Ethical Issues 70
Types of Ethical Issues 72
Ethical Frameworks for Decision Making 74
Principles of Ethical Reasoning 75
American Nurses Association Code of Ethics and Professional Standards 79
Ethical Problem Solving and Decision Making 80
The Moral Decision-Making Model 84
Working toward Ethical Behavior as the Norm 86
Ethical Dimensions in Leadership and Management 88
Integrating Leadership Roles and Management Functions in Ethics 89
Key Concepts 90
Additional Learning Exercises and Applications 90
5 Legal and Legislative Issues 94
Sources of Law 95
Types of Laws and Courts 96
Legal Doctrines and the Practice of Nursing 97
Professional Negligence 98
Avoiding Malpractice Claims 101
Extending the Liability 102
Incident Reports 104
Intentional Torts 104
Other Legal Responsibilities of the Manager 105
Legal Considerations of Managing a Diverse Workforce 111
Professional Versus Institutional Licensure 112
Integrating Leadership Roles and Management Functions
in Legal and Legislative Issues 113
Key Concepts 114
Additional Learning Exercises and Applications 114
6 Patient, Subordinate, and Professional Advocacy 117
Becoming an Advocate 118
Patient Advocacy 120
Patient Rights 121
Subordinate and Workplace Advocacy 124
Whistleblowing as Advocacy 125
Professional Advocacy 127
Integrating Leadership Roles and Management Functions in Advocacy 131
Key Concepts 132
Additional Learning Exercises and Applications 133

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contents xvii
UNIT III
Roles and Functions in Planning 137
7 Strategic and Operational Planning 138
Looking to the Future 140
Proactive Planning 142
Strategic Planning 144
Organizational Planning: The Planning Hierarchy 146
Vision and Mission Statements 147
The Organization’s Philosophy Statement 148
Societal Philosophies and Values 151
Individual Philosophies and Values 151
Goals and Objectives 153
Policies and Procedures 155
Rules 157
Overcoming Barriers to Planning 157
Integrating Leadership Roles and Management Functions
in Planning 158
Key Concepts 158
Additional Learning Exercises and Applications 159
8 Planned Change 162
The Development of Change Theory: Kurt Lewin 164
Lewin’s Driving and Restraining Forces 166
A Contemporary Adaptation of Lewin’s Model 167
Classic Change Strategies 167
Resistance: The Expected Response to Change 169
Planned Change as a Collaborative Process 171
The Leader-Manager as a Role Model during Planned Change 171
Organizational Change Associated with Nonlinear Dynamics 172
Organizational Aging: Change as a Means of Renewal 174
Integrating Leadership Roles and Management Functions
in Planned Change 175
Key Concepts 176
Additional Learning Exercises and Applications 177
9 Time Management 181
Three Basic Steps to Time Management 183
Personal Time Management 191
Integrating Leadership Roles and Management Functions
in Time Management 195
Key Concepts 195
Additional Learning Exercises and Applications 196
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xviii contents
10 Fiscal Planning 204
Balancing Cost and Quality 207
Responsibility Accounting and Forecasting 208
Basics of Budgets 208
Steps in the Budgetary Process 208
Types of Budgets 212
Budgeting Methods 216
Critical Pathways 218
Health-Care Reimbursement 218
Medicare and Medicaid 219
The Prospective Payment System 220
The Managed Care Movement 221
Proponents and Critics of Managed Care Speak Up 223
The Future of Managed Care 224
Health-Care Reform and the Patient Protection and
Affordable Care Act 226
Integrating Leadership Roles and Management
Functions in Fiscal Planning 228
Key Concepts 228
Additional Learning Exercises and Applications 229
11 Career Development: From New Graduate to Retirement 235
Career Stages 237
Justifications for Career Development 238
Individual Responsibility for Career Development 238
The Organization’s Responsibility for Career Development 239
Career Coaching 240
Management Development 243
Competency Assessment as Part of Career Development 245
Professional Specialty Certification 246
Reflective Practice and the Professional Portfolio 248
Career Planning and the New Graduate Nurse 249
Transition-to-Practice Programs/Residencies for New Graduate Nurses 249
Resume Preparation 251
Integrating Leadership Roles and Management Functions in Career
Development 253
Key Concepts 253
Additional Learning Exercises and Applications 254

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contents xix
UNIT IV
Roles and Functions in Organizing 259
12 Organizational Structure 260
Formal and Informal Organizational Structure 261
Organizational Theory and Bureaucracy 263
Components of Organizational Structure 264
Limitations of Organization Charts 269
Types of Organizational Structures 270
Decision Making within the Organizational Hierarchy 272
Stakeholders 273
Organizational Culture 274
Shared Governance: Organizational Design for the 21st Century? 277
Magnet Designation and Pathway to Excellence 278
Committee Structure in an Organization 280
Responsibilities and Opportunities of Committee Work 280
Organizational Effectiveness 281
Integrating Leadership Roles and Management Functions Associated with
Organizational Structure 282
Key Concepts 283
Additional Learning Exercises and Applications 284
13 Organizational, Political, and Personal Power 287
Understanding Power 289
The Authority–Power Gap 292
Mobilizing the Power of Nursing 296
Strategies for Building a Personal Power Base 299
The Politics of Power 302
Integrating Leadership Roles and Management Functions When Using
Authority and Power in Organizations 305
Key Concepts 306
Additional Learning Exercises and Applications 307
14 Organizing Patient Care 311
Traditional Modes of Organizing Patient Care 313
Disease Management 323
Selecting the Optimum Mode of Organizing Patient Care 324
Integrating Leadership Roles and Management Functions in Organizing Patient
Care 329
Key Concepts 329
Additional Learning Exercises and Applications 330
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xx contents
UNIT V
Roles and Functions in Staffing 333
15 Employee Recruitment, Selection, Placement, and Indoctrination 334
Predicting Staffing Needs 336
Is There a Current Nursing Shortage? 336
Recruitment 338
Interviewing as a Selection Tool 339
Tips for the Interviewee 348
Selection 349
Placement 353
Indoctrination 354
Integrating Leadership Roles and Management Functions in Employee
Recruitment, Selection, Placement, and Indoctrination 358
Key Concepts 358
Additional Learning Exercises and Applications 359
16 Socializing and Educating Staff for Team Building in a
Learning Organization 363
The Learning Organization 365
Staff Development 366
Learning Theories 367
Assessing Staff Development Needs 371
Evaluation of Staff Development Activities 372
Shared Responsibility for Implementing Evidence-Based Practice 373
Socialization and Resocialization 373
Overcoming Motivational Deficiencies 380
Coaching as a Teaching Strategy 381
Meeting the Educational Needs of a Culturally Diverse Staff 382
Integrating Leadership and Management in Team Building through Socializing
and Educating Staff for Team Building in a Learning Organization 383
Key Concepts 384
Additional Learning Exercises and Applications 384
17 Staffing Needs and Scheduling Policies 388
Unit Manager’s Responsibilities in Meeting Staffing Needs 390
Centralized and Decentralized Staffing 390
Complying with Staffing Mandates 391
Staffing and Scheduling Options 393
Workload Measurement Tools 397
The Relationship between Nursing Care Hours, Staffing Mix,
and Quality of Care 401
Managing a Diverse Staff 402

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contents xxi
Generational Considerations for Staffing 403
The Impact of Nursing Staff Shortages upon Staffing 404
Fiscal and Ethical Accountability for Staffing 405
Developing Staffing and Scheduling Policies 406
Integrating Leadership Roles and Management Functions
in Staffing and Scheduling 407
Key Concepts 408
Additional Learning Exercises and Applications 408
UNIT VI
Roles and Functions in Directing 413
18 Creating a Motivating Climate 414
Intrinsic Versus Extrinsic Motivation 416
Motivational Theory 417
Creating a Motivating Climate 422
Strategies for Creating a Motivating Climate 424
Promotion: A Motivational Tool 426
Promoting Self-Care 428
Integrating Leadership Roles and Management Functions in Creating
a Motivating Climate at Work 429
Key Concepts 430
Additional Learning Exercises and Applications 431
19 Organizational, Interpersonal, and Group Communication 436
The Communication Process 438
Variables Affecting Organizational Communication 440
Organizational Communication Strategies 441
Communication Modes 443
Elements of Nonverbal Communication 444
Verbal Communication Skills 446
Listening Skills 449
Written Communication within the Organization 450
The Impact of Technology on Contemporary Organizational Communication 452
Communication, Confidentiality, and Health Insurance Portability and
Accountability Act 454
Group Dynamics 457
Integrating Leadership and Management in Organizational, Interpersonal, and
Group Communication 459
Key Concepts 460
Additional Learning Exercises and Applications 461
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xxii contents
20 Delegation 466
Delegating Effectively 468
Common Delegation Errors 471
Delegation as a Function of Professional Nursing 473
Delegating to a Transcultural Work Team 479
Integrating Leadership Roles and Management Functions
in Delegation 480
Key Concepts 481
Additional Learning Exercises and Applications 482
21 Effective Conflict Resolution and Negotiation 487
The History of Conflict Management 489
Categories of Conflict: Intergroup, Intrapersonal,
and Interpersonal 490
The Conflict Process 493
Conflict Management 495
Managing Unit Conflict 498
Negotiation 500
Alternative Dispute Resolution 505
Seeking Consensus 506
Integrating Leadership Skills and Management Functions
in Managing Conflict 506
Key Concepts 507
Additional Learning Exercises and Applications 507
22 Collective Bargaining, Unionization, and Employment Laws 514
Unions and Collective Bargaining 516
Historical Perspective of Unionization in America 517
Union Representation of Nurses 518
American Nurses Association and Collective Bargaining 519
Employee Motivation to Join or Reject Unions 520
Averting the Union 522
The Nurse as Supervisor: Eligibility for Protection Under the National
Labor Relations Act 523
Union-Organizing Strategies 524
Managers’ Role During Union-Organizing 525
Steps to Establish a Union 526
Effective Labor–Management Relations 526
Employment Legislation 528
State Health Facilities Licensing Boards 535
Integrating Leadership Skills and Management Functions When Working with
Collective Bargaining, Unionization and Employment Laws 536
Key Concepts 536
Additional Learning Exercises and Applications 537

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contents xxiii
UNIT VII
Roles and Functions in Controlling 541
23 Quality Control 542
Defining Quality Health Care 545
Quality Control as a Process 546
The Development of Standards 548
Audits as a Quality Control Tool 551
Standardized Nursing Languages 553
Quality Improvement Models 554
Who Should Be Involved in Quality Control? 556
Quality Measurement as an Organizational Mandate 556
Centers for Medicare and Medicaid Services 559
Medical Errors: An Ongoing Threat to Quality of Care 562
Integrating Leadership Roles and Management Functions with Quality
Control 565
Key Concepts 566
Additional Learning Exercises and Applications 568
24 Performance Appraisal 573
Using the Performance Appraisal to Motivate Employees 575
Strategies to Ensure Accuracy and Fairness in the Performance Appraisal 576
Performance Appraisal Tools 579
Planning the Appraisal Interview 587
Overcoming Appraisal Interview Difficulties 587
Performance Management 590
Coaching: A Mechanism for Informal Performance Appraisal 590
Becoming an Effective Coach 591
Using Leadership Skills and Management Functions in Conducting Performance
Appraisals 591
Key Concepts 591
Additional Learning Exercises and Applications 592
25 Problem Employees: Rule Breakers, Marginal Employees, and the Chemically
or Psychologically Impaired 596
Constructive Versus Destructive Discipline 599
Self-Discipline and Group Norms 600
Fair and Effective Rules 600
Discipline as a Progressive Process 601
Disciplinary Strategies for the Nurse-Manager 604
Transferring the Problem Employee 609
Grievance Procedures 610
Disciplining the Unionized Employee 611
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xxiv contents
The Marginal Employee 612
The Chemically Impaired Employee 614
Recognizing the Chemically Impaired Employee 615
Integrating Leadership Roles and Management Functions through Dealing with
Problem Employees 622
Key Concepts 623
Additional Learning Exercises and Applications 623
Appendix 627
Solutions to Selected Learning Exercises 627
Index 637

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The Critical Triad:
Decision Making, Management,
and Leadership
UNIT I
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2
1
Decision Making, Problem Solving, Critical
Thinking, and Clinical Reasoning: Requisites
for Successful Leadership and Management
… again and again, the impossible problem is solved when we see that the problem is only a tough
decision waiting to be made.
—Robert H. Schuller
… in any moment of decision the best thing you can do is the right thing, the next best thing is the
wrong thing, and the worst thing you can do is nothing.
—Theodore Roosevelt
CROSSWALK ThiS chapTeR addReSSeS:
BSN Essential I: Liberal education for baccalaureate generalist nursing practice
BSN Essential III: Scholarship for evidence-based practice
BSN Essential IV: information management and application of patient care technology
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
MSN Essential I: Background for practice from sciences and humanities
QSEN Competency: informatics
MSN Essential IV: Translating and integrating scholarship into practice
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency III: Leadership
QSEN Competency: evidence-based practice
LEARNING OBJECTIVES The learner will:
l differentiate between problem solving, decision making, critical thinking, and clinical
reasoning
l describe how case studies, simulation, and problem-based learning can be used to improve
the quality of decision making
l explore strengths and limitations of using intuition and heuristics as adjuncts to problem
solving and decision making
l identify characteristics of successful decision makers
l select appropriate models for decision making in specific situations
l describe the importance of the individual in the decision-making process
l identify critical elements of decision making
l explore his or her personal propensity for risk taking in decision making
l discuss the effect of organizational power on decision making
l differentiate between the economic man and the administrative man in decision making

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 3
l select appropriate management decision-making tools that would be helpful in making
specific decisions
l differentiate between autocratic, democratic, and laissez-faire decision styles and identify
situation variables that might suggest using one decision style over another
Decision making is often thought to be synonymous with management and is one of the criteria
on which management expertise is judged. Much of any manager’s time is spent critically
examining issues, solving problems, and making decisions. The quality of the decisions that
leader-managers make is the factor that often weighs most heavily in their success or failure.
Decision making, then, is both an innermost leadership activity and the core of management.
This chapter explores the primary requisites for successful management and leadership:
decision making, problem solving, and critical thinking. Also, because it is the authors’ belief
that decision making, problem solving, and critical thinking are learned skills that improve
with practice and consistency, an introduction to established tools, techniques, and strategies
for effective decision making is included. This chapter also introduces the learning exercise as
a new approach for vicariously gaining skill in management and leadership decision making.
Finally, evidence-based decision making is introduced as an imperative for both personal and
professional problem solving.
DECISION MAKING, PROBLEM SOLVING, CRITICAL THINKING,
AND CLINICAL REASONING
Decision making is a complex, cognitive process often defined as choosing a particular course
of action. BusinessDictionary.com (2013, para 1) defines decision making as “the thought
process of selecting a logical choice from the available options.” This implies that doubt
exists about several courses of action and that a choice is made to eliminate uncertainty.
Problem solving is part of decision making and is a systematic process that focuses on
analyzing a difficult situation. Problem solving always includes a decision-making step.
Many educators use the terms problem solving and decision making synonymously, but there
is a small yet important difference between the two. Although decision making is the last
step in the problem-solving process, it is possible for decision making to occur without the
full analysis required in problem solving. Because problem solving attempts to identify the
root problem in situations, much time and energy are spent on identifying the real problem.
Decision making, on the other hand, is usually triggered by a problem but is often handled
in a manner that does not focus on eliminating the underlying problem. For example, if a
person decided to handle a conflict when it occurred but did not attempt to identify the real
problem causing the conflict, only decision-making skills would be used. The decision maker
might later choose to address the real cause of the conflict or might decide to do nothing at
all about the problem. The decision has been made not to problem solve. This alternative may
be selected because of a lack of energy, time, or resources to solve the real problem. In some
situations, this is an appropriate decision. For example, assume that a nursing supervisor has a
staff nurse who has been absent a great deal over the last 3 months. Normally, the supervisor
would feel compelled to intervene. However, the supervisor has reliable information that the
nurse will be resigning soon to return to school in another state. Because the problem will
soon no longer exist, the supervisor decides that the time and energy needed to correct the
problem are not warranted.
Critical thinking, sometimes referred to as reflective thinking, is related to evaluation and
has a broader scope than decision making and problem solving. Dictionary.com (2013) defines
critical thinking as “the mental process of actively and skillfully conceptualizing, applying,
analyzing, synthesizing, and evaluating information to reach an answer or conclusion”
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4 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
(para 1). Critical thinking also involves reflecting upon the meaning of statements, examining
the offered evidence and reasoning, and forming judgments about facts.
Whatever definition of critical thinking is used, most agree that it is more complex than
problem solving or decision making, involves higher-order reasoning and evaluation, and has
both cognitive and affective components. The authors believe that insight, intuition, empathy,
and the willingness to take action are additional components of critical thinking. These same
skills are necessary to some degree in decision making and problem solving. See Display 1.1
for additional characteristics of a critical thinker.
DISPLAy 1.1 Characteristics of a Critical Thinker
Open to new ideas Flexible creative
intuitive empathetic insightful
energetic caring Willing to take action
analytical Observant Outcome directed
persistent Risk taker Willing to change
assertive Resourceful Knowledgeable
communicator “Outside-the-box” thinker circular thinking
Insight, intuition, empathy, and the willingness to take action are components of critical thinking.
Nurses today must have higher-order thinking skills to identify patient problems and to direct
clinical judgments and actions that result in positive patient outcomes. When nurses integrate
and apply different types of knowledge to weigh evidence, critically think about arguments
and reflect upon the process used to arrive at a diagnosis; this is known as clinical reasoning
(Linn, Khaw, Kildea, & Tonkin, 2012). Thus, clinical reasoning uses both knowledge and
experience to make decisions at the point of care.
VICARIOUS LEARNING TO INCREASE PROBLEM-SOLVING AND
DECISION-MAKING SKILLS
Decision making, one step in the problem-solving process, is an important task that relies
heavily on critical thinking and clinical reasoning skills. How do people become successful
problem solvers and decision makers? Although successful decision making can be learned
through life experience, not everyone learns to solve problems and judge wisely by this trial-
and-error method because much is left to chance. Some educators feel that people are not
successful in problem solving and decision making because individuals are not taught how to
reason insightfully from multiple perspectives.
Moreover, information and new learning may not be presented within the context of real-
life situations, although this is changing. For example, in teaching clinical reasoning, nurse
educators strive to see that the elements of clinical reasoning, such as noticing crucial changes
in patient status, analyzing these changes to decide on a course of action, and evaluating
responses to modify care, are embedded at every opportunity throughout the nursing curricula
(Russell, Geist, & Maffett, 2013). In addition, time is included for meaningful reflection on
the decisions that are made and the outcomes that result. Such learning can occur in both
real-world settings and through vicarious learning, where students problem solve and make
decisions based on simulated situations that are made real to the learner.
Case Studies, Simulation, and Problem-Based Learning
Case studies, simulation, and problem-based learning (PBL) are some of the strategies that
have been developed to vicariously improve problem solving and decision making. Case

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 5
studies may be thought of as stories that impart learning. They may be fictional or include
real persons and events, be relatively short and self-contained for use in a limited amount of
time, or be longer with significant detail and complexity for use over extended periods of
time. Case studies, particularly those that unfold or progress over time, are becoming much
more common in nursing education since they provide a more interactive, learning experience
for students than the traditional didactic approach.
Similarly, simulation provides learners opportunities for problem solving that have little
or no risk to patients or to organizational performance. For example, some organizations
are now using computer simulation (known as discrete event simulation) to imitate the
operation of a real-life system such as a hospital. Based on chosen alternatives, the simulation
can determine the relative performance of patient throughputs, the timeliness of care, and
the appropriateness of resource utilization, thus integrating management priorities and
operational decision making (Hamrock, Paige, Parks, Scheulen, & Levin, 2013).
In addition, simulation models are increasingly being used by schools of nursing to allow
students the opportunity to gain skill mastery before working directly with acutely ill and
vulnerable clients. In addition, simulation allows students to apply and improve the critically
important “nontechnical” skills of communication, teamwork, leadership, and decision
making (Lewis, Strachan, & Smith, 2012). (See Examining the Evidence 1.1.)
Source: Lewis, R., Strachan, A., & Smith, M. (2012). Is high fidelity simulation the most effective method for the
development of non-technical skills in nursing? A review of the current evidence. Open Nursing Journal, 6, 82–89.
This literature review suggested that simulation was positively associated with significantly
improved interpersonal communication skills at patient handover as well as improved team per-
formance in the management of crisis situations. It also appeared to enable the development of
transferable, transformational leadership skills, improved students’ critical thinking and clinical
reasoning in complex care situations, and aided in the development of students’ self-efficacy
and confidence in their own clinical abilities. The authors concluded that simulation provides a
learning environment in which both technical and nontechnical skills can be improved without
fear of compromising patient safety.
Examining the Evidence 1.1
PBL also provides opportunities for individuals to address and learn from authentic
problems vicariously. Typically, in PBL, learners meet in small groups to discuss and analyze
real-life problems. Thus, they learn by problem solving. The learning itself is collaborative as
the teacher guides the students to be self-directed in their learning, and many experts suggest
that this type of active learning helps to develop critical thinking skills.
The Marquis-Huston Critical Thinking Teaching Model
The desired outcome for teaching and learning decision making and critical thinking in
management is an interaction between learners and others that results in the ability to
critically examine management and leadership issues. This is a learning of appropriate social/
professional behaviors rather than a mere acquisition of knowledge. This type of learning
occurs best in groups, using a PBL approach.
In addition, learners retain didactic material more readily when it is personalized or when
they can relate to the material being presented. The use of case studies that learners can
identify with assists in retention of didactic materials.
Also, while formal instruction in critical thinking is important, using a formal decision-
making process improves both the quality and consistency of decision making. Many new
leaders and managers struggle to make quality decisions because their opportunity to practice
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6 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
making management and leadership decisions is very limited until they are appointed to
a management position. These limitations can be overcome by creating opportunities for
vicariously experiencing the problems that individuals would encounter in the real world of
leadership and management.
The Marquis-Huston model for teaching critical thinking assists in achieving desired
learner outcomes (Fig. 1.1). Basically, the model comprises four overlapping spheres,
each being an essential component for teaching leadership and management. The first is a
didactic theory component, such as the material that is presented in each chapter; second,
a formalized approach to problem solving and decision making must be used. Third, there
must be some use of the group process, which can be accomplished through large and small
groups and classroom discussion. Finally, the material must be made real for the learner so
that the learning is internalized. This can be accomplished through writing exercises, personal
exploration, and values clarification, along with risk taking, as case studies are examined.
Experiential learning provides mock experiences that have tremendous value in applying
leadership and management theory.
This book was developed with the perspective that experiential learning provides mock
experiences that have tremendous value in applying leadership and management theory. The
text includes numerous opportunities for readers to experience the real world of leadership
and management. Some of these learning situations, called learning exercises, include
case studies, writing exercises, specific management or leadership problems, staffing and
budgeting calculations, group discussion or problem-solving situations, and assessment
of personal attitudes and values. Some exercises include opinions, speculation, and value
judgments. All of the learning exercises, however, require some degree of critical thinking,
problem solving, decision making, or clinical reasoning.
Didactic
theory
Personalized
learning
Group
process
Problem
solving
FIGURE 1.1 • The Marquis-huston critical thinking teaching model.

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 7
Some of the case studies have been solved (solutions are found at the back of the book)
so that readers can observe how a systematic problem-solving or decision-making model
can be applied in solving problems common to nurse-managers. The authors feel strongly,
however, that the problem solving suggested in the solved cases should not be considered the
only plausible solution or “the right solution” to that learning exercise. Most of the learning
exercises in the book have multiple solutions that could be implemented successfully to solve
the problem.
THEORETICAL APPROACHES TO PROBLEM SOLVING
AND DECISION MAKING
Most people make decisions too quickly and fail to systematically examine a problem or
its alternatives for solution. Instead, most individuals rely on discrete, often unconscious
processes known as heuristics, which allows them to solve problems more quickly and to
build upon experiences they have gained in their lives. Thus, heuristics use trial-and-error
methods or a rule-of-thumb approach to problem solving, rather than set rules.
For example, a study by Muoni (2012) found that nurse midwives often use heuristics
(which are defined as shortcut mental strategies that help simplify information), coupled with
intuition, to make clinical decisions. While Muoni notes that the use of such heuristics does
allow midwives to make decisions more quickly, she questions the reliability of heuristics
and suggests that clinical decisions should always be evidence based and follow a systematic
continuum that clearly portrays the process used to make the decision.
Formal process and structure can benefit the decision-making process, as they force decision
makers to be specific about options and to separate probabilities from values. A structured
approach to problem solving and decision making increases clinical reasoning and is the best
way to learn how to make quality decisions because it eliminates trial and error and focuses
the learning on a proven process. A structured or professional approach involves applying a
theoretical model in problem solving and decision making. Many acceptable problem solving
models exist, and most include a decision-making step; only four are reviewed here.
A structured approach to problem solving and decision making increases clinical reasoning.
Traditional Problem-Solving Process
One of the most well-known and widely used problem-solving models is the traditional
problem-solving model. The seven steps follow in Display 1.2. (Decision-making occurs at
step 5.)
Although the traditional problem-solving process is an effective model, its weakness lies
in the amount of time needed for proper implementation. This process, therefore, is less
effective when time constraints are a consideration. Another weakness is lack of an initial
1. identify the problem.
2. Gather data to analyze the causes and consequences of the problem.
3. explore alternative solutions.
4. evaluate the alternatives.
5. Select the appropriate solution.
6. implement the solution.
7. evaluate the results.
DISPLAy 1.2 Traditional Problem Solving Process
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8 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
objective-setting step. Setting a decision goal helps to prevent the decision maker from
becoming sidetracked.
Managerial Decision-Making Models
To address the weaknesses of the traditional problem-solving process, many contemporary
models for management decision making have added an objective-setting step. These models
are known as managerial decision-making models or rational decision-making models. One
such model suggested by Decision-making-confidence.com (2006–2013) includes the six
steps shown in Display 1.3.
1. determine the decision and the desired outcome (set objectives).
2. Research and identify options.
3. compare and contrast these options and their consequences.
4. Make a decision.
5. implement an action plan.
6. evaluate results.
DISPLAy 1.3 Managerial Decision Making Model
In the first step, problem solvers must identify the decision to be made, who needs to be
involved in the decision process, the timeline for the decision, and the goals or outcomes that
should be achieved. Identifying objectives to guide the decision making helps the problem
solver determine which criteria should be weighted most heavily in making their decision.
Most important decisions require this careful consideration of context.
In step 2, problem solvers must attempt to identify as many alternatives as possible.
Alternatives are then analyzed in step 3, often using some type of SWOT (strengths,
weaknesses, opportunities, and threats) analysis. Decision makers may choose to apply
quantitative decision-making tools, such as decision-making grids and payoff tables
(discussed further later in this chapter), to objectively review the desirability of alternatives.
In step 4, alternatives are rank ordered on the basis of the analysis done in step 3 so
that problem solvers can make a choice. In step 5, a plan is created to implement desirable
alternatives or combinations of alternatives. In the final step, challenges to successful
implementation of chosen alternatives are identified and strategies are developed to manage
those risks. An evaluation is then conducted of both process and outcome criteria, with
outcome criteria typically reflecting the objectives that were set in step 1.
The Nursing Process
The nursing process, developed by Ida Jean Orlando in the late 1950s, provides another
theoretical system for solving problems and making decisions. Originally a four-step model
(assess, plan, implement, and evaluate) diagnosis was delineated as a separate step, and most
contemporary depictions of this model now include at least five steps. (See Display 1.4.)
1. assess
2. diagnose
3. plan
4. implement
5. evaluate
DISPLAy 1.4 Nursing Process
As a decision-making model, the greatest strength of the nursing process may be its
multiple venues for feedback. The arrows in Figure 1.2 show constant input into the process.

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 9
When the decision point has been identified, initial decision making occurs and continues
throughout the process via a feedback mechanism.
Although the process was designed for nursing practice with regard to patient care and
nursing accountability, it can easily be adapted as a theoretical model for solving leadership
and management problems. Table 1.1 shows how closely the nursing process parallels the
decision-making process.
The weakness of the nursing process, like the traditional problem-solving model, is in not
requiring clearly stated objectives. Goals should be clearly stated in the planning phase of the
process, but this step is frequently omitted or obscured. However, because nurses are familiar
with this process and its proven effectiveness, it continues to be recommended as an adapted
theoretical process for leadership and managerial decision making.
Integrated Ethical Problem-Solving Model
A more contemporary model for effective thinking and problem solving was developed by
Park (2012) upon review of 20 existing models for ethical decision making (Display 1.5).
While developed primarily for use in solving ethical problems, the model also works well
as a general problem-solving model. Similar to the three models already discussed, this
model provides a structured approach to problem solving that includes an assessment of
Assess
Implement
nalPetaulavE
Diagnose
FIGURE 1.2 • Feedback mechanism of the nursing process.
TABLE 1.1 Comparing the Decision-Making Process with the Nursing Process
Decision-Making Process Simplified Nursing Process
identify the decision assess
collect data
identify criteria for decision plan
identify alternatives
choose alternative implement
implement alternative
evaluate steps in decision evaluate
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10 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
the problem, problem identification, the analysis and selection of the best alternative, and a
means for evaluation. The model does go one step further, however, in requiring the learner
to specifically identify strategies that reduce the likelihood of a problem recurring.
Intuitive Decision-Making Models
There are theorists who suggest that intuition should always be used as an adjunct to
empirical or rational decision-making models. Experienced nurses often report that gut-level
feelings encourage them to take appropriate strategic action that impacts patient outcomes,
1. State the problem.
2. collect additional information and analyze the problem.
3. develop alternatives and analyze and compare them.
4. Select the best alternative and justify your decision.
5. develop strategies to successfully implement a chosen alternative and take action.
6. evaluate the outcomes and prevent a similar occurrence.
DISPLAy 1.5 Integrated Ethical Problem Solving Model
Many other excellent problem analysis and decision models exist. The model selected
should be one with which the decision maker is familiar and one appropriate for the problem
to be solved. Using models or processes consistently will increase the likelihood that critical
analysis will occur. Moreover, the quality of management/leadership problem solving and
decision making will improve tremendously via a scientific approach.
LEARNING EXERCISE 1.1
Applying Scientific Models to Decision Making
You are a registered nurse who graduated 3 years ago. during the last 3 years, your
responsibilities in your first position have increased. although you enjoy your family (spouse
and one preschool-aged child), you realize that you love your job and that your career is very
important to you. Recently, you and your spouse decided to have another baby. at that time, you
and your spouse reached a joint decision that if you had another baby, you wanted to reduce
your work time and spend more time at home with the children. Last week, your supervisor told
you that the charge nurse is leaving. You were thrilled and excited when she said that she wants
to appoint you to the position. Yesterday, you found out that you and your spouse are expecting
a baby.
Last night, you spoke with your spouse about your career future. Your spouse is an attorney
whose practice has suddenly gained momentum. although the two of you have shared child
rearing equally until this point, your spouse is not sure how much longer this can be done if the
law practice continues to expand. if you take the position, which you would like to do, it would
mean full-time work. You want the decision that you and your spouse reach to be well thought
out, as it has far-reaching consequences and concerns many people.
Assignment: determine what you should do. after you have made your decision, get together
in a group (four to six people) and share your decisions. Were they the same? how did you
approach the problem solving differently from others in your group? Was a rational systematic
problem-solving process used, or was the chosen solution based more on intuition? how many
alternatives were generated? did some of the group members identify alternatives that you had
not considered? Was a goal(s) or objective identified? how did your personal values influence
your decision?

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 11
although intuition should generally serve as an adjunct to decision making founded on nurse’s
scientific knowledge base.
Pearson (2013) agrees, suggesting that intuition can and should be used in conjunction
with evidence-based practice and that it deserves to be acknowledged as a factor in achieving
good outcomes within clinical practice. Pearson goes on to say that intuition is, in reality,
often a rapid, automatic process of recognizing familiar problems instantly and using
experience to identify solutions. Thus, intuition may be perceived as a cognitive skill rather
than a perception or knowing without knowing how.
This recognition of familiar problems and the use of intuition to identify solutions is a focus
of contemporary research on intuitive decision-making research. Klein and his colleagues
(Klein, 2008) developed the recognition-primed decision (RPD) model for intuitive decision
making in the mid-1980s to explain how people can make effective decisions under time
pressure and uncertainty. Considered a part of naturalistic decision making, the RPD model
attempts to understand how humans make relatively quick decisions in complex, real-world
settings such as firefighting and critical care nursing without having to compare options.
Klein’s work suggests that instead of using classical rational or systematic decision-
making processes, many individuals act on their first impulse if the “imagined future” looks
acceptable. If this turns out not to be the case, another idea or concept is allowed to emerge
from their subconscious and is examined for probable successful implementation. Thus,
the RPD model blends intuition and analysis, but pattern recognition and experience guide
decision makers when time is limited or systematic rational decision making is not possible.
CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING
Because decisions may have far-reaching consequences, some problem solving and decision
making must be of high quality. Using a scientific approach alone for problem solving and
decision making does not, however, ensure a quality decision. Special attention must be paid
to other critical elements. The elements in Display 1.6, considered crucial in problem solving,
must occur if a high-quality decision is to be made.
Define Objectives Clearly
Decision makers often forge ahead in their problem-solving process without first determining
their goals or objectives. However, it is especially important to determine goals and
objectives when problems are complex. Even when decisions must be made quickly, there
is time to pause and reflect on the purpose of the decision. A decision that is made without a
clear objective in mind or a decision that is inconsistent with one’s philosophy is likely to be
a poor-quality decision. Sometimes the problem has been identified but the wrong objectives
are set.
If a decision lacks a clear objective or if an objective is not consistent with the individual’s or
organization’s stated philosophy, a poor-quality decision is likely.
1. define objectives clearly.
2. Gather data carefully.
3. Take the time necessary.
4. Generate many alternatives.
5. Think logically.
6. choose and act decisively.
DISPLAy 1.6 Critical Elements in Decision Making
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For example, it would be important for the decision maker in Learning Exercise 1.1 to
determine whether their most important objective is career advancement, having more time
with family, or meeting the needs of their spouse. None of these goals is more “right” than the
others, but not having clarity about which objective(s) is paramount makes decision making
very difficult.
Gather Data Carefully
Because decisions are based on knowledge and information available to the problem solver
at the time the decision must be made, one must learn how to process and obtain accurate
information. The acquisition of information begins with identifying the problem or the
occasion for the decision and continues throughout the problem-solving process. Often the
information is unsolicited, but most information is sought actively. Acquiring information
always involves people, and no tool or mechanism is infallible to human error. Questions that
should be asked in data gathering are shown in Display 1.7.
1. What is the setting?
2. What is the problem?
3. Where is it a problem?
4. When is it a problem?
5. Who is affected by the problem?
6. What is happening?
7. Why is it happening? What are the causes of the problem? can the causes be prioritized?
8. What are the basic underlying issues? What are the areas of conflict?
9. What are the consequences of the problem? Which is the most serious?
DISPLAy 1.7 Questions to Examine in Data Gathering
In addition, human values tremendously influence our perceptions. Therefore, as problem
solvers gather information, they must be vigilant that their own preferences and those of
others are not mistaken for facts.
Facts can be misleading if they are presented in a seductive manner, if they are taken out of
context, or if they are past oriented.
How many parents have been misled by the factual statement, “Johnny hit me”? In this
case, the information seeker needs to do more fact finding. What was the accuser doing
before Johnny hit him? What was he hit with? Where was he hit? When was he hit? Like the
parent, the manager who becomes expert at acquiring adequate, appropriate, and accurate
information will have a head start in becoming an expert decision maker and problem solver.
Take the Time Necessary
Moxley, Anders Ericsson, Charness, and Krampe (2012) suggest that most current problem-
solving and decision-making theories argue that human decision making is largely based on
LEARNING EXERCISE 1.2
Gathering Necessary Information
identify a poor decision that you recently made because of faulty data gathering. have you
ever made a poor decision because necessary information was intentionally or unintentionally
withheld from you?

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 13
the quick, automatic, and intuitive processes that are a part of heuristics, and that these are
only occasionally supplemented by slow controlled deliberation. Moxley et al. (2012) argue
that slow deliberation results in improved decision making for both experts and those less
skilled, regardless of whether the problem is easy or difficult.
Use an Evidence-Based Approach
To gain knowledge and insight into managerial and leadership decision making, individuals
must reach outside their current sphere of knowledge in solving the problems presented in
this text. Some data-gathering sources include textbooks, periodicals, experts in the field,
colleagues, and current research. Indeed, most experts agree that the best practices in nursing
care and decision making are also evidence-based practices (Prevost, 2014).
While there is no one universally accepted definition for an evidence-based approach,
most definitions suggest the term evidence based can be used synonymously with research
based or science based. Others suggest that evidence based means that the approach has
been reviewed by experts in the field using accepted standards of empirical research and that
reliable evidence exists that the approach or practice works to achieve the desired outcomes.
Typically, a PICO (patient or population, intervention, comparison, and outcome) format is
used in evidence-based practice to guide the search for the current best evidence to address
a problem.
Given that human lives are often at risk, nurses, then, should feel compelled to use
an evidence-based approach in gathering data to make decisions regarding their nursing
practice. Yet, Prevost (2014) suggests that many practicing nurses feel they do not have
the time, access, or expertise needed to search and analyze the research literature to answer
clinical questions. In addition, most staff nurses practicing in clinical settings have less than
a baccalaureate degree and therefore may not have been exposed to a formal research course.
Findings from research studies may also be technical, difficult to understand, and even more
difficult to translate into practice. Strategies the new nurse might use to promote evidence-
based practice are shown in Display 1.8.
Evidence-based decision making and evidence-based practice should be viewed as imperatives
for all nurses today as well as for the profession in general.
It is important to recognize that the implementation of evidence-based best practices is not
just an individual, staff nurse–level pursuit (Prevost, 2014). Too few nurses understand what
best practices and evidence-based practice are all about, and many organizational cultures do
not support nurses who seek out and use research to change long-standing practices rooted
in tradition rather than in science. Administrative support is needed to access the resources,
DISPLAy 1.8 Strategies for the New Nurse to Promote Evidence-Based Best Practice
1. Keep abreast of the evidence—subscribe to professional journals and read widely.
2. Use and encourage use of multiple sources of evidence.
3. Use evidence not only to support clinical interventions but also to support teaching strategies.
4. Find established sources of evidence in your specialty—do not reinvent the wheel.
5. implement and evaluate nationally sanctioned clinical practice guidelines.
6. Question and challenge nursing traditions and promote a spirit of risk taking.
7. dispel myths and traditions not supported by evidence.
8. collaborate with other nurses locally and globally.
9. interact with other disciplines to bring nursing evidence to the table.
Source: Reprinted from Prevost, S. (2014). Evidence-based practice. In C. Huston (Ed.), professional issues in nursing
(3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
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14 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
provide the support personnel, and sanction the necessary changes in policies, procedures,
and practices for evidence-based data gathering to be a part of every nurse’s practice
(Prevost, 2014). This approach to care is even being recognized as a standard expectation
of accrediting bodies, such as the Joint Commission as well as an expectation for magnet
hospital designation.
Generate Many Alternatives
The definition of decision making implies that there are at least two choices in every decision.
Unfortunately, many problem solvers limit their choices to two when many more options
usually are available. Remember that one alternative in each decision should be the choice not
to do anything. When examining decisions to be made by using a formal process, it is often
found that the status quo is the right alternative.
The greater the number of alternatives that can be generated, the greater the chance that the
final decision will be sound.
Several techniques can help to generate more alternatives. Involving others in the process
confirms the adage that two heads are better than one. Because everyone thinks uniquely,
increasing the number of people working on a problem increases the number of alternatives
that can be generated.
Brainstorming is another frequently used technique. The goal in brainstorming is to
think of all possible alternatives, even those that may seem “off target.” By not limiting the
possible alternatives to only apparently appropriate ones, people can break through habitual
or repressive thinking patterns and allow new ideas to surface. Although most often used by
groups, people who make decisions alone also may use brainstorming.
LEARNING EXERCISE 1.3
Possible Alternatives in Problem Solving
in the personal-choice scenario presented in Learning exercise 1.1, some of the following
alternatives could have been generated:
● do not take the new position.
● hire a full-time housekeeper, and take the position.
● ask your spouse to quit working.
● have an abortion.
● ask one of the parents to help.
● Take the position, and do not hire child care.
● Take the position, and hire child care.
● have your spouse reduce the law practice and continue helping with child care.
● ask the supervisor if you can work 4 days a week and still have the position.
● Take the position and wait and see what happens after the baby is born.
Assignment: how many of these alternatives did you or your group generate? What alternatives
did you identify that are not included in this list?
Think Logically
During the problem-solving process, one must draw inferences from information. An
inference is part of deductive reasoning. People must carefully think through the information
and the alternatives. Faulty logic at this point may lead to poor-quality decisions. Primarily,
people think illogically in three ways.

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 15
1. Overgeneralizing: This type of “crooked” thinking occurs when one believes that
because A has a particular characteristic, every other A also has the same characteristic.
This kind of thinking is exemplified when stereotypical statements are used to justify
arguments and decisions.
2. Affirming the consequences: In this type of illogical thinking, one decides that if B is
good and he or she is doing A, then A must not be good. For example, if a new method
is heralded as the best way to perform a nursing procedure and the nurses on your unit
are not using that technique, it is illogical to assume that the technique currently used
in your unit is wrong or bad.
3. Arguing from analogy: This thinking applies a component that is present in two separate
concepts and then states that because A is present in B, then A and B are alike in all respects.
An example of this would be to argue that because intuition plays a part in clinical and
managerial nursing, then any characteristic present in a good clinical nurse also should
be present in a good nurse-manager. However, this is not necessarily true; a good nurse-
manager does not necessarily possess all the same skills as a good nurse-clinician.
Various tools have been designed to assist managers with the important task of analysis.
Several of these tools are discussed in this chapter. In analyzing possible solutions, individuals
may want to look at the following questions:
1. What factors can you influence? How can you make the positive factors more important
and minimize the negative factors?
2. What are the financial implications in each alternative? The political implications?
Who else will be affected by the decision and what support is available?
3. What are the weighting factors?
4. What is the best solution?
5. What are the means of evaluation?
6. What are the consequences of each alternative?
Choose and Act Decisively
It is not enough to gather adequate information, think logically, select from among many
alternatives, and be aware of the influence of one’s values. In the final analysis, one must act.
Many individuals delay acting because they do not want to face the consequences of their
choices (e.g., if managers granted all employees’ requests for days off, they would have to
accept the consequences of dealing with short staffing).
Many individuals choose to delay acting because they lack the courage to face the
consequences of their choices.
It may help the reluctant decision maker to remember that even though decisions often have
long-term consequences and far-reaching effects, they are not usually cast in stone. Often,
judgments found to be ineffective or inappropriate can be changed. By later evaluating
decisions, managers can learn more about their abilities and where the problem solving was
faulty. However, decisions must continue to be made, although some are of poor quality,
because through continued decision making, people develop improved decision-making skills.
INDIVIDUAL VARIATIONS IN DECISION MAKING
If each person receives the same information and uses the same scientific approach to solve
problems, an assumption could be made that identical decisions would result. However, in
practice, this is not true. Because decision making involves perceiving and evaluating, and
people perceive by sensation and intuition and evaluate their perception by thinking and
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16 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
feeling, it is inevitable that individuality plays a part in decision making. Because everyone
has different values and life experiences, and each person perceives and thinks differently,
different decisions may be made given the same set of circumstances. No discussion of
decision making would, therefore, be complete without a careful examination of the role of
the individual in decision making.
Gender
New research suggests that gender may play a role in how individuals make decisions,
although some debate continues as to whether these differences are more gender role based
than gender based. Research does suggest, however, that men and women do have different
structures and wiring in the brain and that men and women may use their brains differently
(Edmonds, 1998–2013). For example, Harvard researchers have found that parts of the frontal
lobe, responsible for problem solving and decision making, and the limbic cortex, responsible
for regulating emotions, are larger in women (Hoag as cited by Edmonds). Men also have
approximately 6.5 times more gray matter in the brain than women, but women have about
10 times more white matter than men (Carey as cited by Edmonds). Researchers believe that
men may think more with their gray matter, while women think more with the white matter.
This use of white matter may allow a woman’s brain to work faster than a man’s (Hotz as
cited by Edmonds).
Values
Individual decisions are based on each person’s value system. No matter how objective
the criteria, value judgments will always play a part in a person’s decision making, either
consciously or subconsciously. The alternatives generated and the final choices are limited by
each person’s value system. For some, certain choices are not possible because of a person’s
beliefs. Because values also influence perceptions, they invariably influence information
gathering, information processing, and final outcome. Values also determine which problems
in one’s personal or professional life will be addressed or ignored.
No matter how objective the criteria, value judgments will always play a part in a person’s
decision making, either consciously or subconsciously.
Life Experience
Each person brings to the decision-making task past experiences that include education
and decision-making experience. The more mature the person and the broader his or her
background, the more alternatives he or she can identify. Each time a new behavior or
decision is observed, that possibility is added to the person’s repertoire of choices.
In addition, people vary in their desire for autonomy, so some nurses may want more
autonomy than others. It is likely that people seeking autonomy may have much more
experience at making decisions than those who fear autonomy. Likewise, having made good
or poor decisions in the past will influence a person’s decision making.
Individual Preference
With all the alternatives a person considers in decision making, one alternative may be
preferred over another. The decision maker, for example, may see certain choices as involving
greater personal risk than others and therefore may choose the safer alternative. Physical,
economic, and emotional risks and time and energy expenditures are types of personal
risk and costs involved in decision making. For example, people with limited finances or a
reduced energy level may decide to select an alternative solution to a problem that would not
have been their first choice had they been able to overcome limited resources.

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 17
Brain Hemisphere Dominance and Thinking Styles
Our way of evaluating information and alternatives on which we base our final decision
constitutes a thinking skill. Individuals think differently. Some think systematically—and
are often called analytical thinkers—whereas others think intuitively. It is believed that most
people have either right- or left-brain hemisphere dominance. Analytical, linear, left-brain
thinkers process information differently from creative, intuitive, right-brain thinkers. Left-
brain thinkers are typically better at processing language, logic, numbers, and sequential
ordering while right-brain thinkers excel at nonverbal ideation and holistic synthesizing
(Rigby, Gruver, & Allen, 2009). The end result is that individuals with left-brain dominance do
well in mathematics, reading, planning, and organizing while right-brain dominant individuals
are better at handling images, music, colors, and patterns (Rigby et al., 2009). Although the
authors encourage whole-brain thinking, and studies have shown that people can strengthen
the use of the less dominant side of the brain, most people continue to have a dominant side.
Some researchers, including Nobel Prize winner Roger Sperry, suggest that there
are actually four different thinking styles based on brain dominance. Ned Herrmann, a
researcher in critical thinking and whole-brain methods, also suggested that there are four
brain hemispheres and that decision making varies with brain dominance (12 Manage: The
Executive Fast Track, 2013). For example, Herrmann suggested that individuals with upper-
left-brain dominance truly are analytical thinkers who like working with factual data and
numbers. These individuals deal with problems in a logical and rational way. Individuals
with lower-left-brain dominance are highly organized and detail oriented. They prefer a stable
work environment and value safety and security over risk taking.
Individuals with upper-right-brain dominance are big picture thinkers who look for hidden
possibilities and are futuristic in their thinking. They also frequently rely on intuition to solve
problems and are willing to take risks to seek new solutions to problems. Individuals with
lower-right-brain dominance experience facts and problem solve in a more emotional way
than the other three types. They are sympathetic, kinesthetic, and empathetic and focus more
on interpersonal aspects of decision making (12 Manage: The Executive Fast Track, 2013).
In the past, some organizations more openly valued their logical, analytical thinkers but
more recently have recognized that intuitive thinking is also a valuable managerial resource.
Indeed, organizations need all types of thinkers, and in fact, smart leaders will see that teams
are composed of individuals with different types of brain dominance. Rigby et al. (2009,
p. 79) agree, suggesting that when resources are constrained, “the key to growth is pairing
an analytic left-brained thinker with an imaginative right-brain partner.” The right-brained
thinker will be creative in producing innovation, and the left-brained thinker will give the
idea structure so that it can become a reality.
There is no evidence that any one thinking style or that having either right- or left-brain
dominance is better.
LEARNING EXERCISE 1.4
Thinking Styles
in small groups, examine how each individual in the group thinks. did you have a majority of
individuals with right- or left-brain dominance? did group members self-identify with one or
more of the four thinking styles noted by herrmann (12 Manage: The executive Fast Track,
2013)? did gender seem to influence thinking style or brain hemisphere dominance? What
types of thinkers were represented in group members’ families? did most group members view
variances in a positive way?
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18 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
OVERCOMING INDIVIDUAL VULNERABILITy IN DECISION MAKING
How do people overcome subjectivity in making decisions? This can never be completely
overcome, nor should it. After all, life would be boring if everyone thought alike. However,
managers and leaders must become aware of their own vulnerability and recognize how it
influences and limits the quality of their decision making. Using the following suggestions
will help decrease individual subjectivity and increase objectivity in decision making.
Values
Being confused and unclear about one’s values may affect decision-making ability. Overcoming
a lack of self-awareness through values clarification decreases confusion. People who
understand their personal beliefs and feelings will have a conscious awareness of the values on
which their decisions are based. This awareness is an essential component of decision making
and critical thinking. Therefore, to be successful problem solvers, managers must periodically
examine their values. Values clarification exercises are included in Chapter 7.
Life Experience
It is difficult to overcome inexperience when making decisions. However, a person can do
some things to decrease this area of vulnerability. First, use available resources, including
current research and literature, to gain a fuller understanding of the issues involved. Second,
involve other people, such as experienced colleagues, mentors, trusted friends, and experts,
to act as sounding boards and advisors. Third, analyze decisions later to assess their success.
By evaluating decisions, people learn from mistakes and are able to overcome inexperience.
In addition, novice nurse-leaders of the future may increasingly choose to improve the
quality of their decision making by the use of commercially purchased expert networks—
communities of top thinkers, managers, and scientists—to help them make decisions. Such
network panels are typically made up of researchers, health-care professionals, attorneys, and
industry executives.
Individual Preference
Overcoming this area of vulnerability involves self-awareness, honesty, and risk taking.
The need for self-awareness was discussed previously, but it is not enough to be self-aware;
people also must be honest with themselves about their choices and their preferences for
those choices. In addition, the successful decision maker must take some risks. Nearly
every decision has some element of risk, and most decisions involve consequences and
accountability.
Those who can do the right but unpopular thing and who dare to stand alone will emerge as
leaders.
Individual Ways of Thinking
People making decisions alone are frequently handicapped because they are not able to
understand problems fully or make decisions from both analytical and intuitive perspectives.
However, most organizations include both types of thinkers. Using group process, talking
management problems over with others, and developing whole-brain thinking also are
methods for ensuring that both intuitive and analytical approaches will be used in solving
problems and making decisions. Use of heterogeneous rather than homogeneous groups will
usually result in better-quality decision making. Indeed, learning to think “outside the box”
is often accomplished by including a diverse group of thinkers when solving problems and
making decisions.

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 19
Although not all experts agree, many consider the following to be qualities of a successful
decision maker:
• Courage: Courage is particularly important and involves the willingness to take risks.
• Sensitivity: Good decision makers seem to have some sort of antenna that makes them
particularly sensitive to situations and others.
• Energy: People must have the energy and desire to make things happen.
• Creativity: Successful decision makers tend to be creative thinkers. They develop new
ways to solve problems.
DECISION MAKING IN ORGANIZATIONS
In the beginning of this chapter, the need for managers and leaders to make quality decisions
was emphasized. The effect of the individual’s values and preferences on decision making
was discussed, but it is important for leaders and managers to also understand how the
organization influences the decision-making process. Because organizations are made up of
people with differing values and preferences, there is often conflict in organizational decision
dynamics.
Effect of Organizational Power
Powerful people in organizations are more likely to have decisions made (by themselves or
their subordinates) that are congruent with their own preferences and values. On the other
hand, people wielding little power in organizations must always consider the preference of
the powerful when they make management decisions. In organizations, choice is constructed
and constrained by many factors, and therefore choice is not equally available to all people.
In addition, not only do the preferences of the powerful influence decisions of the less
powerful, but the powerful also can inhibit the preferences of the less powerful. This occurs
because individuals who remain and advance in organizations are those who feel and express
values and beliefs congruent with the organization. Therefore, a balance must be found
between the limitations of choice posed by the power structure within the organization and
totally independent decision making that could lead to organizational chaos.
The ability of the powerful to influence individual decision making in an organization often
requires adopting a private personality and an organizational personality.
For example, some might believe they would have made a different decision had they been
acting on their own, but they went along with the organizational decision. This “going along”
in itself constitutes a decision. People choose to accept an organizational decision that differs
from their own preferences and values. The concept of power in organizations is discussed
in more detail in Chapter 13.
Rational and Administrative Decision Making
For many years, it was widely believed that most managerial decisions were based on a
careful, scientific, and objective thought process and that managers made decisions in a
rational manner. In the late 1940s, Herbert A. Simon’s work revealed that most managers
made many decisions that did not fit the objective rationality theory. Simon (1965) delineated
two types of management decision makers: the economic man and the administrative man.
Managers who are successful decision makers often attempt to make rational decisions,
much like the economic man described in Table 1.2. Because they realize that restricted
knowledge and limited alternatives directly affect a decision’s quality, these managers
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20 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
gather as much information as possible and generate many alternatives. Simon believed
that the economic model of man, however, was an unrealistic description of organizational
decision making. The complexity of information acquisition makes it impossible for
the human brain to store and retain the amount of information that is available for each
decision. Because of time constraints and the difficulty of assimilating large amounts of
information, most management decisions are made using the administrative man model of
decision making.
Most management decisions are made by using the administrative man model of decision making.
The administrative man never has complete knowledge and generates fewer alternatives.
Simon argued that the administrative man carries out decisions that are only satisficing, a
term used to describe decisions that may not be ideal but result in solutions that have adequate
outcomes. These managers want decisions to be “good enough” so that they “work,” but they
are less concerned that the alternative selected is the optimal choice. The “best” choice for
many decisions is often found to be too costly in terms of time or resources, so another less
costly but workable solution is found.
DECISION-MAKING TOOLS
There is always some uncertainty in making decisions. However, management analysts have
developed tools that provide some order and direction in obtaining and using information or
that are helpful in selecting who should be involved in making the decision. Because there are
so many decision aids, this chapter presents selected technology that would be most helpful to
beginning- or middle-level managers, including decision grids, payoff tables, decision trees,
consequence tables, logic models, and program evaluation and review technique (PERT). It is
important to remember, though, that any decision-making tool always results in the need for
the person to make a final decision and that all such tools are subject to human error.
Decision Grids
A decision grid allows one to visually examine the alternatives and compare each against the
same criteria. Although any criteria may be selected, the same criteria are used to analyze each
alternative. An example of a decision grid is depicted in Figure 1.3. When many alternatives
have been generated or a group or committee is collaborating on the decision, these grids are
particularly helpful to the process. This tool, for instance, would be useful when changing
TABLE 1.2 Comparing the Economic Man with the Administrative Man
Economic Administrative
Makes decisions in a very rational manner Makes decisions that are good enough
has complete knowledge of the problem or
decision situation
Because complete knowledge is not possible,
knowledge is always fragmented
has a complete list of possible alternatives Because consequences of alternatives occur in the
future, they are impossible to predict accurately
has a rational system of ordering preference of
alternatives
Usually chooses from among a few alternatives, not
all possible ones
Selects the decision that will maximize utility The final choice is satisficing rather than maximizing
Source: adapted from Simon, h. a. (1965). The shape of automation for man and management. New York, NY:
harper Textbooks.

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 21
the method of managing care on a unit or when selecting a candidate to hire from a large
interview pool. The unit manager or the committee would evaluate all of the alternatives
available using a decision grid. In this manner, every alternative is evaluated using the same
criteria. It is possible to weight some of the criteria more heavily than others if some are more
important. To do this, it is usually necessary to assign a number value to each criterion. The
result would be a numeric value for each alternative considered.
Payoff Tables
The decision aids known as payoff tables have a cost–profit–volume relationship and are very
helpful when some quantitative information is available, such as an item’s cost or predicted
use. To use payoff tables, one must determine probabilities and use historical data, such as a
hospital census and a report on the number of operating procedures performed. To illustrate, a
payoff table might be appropriately used in determining how many participants it would take
to make an in-service program break even in terms of costs.
If the instructor for the class costs $500, the in-service director would need to charge each
of the 20 participants $25 for the class, but for 40 participants, the class would cost only
$12.50 each. The in-service director would use attendance data from past classes and the
number of nurses potentially available to attend to determine probable class size and thus
how much to charge for the class. Payoff tables do not guarantee that a correct decision will
be made, but they assist in visualizing data.
Decision Trees
Because decisions are often tied to the outcome of other events, management analysts have
developed decision trees.
The decision tree in Figure 1.4 compares the cost of hiring regular staff with the cost of
hiring temporary employees. Here, the decision is whether to hire extra nurses at regular
salary to perform outpatient procedures on an oncology unit or to have nurses available to the
unit on an on-call basis and pay them on-call and overtime wages. The possible consequences
of a decreased volume of procedures and an increased volume must be considered. Initially,
costs would increase in hiring a regular staff, but over a longer time, this move would mean
greater savings if the volume of procedures does not dramatically decrease.
Consequence Tables
Consequence tables demonstrate how various alternatives create different consequences. A
consequence table lists the objectives for solving a problem down one side of a table and rates
how each alternative would meet the desired objective.
#1
#2
#3
#4
Financial
effect
Political
effect
Departmental
effect Time DecisionAlternative
FIGURE 1.3 • a decision grid.
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22 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
For example, consider this problem: “The number of patient falls has exceeded the
benchmark rate for two consecutive quarters.” After a period of analysis, the following
alternatives were selected as solutions:
1. Provide a new educational program to instruct staff on how to prevent falls.
2. Implement a night check to ensure that patients have side rails up and beds in low
position.
3. Implement a policy requiring soft restraint orders on all confused patients.
The decision maker then lists each alternative opposite the objectives for solving the
problem, which for this problem might be (a) reduces the number of falls, (b) meets
regulatory standards, (c) is cost-effective, and (d) fits present policy guidelines. The
decision maker(s) then ranks each desired objective and examines each of the alternatives
through a standardized key, which allows a fair comparison between alternatives and assists
in eliminating undesirable choices. It is important to examine long-term effects of each
alternative as well as how the decision will affect others. See Table 1.3 for an example of a
consequence table.
POSSIBLE EVENTS
Increased demand
for procedures
Decreased demand
for procedures
Increased demand
for staff
Decreased demand
for staff
Pay overtime and
on-call wages
Decision point
(last event to occur)
ALTERNATIVE
ACTIONS
Hire regular staff
Variables affecting the direction of the decision tree:
• Revenue from procedures • Net cash flow
• Costs • First-year expected value
FIGURE 1.4 • a decision tree.
TABLE 1.3 A Consequence Table
Objectives for Problem Solving Alternative 1 Alternative 2 Alternative 3
1. Reduces the number of falls X X X
2. Meets regulatory standards X X X
3. is cost-effective X X
4. Fits present policy guidelines X
Decision Score

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 23
Logic Models
Logic models are schematics or pictures of how programs are intended to operate. The
schematic typically includes resources, processes, and desired outcomes and depicts
exactly what the relationships are between the three components. For example, Allmark,
Baxter, Goyder, Guillaume, and Crofton-Martin (2013) used logic models to depict
causal pathways between the provision of advice services and improvements in health.
Data and discussion from 87 documents were used to construct a model describing
interventions, primary outcomes, secondary and tertiary outcomes following advice
interventions.
Program Evaluation and Review Technique
PERT is a popular tool to determine the timing of decisions. Developed by the Booz-Allen-
Hamilton organization and the U.S. Navy in connection with the Polaris missile program,
PERT is essentially a flowchart that predicts when events and activities must take place if
a final event is to occur. Figure 1.5 shows a PERT chart for developing a new outpatient
treatment room for oncology procedures. The number of weeks to complete tasks is listed in
optimistic time, most likely time, and pessimistic time. The critical path shows something that
must occur in the sequence before one may proceed. PERT is especially helpful when a group
of people is working on a project. The flowchart keeps everyone up-to-date, and problems are
easily identified when they first occur. Flowcharts are popular, and many people use them in
their personal lives.
Decision
to develop
a staffed
outpatient
treatment
room
5-7-9 2-3-42-3-4
Renovation
complete
Staff
recruited
Staff
hired
2-3-4
Staff
trained
4-5-6
1-2-3
Equipment
installed
Equipment
received
Equipment
ordered
Equipment
and staff
ready
3-4-5
1-2-3
2-3-4
10-12-14
Critical path
Number of weeks to complete task ranked from most optimistic,
to most likely, to most pessimistic finish times
Planning
complete
Room
gutted
FIGURE 1.5 • example of a peRT flow diagram.
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24 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
PITFALLS IN USING DECISION-MAKING TOOLS
A common flaw in making decisions is to base decisions on first impressions. This then
typically leads to confirmation biases. A confirmation bias is a tendency to affirm one’s
initial impression and preferences as other alternatives are evaluated. So, even the use of
consequence tables, decision trees, and other quantitative decision tools will not guarantee a
successful decision.
It is also human nature to focus on an event that leaves a strong impression, so individuals
may have preconceived notions or biases that influence decisions. Too often, managers allow
the past to unduly influence current decisions.
Many of the pitfalls associated with management decision-making tools can be reduced by
choosing the correct decision-making style and involving others when appropriate.
Although there are times when others should be involved, it is not always necessary to
involve others in decision making, and frequently a manager does not have time to involve
a large group. However, it is important to separate out those decisions that need input from
others and those that a manager can make alone.
SUMMARy
This chapter has discussed effective decision making, problem solving, critical thinking,
and clinical reasoning as requisites for being a successful leader and manager. The effective
leader-manager is aware of the need for sensitivity in decision making. The successful
decision maker possesses courage, energy, and creativity. It is a leadership skill to recognize
the appropriate people to include in decision making and to use a suitable theoretical model
for the decision situation.
Managers who make quality decisions are effective administrators. The manager should
develop a systematic, scientific approach to problem solving that begins with a fixed goal
and ends with an evaluation step. Decision tools exist to help make more effective decisions;
however, leader-managers must remember that they are not foolproof and that they often do
not adequately allow for the human element in management. In addition, managers should
strive to make decisions that reflect research-based best practices and nursing’s scientific
knowledge base. Yet, the role of intuition as an adjunct to quality decision making should not
be overlooked.
The integrated leader-manager understands the significance that gender, personal values,
life experience, preferences, willingness to take risks, brain hemisphere dominance, and
thinking styles have on selected alternatives in making the decision. The critical thinker
LEARNING EXERCISE 1.5
Using a Flowchart for Project Management
Think of a project that you are working on; it could be a dance, a picnic, remodeling your
bathroom, or a semester schedule of activities in a class.
Assignment: draw a flowchart, inserting at the bottom the date that activities for the event are
to be completed. Working backward, insert critical tasks and their completion dates. Refer to
your flowchart throughout the project to see if you are staying on target.

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 25
pondering a decision is aware of the areas of vulnerability that hinder successful decision
making and will expend his or her efforts to avoid the pitfalls of faulty logic and data
gathering.
Both managers and leaders understand the impact that the organization has on decision
making and that some of the decisions that will be made in the organization will be only
satisficing. However, leaders will strive to problem solve adequately in order to reach optimal
decisions as often as possible.
KEY CONCEPTS
● Successful decision makers are self-aware, courageous, sensitive, energetic, and creative.
● The rational approach to problem solving begins with a fixed goal and ends with an evaluation process.
● Naturalistic decision making blends intuition and analysis, but pattern recognition and experience guide
decision makers when time is limited or systematic rational decision making is not possible.
● evidence-based nursing practice integrates the best evidence available to achieve desirable outcomes.
● The successful decision maker understands the significance that gender, personal, individual values,
life experience, preferences, willingness to take risks, brain hemisphere dominance, and predominant
thinking style have on alternative identification and selection.
● The critical thinker is aware of areas of vulnerability that hinder successful decision making and makes
efforts to avoid the pitfalls of faulty logic in his or her data gathering.
● The act of making and evaluating decisions increases the expertise of the decision maker.
● There are many models for improving decision making. Using a systematic decision-making or problem-
solving model reduces heuristic trial-and-error or rule-of-thumb methods and increases the probability
that appropriate decisions will be made.
● Left- and right-brain dominance as well as thinking styles influences, at least to some degree, how
individuals think.
● Two major considerations in organizational decision making are how power affects decision making and
whether management decision making needs to be only satisficing.
● Management science has produced many tools to help decision makers make better and more objective
decisions, but all are subject to human error, and many do not adequately consider the human element.
ADDITIONAL LEARNING ExERCISES AND APPLICATIONS
LEARNING EXERCISE 1.6
Evaluating Decision Making
a. describe the two best decisions that you have made in your life and the two worst. What
factors assisted you in making the wise decisions? What elements of critical thinking went
awry in your poor decision making? how would you evaluate your decision-making ability?
B. examine the process that you used in your decision to become a nurse. Would you
describe it as fitting a profile of the economic man or the administrative man?
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LEARNING EXERCISE 1.7
18 question How Good Are Your Decision-Making Skills? Quiz and Key
Instructions:
For each statement, click the button in the column that best describes you. Please answer
questions as you actually are (rather than how you think you should be), and do not worry if
some questions seem to score in the “wrong direction.” When you are finished, please click
the “Calculate My Total” button at the bottom of the test.
Statement
Not
at all Rarely
Some
times Often
Very
often
1 I evaluate the risks associated with each
alternative before making a decision. ◘ ◘ ◘ ◘ ◘
2 After I make a decision, it is final—because I
know my process is strong. ◘ ◘ ◘ ◘ ◘
3 I try to determine the real issue before starting a
decision-making process. ◘ ◘ ◘ ◘ ◘
4 I rely on my own experience to find potential
solutions to a problem. ◘ ◘ ◘ ◘ ◘
5 I tend to have a strong “gut instinct” about problems,
and I rely on it in decision making. ◘ ◘ ◘ ◘ ◘
6 I am sometimes surprised by the actual
consequences of my decisions. ◘ ◘ ◘ ◘ ◘
7 I use a well-defined process to structure my
decisions. ◘ ◘ ◘ ◘ ◘
8 I think that involving many stakeholders to
generate solutions can make the process more
complicated than it needs to be.
◘ ◘ ◘ ◘ ◘
9 If I have doubts about my decision, I go back and
recheck my assumptions and my process. ◘ ◘ ◘ ◘ ◘
10 I take the time needed to choose the best
decision-making tool for each specific decision. ◘ ◘ ◘ ◘ ◘
11 I consider a variety of potential solutions before I
make my decision. ◘ ◘ ◘ ◘ ◘
12 Before I communicate my decision, I create an
implementation plan. ◘ ◘ ◘ ◘ ◘
13 In a group decision-making process, I tend to
support my friends’ proposals and try to find
ways to make them work.
◘ ◘ ◘ ◘ ◘
14 When communicating my decision, I include my
rationale and justification. ◘ ◘ ◘ ◘ ◘
15 Some of the options I’ve chosen have been much
more difficult to implement than I had expected. ◘ ◘ ◘ ◘ ◘
16 I prefer to make decisions on my own, and then let
other people know what I’ve decided. ◘ ◘ ◘ ◘ ◘

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 27
17 I determine the factors most important to the
decision, and then use those factors to evaluate
my choices.
◘ ◘ ◘ ◘ ◘
18 I emphasize how confident I am in my decision as a
way to gain support for my plans. ◘ ◘ ◘ ◘ ◘
Total = 0
Score Interpretation
Score Comment
18–42 Your decision making has not fully matured. You are not objective enough, and
you rely too much on luck, instinct, or timing to make reliable decisions. Start to
improve your decision-making skills by focusing more on the process that leads to
the decision, rather than on the decision itself. With a solid process, you can face any
decision with confidence. We will show you how.
43–66 Your decision-making process is OK. You have a good understanding of the basics,
but now you need to improve your process and be more proactive. Concentrate on
finding lots of options and discovering as many risks and consequences as you can.
The better your analysis, the better your decision will be in the long term. Focus
specifically on the areas where you lost points, and develop a system that will work
for you across a wide variety of situations.
67–90 You have an excellent approach to decision making! You know how to set up the
process and generate lots of potential solutions. From there, you analyze the options
carefully, and you make the best decisions possible based on what you know. As you
gain more and more experience, use that information to evaluate your decisions, and
continue to build on your decision-making success. Think about the areas where you
lost points, and decide how you can include those areas in your process.
as you answered the questions, did you see some common themes? We based our quiz on
six essential steps in the decision-making process:
1. establishing a positive decision-making environment.
2. Generating potential solutions.
3. evaluating the solutions.
4. deciding.
5. checking the decision.
6. communicating and implementing.
if you are aware of these six basic elements and improve the way you structure them, this will help
you develop a better overall decision-making system. Let us look at the six elements individually.
Establishing a Positive Decision-Making Environment (Statements 3, 7, 13, and 16)
if you have ever been in a meeting where people seem to be discussing different issues,
then you have seen what happens when the decision-making environment has not been
established. it is so important for everyone to understand the issue before preparing to
make a decision. This includes agreeing on an objective, making sure the right issue is being
discussed, and agreeing on a process to move the decision forward.
You also must address key interpersonal considerations at the very beginning. have you
included all the stakeholders? and do the people involved in the decision agree to respect one
another and engage in an open and honest discussion? after all, if only the strongest opinions
are heard, you risk not considering some of the best solutions available.
(Continued)
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28 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
Generating Potential Solutions (Statements 4, 8, and 11)
another important part of a good decision process is generating as many good alternatives as
sensibly possible to consider. if you simply adopt the first solution you encounter, then you are
probably missing a great many even better alternatives.
Evaluating Alternatives (Statements 1, 6, and 15)
The stage of exploring alternatives is often the most time-consuming part of the decision-making
process. This stage sometimes takes so long that a decision is never made! To make this step
efficient, be clear about the factors you want to include in your analysis. There are three key
factors to consider:
1. Risk—Most decisions involve some risk. however, you need to uncover and understand the
risks to make the best choice possible.
2. Consequences—You cannot predict the implications of a decision with 100% accuracy.
But you can be careful and systematic in the way that you identify and evaluate possible
consequences.
3. Feasibility—is the choice realistic and implementable? This factor is often ignored. You
usually have to consider certain constraints when making a decision. as part of this
evaluation stage, ensure that the alternative you have selected is significantly better than
the status quo.
Deciding (Statements 5, 10, and 17)
Making the decision itself can be exciting and stressful. To help you deal with these emotions as
objectively as possible, use a structured approach to the decision. This means taking a look at
what is most important in a good decision.
Take the time to think ahead and determine exactly what will make the decision “right.” This will
significantly improve your decision accuracy.
Checking the Decision (Statements 2 and 9)
Remember that some things about a decision are not objective. The decision has to make sense
on an intuitive, instinctive level as well. The entire process we have discussed so far has been
based on the perspectives and experiences of all the people involved. Now, it is time to check
the alternative you have chosen for validity and “making sense.”
if the decision is a significant one, it is also worth auditing it to make sure that your assumptions
are correct, and that the logical structure you have used to make the decision is sound.
Communicating and Implementing (Statements 12, 14, and 18)
The last stage in the decision-making process involves communicating your choice and preparing
to implement it. You can try to force your decision on others by demanding their acceptance.
Or you can gain their acceptance by explaining how and why you reached your decision. For
most decisions—particularly those that need participant buy-in before implementation—it is more
effective to gather support by explaining your decision.
have a plan for implementing your decision. people usually respond positively to a clear plan—
one that tells them what to expect and what they need to do.
Source: How Good Is Your Decision-Making? Retrieved February 6, 2013, from http://www.mindtools.com/pages/article/
newTED_79.htm. Reproduced with permission from MindTools. © Mind Tools Ltd, 1996–2013.

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 29
LEARNING EXERCISE 1.10
Using Models in Decision Making
do you use a problem-solving or decision-making model to solve problems? have you ever used
an intuitive model? Think of a critical decision that you have made in the last year. What model,
if any, did you use?
Assignment: Write a one-page essay about a problem that you solved or a decision that you
made this year. describe what theoretical model, if any, you used to assist you in the process.
determine if you consciously used the model or if it was purely by accident. did you enlist the
help of other experts in solving the problem?
LEARNING EXERCISE 1.8
Considering Critical Elements in Decision Making
You are a college senior and president of your nursing organization. You are on the committee
to select a slate of officers for the next academic year. Several of the current officers will be
graduating, and you want the new slate of officers to be committed to the organization. Some of
the brightest members of the junior class involved in the organization are not well liked by some
of your friends in the organization.
Assignment: Looking at the critical elements in decision making, compile a list of the most
important points to consider in making the decision for selecting a slate of officers. What must
you guard against, and how should you approach the data gathering to solve this problem?
LEARNING EXERCISE 1.9
Examining the Decision-Making Process
You have been a staff nurse for the 3 years since your graduation from nursing school. There is
a nursing shortage in your area and many openings at other facilities. in addition, you have been
offered a charge nurse position by your present employer. Last, you have always wanted to do
community health nursing and know that this is also a possibility. You are self-aware enough to
know that it is time for a change, but which change, and how should you make the decision?
Assignment: examine both the individual aspects of decision making and the critical elements
in making decisions. Make a plan including a goal, a list of information, and data that you
need to gather and areas where you may be vulnerable to poor decision making. examine the
consequences of each alternative available to you. after you have done this, as an individual,
form a small group and share your decision-making planning with members of your group. how
was your decision making like others in the group, and how was it different?
LEARNING EXERCISE 1.11
Decision Making and Risk Taking
You are a new graduate nurse just finishing your 3-month probation period at your first job in
acute care nursing. You have been working closely with a preceptor; however, he has been
gradually transitioning you to more independent practice. You now have your own patient care
(Continued )
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30 UNIT I The CrITICaL TrIaD: DeCISIoN MakINg, MaNageMeNT, aND LeaDerShIP
assignment and have been giving medications independently for several weeks. Today, your
assignment included an elderly confused patient with severe coronary disease. her medications
include antihypertensives, antiarrhythmics, and beta-blockers. it was a very busy morning, and
you have barely had a moment to reorganize and collect your thoughts.
it is now 2:30 pm, and you are preparing your handoff report. When you review the patient’s
2:00 pm vital signs, you note a significant rise in this patient’s blood pressure and heart rate.
The patient, however, reports no distress. You remember that when you passed the morning
medications, the patient was in the middle of her bath and asked that you just set the
medications on the bedside table and that she would take them in a few minutes. You meant to
return to see that she did but were sidetracked by a problem with another patient.
You now go to the patient’s room to see if she indeed did take the pills. The pill cup and pills are
not where you left them, and a search of the wastebasket, patient bed, and bedside table yields
nothing. The patient is too confused to be an accurate historian regarding whether she took the
pills. No one on your patient care team noticed the pills.
at this point, you are not sure what you should do next. You are frustrated that you did not wait
to give the medications in person but cannot change this now. You charted the medications as
being given this morning when you left them at the bedside. You are reluctant to report this as
a medication error since you are still on probation and you are not sure that the patient did not
take the pills as she said she would. Your probation period has not gone as smoothly as you
would have liked anyway, and you are aware that reporting this incident will likely prolong your
probation and that a copy of the error report will be placed in your personnel file. The patient’s
physician is also frequently short-tempered and will likely be agitated when you report your
uncertainty about whether the patient received her prescribed medications. The reality is that if
you do nothing, it is likely that no one will ever know about the problem.
You do feel responsible, however, for the patient’s welfare. The physician might want to give
additional doses of the medication if indeed the patient did not take the pills. in addition, the rise
in heart rate and blood pressure has only just become apparent, and you realize that her heart
rate and blood pressure could continue to deteriorate over the next shift. The patient is not due
to receive the medications again until 9 pm tonight (b.i.d. every 12 hours).
Assignment: decide how you will proceed. determine whether you will use a systematic
problem-solving model, intuition, or both in making your choices. how did your values,
preferences, life experiences, willingness to take risks, and individual ways of thinking influence
your decision?
LEARNING EXERCISE 1.12
Determining a Need to Know
You are a nursing student. You are also hiV positive as a result of some high-risk behaviors
you engaged in a decade ago. (it seems like a lifetime ago.) You are now in a committed,
monogamous relationship and your partner is aware of your hiV status. You have experienced
relatively few side effects from the antiretroviral drugs you take and you appear to be healthy.
You have not shared your sexual preferences, past history, or hiV status with any of your
classmates, primarily because you do not feel that it is their business and because you fear
being ostracized in the local community, which is fairly conservative.
Today, in the clinical setting, one of the students accidentally stuck herself with a needle right
before she injected it into a patient. Laboratory follow-up was ordered to ensure that the patient
was not exposed to any blood-borne disease from the student. Tonight, for the first time,

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Chapter 1 Decision Making, Problem Solving and Critical Thinking 31
you recognize that no matter how careful you are, there is at least a small risk that you could
inadvertently expose patients to your bodily fluids and thus to some risk.
Assignment: decide what you will do. is there a need to share your hiV status with the school?
With future employers? With patients? What determines whether there is “a need to tell” and a
“need to know”? What objective weighted most heavily in your decision?
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Innovation in turbulent times. Harvard Business
Review, 79–86.
Russell, B. H., Geist, M. J., & Maffett, J. H. (2013, January).
Safety: An integrated clinical reasoning and reflection
framework for undergraduate nursing students.
Journal of Nursing Education, 52(1), 59–62.
Retrieved January 27, 2013, from http://www.healio
.com/nursing/journals/jne/%7Bd04983cb-e91a-
4272-82d1-f44f5eab3e12%7D/safety-an-integrated
-clinical-reasoning-and-reflection-framework-for
-undergraduate-nursing-students
Simon, H. A. (1965). The shape of automation for man and
management. New York, NY: Harper Textbooks.
12 Manage: The Executive Fast Track. (2013). Whole brain
model (Herrmann). Retrieved May 14, 2013, from
http://www.12manage.com/methods_herrmann
_whole_brain.html
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http://www.businessdictionary.com/definition/decision-making.html

http://www.decision-making-confidence.com/six-step-decision-making-process.html

http://www.mindtools.com/pages/article/newTED_79.htm

http://www.racgp.org.au/download/documents/AFP/2012/JanFeb/201201linn

http://www.healio.com/nursing/journals/jne/%7Bd04983cb-e91a-4272-82d1-f44f5eab3e12%7D/safety-an-integrated-clinical-reasoning-and-reflection-framework-for-undergraduate-nursing-students

http://www.12manage.com/methods_herrmann_whole_brain.html

http://dictionary.reference.com/browse/critical+thinking?s=t

http://science.howstuffworks.com/life/men-women-different-brains.htm

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32
2
Classical Views of Leadership
and Management
… management is efficiency in climbing the ladder of success; leadership determines whether the
ladder is leaning against the right wall.
—Stephen R. Covey
… no executive has ever suffered because his subordinates were strong and effective.
—Peter Drucker
CROSSWALK thiS ChaPteR aDDReSSeS:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential IX: Baccalaureate generalist nursing practice
MSN Essential II: Organizational and systems leadership
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
MSN Essential IX: advanced generalist nursing practice
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
QSEN Competency: teamwork and collaboration
LEARNING OBJECTIVES The learner will:
l discuss the evolution of management theory in relationship to changing society
l correlate management theorists with their appropriate theoretical contributions
l discuss the need for health-care managers to have highly integrated, well-developed
leadership and management skills
l define the components of the management process
l differentiate between leadership roles and management functions
l identify common leadership styles and describe situations in which each leadership style
could be used appropriately
l describe the differences between interactional and transformational leadership theories
l analyze the historical development of leadership theory
l differentiate between authoritative, democratic, and laissez-faire leadership styles
l identify contextual factors impacting the relationship between leaders and followers, based
on full-range leadership theory
l delineate variables suggested in situational and contingency theories

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Chapter 2 Classical Views of Leadership and Management 33
The relationship between leadership and management continues to prompt some debate,
although there clearly is a need for both. “Psychologists tend to define leadership in
terms of interpersonal behavior, while management thinkers emphasize how leaders shape
structural features of organizations” (Kaiser, Lindberg McGinnis, & Overfield, 2012, p. 120).
Leadership is also viewed by some as one of management’s many functions; others maintain
that leadership requires more complex skills than management and that management is only
one role of leadership. Still others suggest that management emphasizes control—control
of hours, costs, salaries, overtime, use of sick leave, inventory, and supplies—whereas
leadership increases productivity by maximizing workforce effectiveness.
But if a manager guides, directs, and motivates and a leader empowers others, then it could
be said that every manager should be a leader. Similarly, leadership without management
results in chaos and failure for both the organization and the individual executive.
Thompson (2012) agrees, suggesting that good management, as defined by strong
planning, organizational skills, and control, allows managers to intervene when goals are
threatened. But it is leadership skill that is needed to implement the planned change that is a
part of system improvement. Thus, the integration of both leadership and management skills
is critical to goal attainment.
Dignam et al. (2012) also agree, suggesting that since change is a primary feature of
contemporary health-care environments, managers must be able to shift from a traditional focus
on operational task completion to the leadership skills of visioning, motivating, and inspiring
others before desired outcomes can be achieved. MacLeod (2012) echoes similar thoughts
in his assertion that in the face of significant change, both sound management and strong
leadership skills are essential to the long-term viability of today’s health-care organizations.
Yet, we are all aware of individuals in leadership positions who cannot manage and
individuals in management roles who cannot lead. This chapter first artificially differentiates
between management and leadership, focusing on how theory development in each field of
study has changed over time, and then concludes with a discussion of how closely integrated
the two roles must actually be for individuals in contemporary leadership or management roles.
MANAGERS
Dictionary.com (2013, para 1) defines management as “the act or manner of guiding or taking
charge” or “handling, direction, or control.” Both definitions imply that management is the
process of leading and directing all or part of an organization, often a business, through the
deployment and manipulation of resources. Managers then typically:
• Have an assigned position within the formal organization.
• Have a legitimate source of power due to the delegated authority that accompanies their
position.
• Are expected to carry out specific functions, duties, and responsibilities.
• Emphasize control, decision making, decision analysis, and results.
• Manipulate people, the environment, money, time, and other resources to achieve
organizational goals.
• Have a greater formal responsibility and accountability for rationality and control than
leaders.
• Direct willing and unwilling subordinates.
Management is the process of leading and directing all or part of an organization through the
deployment and manipulation of resources.
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34 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
LEADERS
Although the term leader has been in use since the 1300s, the word leadership was not
known in the English language until the first half of the 19th century. Despite its relatively
new addition to the English language, leadership has many meanings and there is no single
definition broad enough to encompass the total leadership process.
To examine the word leader, however, is to note that leaders lead. Leaders are those
individuals who are out front, taking risks, attempting to achieve shared goals, and inspiring
others to action. Those individuals who choose to follow a leader do so by choice, not because
they have to. Kaiser et al. (2012) agree, suggesting that the essence of leadership is a social
influence process where leaders use interpersonal behaviors to motivate followers to commit
and give their best effort to contribute to group goals.
Leaders are in the front, moving forward, taking risks, and challenging the status quo.
It is important to remember though that a job title alone does not make a person a leader. Only
a person’s behavior determines if he or she holds a leadership role. The manager is the person
who brings things about—the one who accomplishes, has the responsibility, and conducts.
A leader is the person who influences and guides direction, opinion, and course of action.
Display 2.1 includes a partial list of common leadership roles.
Other characteristics of leaders include the following:
• Leaders often do not have delegated authority but obtain their power through other
means, such as influence.
• Leaders have a wider variety of roles than do managers.
• Leaders may or may not be part of the formal organization.
• Leaders focus on group process, information gathering, feedback, and empowering others.
• Leaders emphasize interpersonal relationships.
• Leaders direct willing followers.
• Leaders have goals that may or may not reflect those of the organization.
DISpLAy 2.1 Leadership Roles
Decision maker Coach Forecaster
Communicator Counselor influencer
evaluator teacher Creative problem solver
Facilitator Critical thinker Change agent
Risk taker Buffer Diplomat
Mentor advocate Role model
energizer Visionary innovator
LEARNING EXERCISE 2.1
Leadership Roles and Management Functions
in small or large groups, discuss your views of management and leadership. Do you believe
they are the same or different? if you believe that they are different, do you think that they have
the same importance for the future of nursing? Do you feel that one is more important than the
other? how can novice nurse-managers learn important management functions and develop
leadership skills?

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Chapter 2 Classical Views of Leadership and Management 35
It is important to remember that all it takes to stop being a leader is to have others stop
following you. Leadership then is more dynamic than management and leaders do make
mistakes that can result in the loss of their followers. For example, Zenger and Folkman
(2009), using 360-degree feedback data from more than 450 Fortune 500 executives,
identified 10 fatal flaws that derail leaders (see Display 2.2). Although these flaws seem fairly
obvious, many ineffective leaders are unaware that they exhibit these behaviors.
HISTORICAL DEVELOpMENT OF MANAGEMENT THEORy
Management science, like nursing, develops a theory base from many disciplines, such as
business, psychology, sociology, and anthropology. Because organizations are complex and
varied, theorists’ views of what successful management is and what it should be have changed
repeatedly in the last 100 years.
Theorists’ views of what successful management is and what it should be have changed
repeatedly in the last 100 years.
Scientific Management (1900 to 1930)
Frederick W. Taylor, the “father of scientific management,” was a mechanical engineer in
the Midvale and Bethlehem Steel plants in Pennsylvania in the late 1800s. Frustrated with
what he called “systematic soldiering,” where workers achieved minimum standards doing
the least amount of work possible, Taylor postulated that if workers could be taught the “one
best way to accomplish a task,” productivity would increase. Borrowing a term coined by
Louis Brandeis, a colleague of Taylor’s, Taylor called these principles scientific management.
The four overriding principles of scientific management as identified by Taylor (1911) are:
1. Traditional “rule of thumb” means of organizing work must be replaced with scientific
methods. In other words, by using time and motion studies and the expertise of
experienced workers, work could be scientifically designed to promote greatest
efficiency of time and energy.
2. A scientific personnel system must be established so that workers can be hired, trained,
and promoted based on their technical competence and abilities. Taylor thought that
each employee’s abilities and limitations could be identified so that the worker could
be best matched to the most appropriate job.
3. Workers should be able to view how they “fit” into the organization and how they
contribute to overall organizational productivity. This provides common goals and
1. a lack of energy and enthusiasm
2. acceptance of their own mediocre performance
3. Lack of a clear vision and direction
4. having poor judgment
5. Not collaborating
6. Not walking the talk
7. Resisting new ideas
8. Not learning from mistakes
9. a lack of interpersonal skills
10. Failing to develop others
DISpLAy 2.2 Ten Fatal Leadership Flaws
Source: Zenger, J., & Folkman, J. (2009). Ten fatal flaws that derail leaders. harvard Business Review. 18.
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36 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
a sharing of the organizational mission. One way Taylor thought that this could be
accomplished was by the use of financial incentives as a reward for work accomplished.
Because Taylor viewed humans as “economic animals” motivated solely by money,
workers were reimbursed according to their level of production rather than by an
hourly wage.
4. The relationship between managers and workers should be cooperative and
interdependent, and the work should be shared equally. Their roles, however, were not
the same. The role of managers, or functional foremen as they were called, was to plan,
prepare, and supervise. The worker was to do the work.
What was the result of scientific management? Productivity and profits rose dramatically.
Organizations were provided with a rational means of harnessing the energy of the industrial
revolution. Some experts have argued that Taylor lacked humanism and that his scientific
principles were not in the best interest of unions or workers. However, it is important to
remember the era in which Taylor did his work. During the Industrial Revolution, laissez-
faire economics prevailed, optimism was high, and a Puritan work ethic prevailed. Taylor
maintained that he truly believed managers and workers would be satisfied if financial
rewards were adequate as a result of increased productivity. As the cost of labor rises in the
United States, many organizations are taking a new look at scientific management with the
implication that we need to think of new ways to do traditional tasks so that work is more
efficient.
About the same time that Taylor was examining worker tasks, Max Weber, a well-
known German sociologist, began to study large-scale organizations to determine what
made some workers more efficient than others. Weber saw the need for legalized, formal
authority and consistent rules and regulations for personnel in different positions; he thus
proposed bureaucracy as an organizational design. His essay “Bureaucracy” was written
in 1922 in response to what he perceived as a need to provide more rules, regulations, and
structure within organizations to increase efficiency. Much of Weber’s work and bureaucratic
organizational design are still evident today in many health-care institutions. His work is
discussed further in Chapter 12.
Management Functions Identified (1925)
Henri Fayol (1925) first identified the management functions of planning, organization,
command, coordination, and control. Luther Gulick (1937) expanded on Fayol’s
management functions in his introduction of the “seven activities of management”—
planning, organizing, staffing, directing, coordinating, reporting, and budgeting—as
LEARNING EXERCISE 2.2
Strategies for Efficiency
in small groups, discuss some work routines carried out in health-care organizations that seem
to be inefficient. Could such routines or the time and motion involved to carry out a task be
altered to improve efficiency without jeopardizing quality of care? Make a list of ways that
nurses could work more efficiently. Do not limit your examination to only nursing procedures
and routines, but examine the impact that other departments or the arrangement of the nurse’s
work area may have on preventing nurses from working more efficiently. Share your ideas with
your peers.

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Chapter 2 Classical Views of Leadership and Management 37
denoted by the mnemonic POSDCORB. Although often modified (either by including
staffing as a management function or renaming elements), these functions or activities
have changed little over time. Eventually, theorists began to refer to these functions as the
management process.
The management process, shown in Figure 2.1, is this book’s organizing framework. Brief
descriptions of the five functions for each phase of the management process follow:
1. Planning encompasses determining philosophy, goals, objectives, policies, procedures,
and rules; carrying out long- and short-range projections; determining a fiscal course
of action; and managing planned change.
2. Organizing includes establishing the structure to carry out plans, determining the
most appropriate type of patient care delivery, and grouping activities to meet unit
goals. Other functions involve working within the structure of the organization and
understanding and using power and authority appropriately.
3. Staffing functions consist of recruiting, interviewing, hiring, and orienting staff.
Scheduling, staff development, employee socialization, and team building are also
often included as staffing functions.
4. Directing sometimes includes several staffing functions. However, this phase’s
functions usually entail human resource management responsibilities, such
as motivating, managing conflict, delegating, communicating, and facilitating
collaboration.
5. Controlling functions include performance appraisals, fiscal accountability, quality
control, legal and ethical control, and professional and collegial control.
Human Relations Management (1930 to 1970)
During the 1920s, worker unrest developed. The Industrial Revolution had resulted in great
numbers of relatively unskilled laborers working in large factories on specialized tasks.
Thus, management scientists and organizational theorists began to look at the role of worker
satisfaction in production. This human relations era developed the concepts of participatory
and humanistic management, emphasizing people rather than machines.
Mary Parker Follett (1926) was one of the first theorists to suggest basic principles of
what today would be called participative decision making or participative management.
Planning
Controlling
Directing
Organizing
Staffing
FIGURE 2.1 • the management process.
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38 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
In her essay “The Giving of Orders,” Follett espoused her belief that managers should have
authority with, rather than over, employees. Thus, solutions could be found that satisfied both
sides without having one side dominate the other.
The human relations era also attempted to correct what was perceived as the major
shortcoming of the bureaucratic system—a failure to include the “human element.” Studies
done at the Hawthorne Works of the Western Electric Company near Chicago between 1927
and 1932 played a major role in this shifting focus. The studies, conducted by Elton Mayo
and his Harvard associates, began as an attempt to look at the relationship between light
illumination in the factory and productivity.
Mayo and his colleagues discovered that when management paid special attention to
workers, productivity was likely to increase, regardless of the environmental working
conditions. This Hawthorne effect indicated that people respond to the fact that they are
being studied, attempting to increase whatever behavior they feel will continue to warrant
the attention. Mayo (1953) also found that informal work groups and a socially informal
work environment were factors in determining productivity, and Mayo recommended more
employee participation in decision making.
Douglas McGregor (1960) reinforced these ideas by theorizing that managerial attitudes
about employees (and, hence, how managers treat those employees) can be directly correlated
with employee satisfaction. He labeled this Theory X and Theory Y. Theory X managers
believe that their employees are basically lazy, need constant supervision and direction,
and are indifferent to organizational needs. Theory Y managers believe that their workers
enjoy their work, are self-motivated, and are willing to work hard to meet personal and
organizational goals.
Chris Argyris (1964) supported McGregor and Mayo by saying that managerial domination
causes workers to become discouraged and passive. He believed that if self-esteem and
independence needs are not met, employees will become discouraged and troublesome or
may leave the organization. Argyris stressed the need for flexibility within the organization
and employee participation in decision making.
The human relations era of management science brought about a great interest in the study
of workers. Many sociologists and psychologists took up this challenge, and their work in
management theory contributed to our understanding about worker motivation, which will
be discussed in Chapter 18. Table 2.1 summarizes the development of management theory
up to 1970. By the late 1960s, however, there was growing concern that the human relations
approach to management was not without its problems. Most people continued to work in
a bureaucratic environment, making it difficult to always apply a participatory approach to
management. The human relations approach was time consuming and often resulted in unmet
organizational goals. In addition, not every employee liked working in a less structured
environment. This resulted in a greater recognition of the need to intertwine management and
leadership than ever before.
Theorist Theory
taylor Scientific management
Weber Bureaucratic organizations
Fayol Management functions
Gulick activities of management
Follett Participative management
Mayo hawthorne effect
McGregor theories X and Y
argyris employee participation
TABLE 2.1 Management Theory Development 1900 to 1970

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Chapter 2 Classical Views of Leadership and Management 39
HISTORICAL DEVELOpMENT OF LEADERSHIp THEORy (1900 TO pRESENT)
Because strong management skills were historically valued more than strong leadership
skills, the scientific study of leadership did not begin until the 20th century. Early works
focused on broad conceptualizations of leadership, such as the traits or behaviors of the
leader. Contemporary research focuses more on leadership as a process of influencing others
within an organizational culture and the interactive relationship of the leader and follower.
To better understand newer views about leadership, it is necessary to look at how leadership
theory has evolved over the last century.
Like management theory, leadership theory has been dynamic; that is, what is “known” and
believed about leadership continues to change over time.
The Great Man Theory/Trait Theories (1900 to 1940)
The Great Man theory and trait theories were the basis for most leadership research until the
mid-1940s. The Great Man theory, from Aristotelian philosophy, asserts that some people are
born to lead, whereas others are born to be led. It also suggests that great leaders will arise
when the situation demands it.
Trait theories assume that some people have certain characteristics or personality traits
that make them better leaders than others. To determine the traits that distinguish great
leaders, researchers studied the lives of prominent people throughout history. The effect of
followers and the impact of the situation were ignored. Although trait theories have obvious
shortcomings (e.g., they neglect the impact of others or the situation on the leadership role),
they are worth examining. Many of the characteristics identified in trait theories (Display 2.3)
are still used to describe successful leaders today.
Contemporary opponents of these theories argue that leadership skills can be developed,
not just inherited. Avolio, Walumbwa, and Weber (2009) suggest, however, that very little
work has been done in the last 100 years to determine whether leadership can actually
be developed. A recent meta-analytic review suggested that only about one-third of the
201 interventional leadership studies focused on developing leadership skills rather than
manipulating it for impact.
Perhaps leaders are both born and made that way.
LEARNING EXERCISE 2.3
Effective Leadership
in groups or individually, list additional characteristics that you believe an effective leader
possesses. Which leadership characteristics do you have? Do you believe that you were born
with leadership skills, or have you consciously developed them during your lifetime? if so, how
did you develop them?
Behavioral Theories (1940 to 1980)
During the human relations era, many behavioral and social scientists studying management
also studied leadership. For example, McGregor’s (1960) theories had as much influence
on leadership research as they did on management science. As leadership theory developed,
researchers moved away from studying what traits the leader had and placed emphasis on
what he or she did—the leader’s style of leadership.
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40 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
A major breakthrough occurred when Lewin (1951) and White and Lippitt (1960) isolated
common leadership styles. Later, these styles came to be called authoritarian, democratic,
and laissez-faire.
The authoritarian leader is characterized by the following behaviors:
• Strong control is maintained over the work group.
• Others are motivated by coercion.
• Others are directed with commands.
• Communication flows downward.
• Decision making does not involve others.
• Emphasis is on difference in status (“I” and “you”).
• Criticism is punitive.
Authoritarian leadership results in well-defined group actions that are usually predictable,
reducing frustration in the work group and giving members a feeling of security. Productivity
is usually high, but creativity, self-motivation, and autonomy are reduced. Authoritarian
leadership is frequently found in very large bureaucracies such as the armed forces.
The democratic leader exhibits the following behaviors:
• Less control is maintained.
• Economic and ego awards are used to motivate.
• Others are directed through suggestions and guidance.
• Communication flows up and down.
• Decision making involves others.
• Emphasis is on “we” rather than “I” and “you.”
• Criticism is constructive.
Democratic leadership, appropriate for groups who work together for extended periods,
promotes autonomy and growth in individual workers. In fact, Wong (2012) suggests that
relational leadership styles such as democratic leadership are related to both positive
nurse and patient outcomes since they emphasize the leader’s ability to create positive
relationships within the organization. Democratic leadership is particularly effective
when cooperation and coordination between groups are necessary. Studies have shown,
however, that democratic leadership may be less efficient quantitatively than authoritative
leadership.
Because many people must be consulted, democratic leadership takes more time and, therefore,
may be frustrating for those who want decisions made rapidly.
DISpLAy 2.3 Characteristics Associated with Leadership
intelligence adaptability ability
Knowledge Creativity able to enlist cooperation
Judgment Cooperativeness interpersonal skills
Decisiveness alertness tact
Oral fluency Self-confidence Diplomacy
emotional intelligence Personal integrity Prestige
independence emotional balance and control Social participation
Personable Risk taking Charisma

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Chapter 2 Classical Views of Leadership and Management 41
The laissez-faire leader is characterized by the following behaviors:
• Is permissive, with little or no control.
• Motivates by support when requested by the group or individuals.
• Provides little or no direction.
• Uses upward and downward communication between members of the group.
• Disperses decision making throughout the group.
• Places emphasis on the group.
• Does not criticize.
Because it is nondirected leadership, the laissez-faire style can be frustrating; group apathy
and disinterest can occur. However, when all group members are highly motivated and self-
directed, this leadership style can result in much creativity and productivity. Laissez-faire
leadership is appropriate when problems are poorly defined and brainstorming is needed to
generate alternative solutions.
A person’s leadership style has a great deal of influence on the climate and outcome of the
work group.
LEARNING EXERCISE 2.4
What Is Your Leadership Style?
Define your predominant leadership style. ask those who work with you if in their honest opinion
this is indeed the leadership style that you use most often. What style of leadership do you work
best under? What leadership style best describes your present or former managers?
For some time, theorists believed that leaders had a predominant leadership style and used
it consistently. During the late 1940s and early 1950s, however, theorists began to believe
that most leaders did not fit a textbook picture of any one style but rather fell somewhere on
a continuum between authoritarian and laissez-faire. They also came to believe that leaders
moved dynamically along the continuum in response to each new situation. This recognition
was a forerunner to what is known as situational or contingency leadership theory.
Situational and Contingency Leadership Theories (1950 to 1980)
The idea that leadership style should vary according to the situation or the individuals involved
was first suggested almost 100 years ago by Mary Parker Follett, one of the earliest management
consultants and among the first to view an organization as a social system of contingencies.
Her ideas, published in a series of books between 1896 and 1933, were so far ahead of their
time that they did not gain appropriate recognition in the literature until the 1970s. Her law of
the situation, which said that the situation should determine the directives given after allowing
everyone to know the problem, was contingency leadership in its humble origins.
Fiedler’s (1967) contingency approach reinforced these findings, suggesting that no one
leadership style is ideal for every situation. Fiedler felt that the interrelationships between the
group’s leader and its members were most influenced by the manager’s ability to be a good
leader. The task to be accomplished and the power associated with the leader’s position also
were cited as key variables.
In contrast to the continuum from autocratic to democratic, Blake and Mouton’s (1964) grid
showed various combinations of concern or focus that managers had for or on productivity,
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42 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
tasks, people, and relationships. In each of these areas, the leader-manager may rank high or
low, resulting in numerous combinations of leadership behaviors. Various formations can be
effective depending on the situation and the needs of the worker.
Hersey and Blanchard (1977) also developed a situational approach to leadership. Their
tridimensional leadership effectiveness model predicts which leadership style is most
appropriate in each situation on the basis of the level of the followers’ maturity. As people
mature, leadership style becomes less task focused and more relationship oriented.
Tannenbaum and Schmidt (1958) built on the work of Lewin and White, suggesting that
managers need varying mixtures of autocratic and democratic leadership behavior. They
believed that the primary determinants of leadership style should include the nature of the
situation, the skills of the manager, and the abilities of the group members.
Although situational and contingency theories added necessary complexity to leadership
theory and continue to be applied effectively by managers, by the late 1970s, theorists began
arguing that effective leadership depended on an even greater number of variables, including
organizational culture, the values of the leader and the followers, the work, the environment,
the influence of the leader-manager, and the complexities of the situation. Efforts to integrate
these variables are apparent in more contemporary interactional and transformational
leadership theories.
INTERACTIONAL LEADERSHIp THEORIES (1970 TO pRESENT)
The basic premise of interactional theory is that leadership behavior is generally determined
by the relationship between the leader’s personality and the specific situation. Schein (1970),
an interactional theorist, was the first to propose a model of humans as complex beings whose
working environment was an open system to which they responded. A system may be defined
as a set of objects, with relationships between the objects and between their attributes. A
system is considered open if it exchanges matter, energy, or information with its environment.
Schein’s model, based on systems theory, had the following assumptions:
• People are very complex and highly variable. They have multiple motives for doing
things. For example, a pay raise might mean status to one person, security to another,
and both to a third.
• People’s motives do not stay constant but change over time.
• Goals can differ in various situations. For example, an informal group’s goals may be
quite distinct from a formal group’s goals.
• A person’s performance and productivity are affected by the nature of the task and by
his or her ability, experience, and motivation.
• No single leadership strategy is effective in every situation.
To be successful, the leader must diagnose the situation and select appropriate strategies
from a large repertoire of skills. Hollander (1978) was among the first to recognize that both
leaders and followers have roles outside of the leadership situation and that both may be
influenced by events occurring in their other roles.
With leader and follower contributing to the working relationship and both receiving
something from it, Hollander (1978) saw leadership as a dynamic two-way process.
According to Hollander, a leadership exchange involves three basic elements:
• The leader, including his or her personality, perceptions, and abilities.
• The followers, with their personalities, perceptions, and abilities.
• The situation within which the leader and the followers function, including formal and
informal group norms, size, and density.

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Chapter 2 Classical Views of Leadership and Management 43
Leadership effectiveness, according to Hollander, requires the ability to use the
problem-solving process; maintain group effectiveness; communicate well; demonstrate
leader fairness, competence, dependability, and creativity; and develop group
identification.
Ouchi (1981) was a pioneer in introducing interactional leadership theory in his
application of Japanese style management to corporate America. Theory Z, the term
Ouchi used for this type of management, is an expansion of McGregor’s Theory Y and
supports democratic leadership. Characteristics of Theory Z include consensus decision
making, fitting employees to their jobs, job security, slower promotions, examining the
long-term consequences of management decision making, quality circles, guarantee of
lifetime employment, establishment of strong bonds of responsibility between superiors
and subordinates, and a holistic concern for the workers (Ouchi, 1981). Ouchi was
able to find components of Japanese-style management in many successful American
companies.
In the 1990s, Theory Z lost its favor with many management theorists. American managers
are unable to put these same ideas into practice in the United States. Instead, they continue to
boss-manage workers in an attempt to make them do what they do not want to do. Although
Theory Z is more comprehensive than many of the earlier theories, it too neglects some of the
variables that influence leadership effectiveness. It has the same shortcomings as situational
theories in inadequately recognizing the dynamics of the interaction between the worker and
the leader.
One of the pioneering leadership theorists of this time was Kanter (1977), who developed
the theory that the structural aspects of the job shape a leader’s effectiveness. She postulated
that the leader becomes empowered through both formal and informal systems of the
organization. A leader must develop relationships with a variety of people and groups within
the organization in order to maximize job empowerment and be successful. The three major
work empowerment structures within the organization are opportunity, power, and proportion.
Kanter asserts that these work structures have the potential to explain differences in leader
responses, behaviors, and attitudes in the work environment.
Nelson and Burns (1984) suggested that organizations and their leaders have four
developmental levels and that these levels influence productivity and worker satisfaction. The
first of these levels is reactive. The reactive leader focuses on the past, is crisis driven, and
is frequently abusive to subordinates. In the next level, responsive, the leader is able to mold
subordinates to work together as a team, although the leader maintains most decision-making
responsibility. At the proactive level, the leader and followers become more future oriented
and hold common driving values. Management and decision making are more participative.
At the last level, high-performance teams, maximum productivity and worker satisfaction
are apparent.
Brandt’s (1994) interactive leadership model suggests that leaders develop a work
environment that fosters autonomy and creativity through valuing and empowering
followers. This leadership “affirms the uniqueness of each individual,” motivating them to
“contribute their unique talents to a common goal.” The leader must accept the responsibility
for quality of outcomes and quality of life for followers. Brandt states that this type of
leadership affords the leader greater freedom while simultaneously adding to the burdens
of leadership. The leader’s responsibilities increase because priorities cannot be limited to
the organization’s goals, and authority confers not only power but also responsibility and
obligation. The leader’s concern for each worker decreases the need for competition and
fosters an atmosphere of collegiality, freeing the leader from the burden of having to resolve
follower conflicts.
Wolf, Boland, and Aukerman (1994) also emphasized an interactive leadership model in
their creation of a collaborative practice matrix. This matrix highlights the framework for the
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44 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
development and ongoing support of relationships between and among professionals working
together. The “social architecture” of the work group is emphasized, as is how expectations,
personal values, and interpersonal relationships affect the ability of leaders and followers to
achieve the vision of the organization.
Kanter (1989) perhaps best summarized the work of the interactive theorists by her
assertion that title and position authority were no longer sufficient to mold a workforce where
subordinates are encouraged to think for themselves, and instead managers must learn to
work synergistically with others.
Transactional and Transformational Leadership
Similarly, Burns (2003), a noted scholar in the area of leader–follower interactions, was
among the first to suggest that both leaders and followers have the ability to raise each other
to higher levels of motivation and morality. Identifying this concept as transformational
leadership, Burns maintained that there are two primary types of leaders in management. The
traditional manager, concerned with the day-to-day operations, was termed a transactional
leader. The manager who is committed, has a vision, and is able to empower others with
this vision was termed a transformational leader. A composite of the two different types of
leaders is shown in Table 2.2.
Transactional leaders focus on tasks and getting the work done. Transformational leaders focus
on vision and empowerment.
Similarly, Bass and Avolio (1994) suggested that transformational leadership leads followers
to levels of higher morals because such leaders do the right thing for the right reason, treat
people with care and compassion, encourage followers to be more creative and innovative,
and inspire others with their vision. This new shared vision provides the energy required to
move toward the future.
Doody and Doody (2012) agree, suggesting that traditionally, nurses have been
overmanaged and inadequately led, and that contemporary health-care organizations need
increasingly adaptive and flexible leadership. Doody and Doody suggest that transformational
leadership “motivates followers by appealing to higher ideas and moral values, where the
leader has a deep set of internal values and ideas. This leads followers acting to sustain
the greater good, rather than their own interests, and supportive environments where
responsibility is shared” (p. 1212).
Kouzes and Posner (2007) are perhaps the best known authors to further the work on
transformational leadership in the past decade. Kouzes and Posner suggest that exemplary
leaders foster a culture in which relationships between aspiring leaders and willing followers
can thrive. This requires the development of the five practices shown in Display 2.4. Kouzes
and Posner suggest that when these five practices are employed, anyone can further their
ability to lead others to get extraordinary things done.
TABLE 2.2 Transactional and Transformational Leaders
Transformational Leader Transactional Leader
Focuses on management tasks identifies common values
is committed is a caretaker
Uses trade-offs to meet goals inspires others with vision
Does not identify shared values has long-term vision
examines causes Looks at effects
Uses contingency reward empowers others

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Chapter 2 Classical Views of Leadership and Management 45
Although the transformational leader is held as the current ideal, many management
theorists sound a warning about transformational leadership. Although transformational
qualities are highly desirable, they must be coupled with the more traditional transactional
qualities of the day-to-day managerial role. In addition, both sets of characteristics need
to be present in the same person in varying degrees. The transformational leader will
fail without traditional management skills. Indeed, Avolio et al. (2009, p. 428) note
that much of the disillusionment with leadership theory and research in the early 1980s
was related to “the fact that most models of leadership and measures accounted for a
relatively small percentage of variance in performance outcomes such as productivity
and effectiveness.”
Although transformational qualities are highly desirable, they must be coupled with the more
traditional transactional qualities of the day-to-day managerial role or the leader will fail.
In addition, Badaracco cautions that “because we admire heroes, it is easy to overlook the
inconvenient fact that some leaders are effective without being either visionary or very
inspiring. There must be a place for leading by example and other forms of quiet leadership”
(McCrimmon, n.d., para 2). Similarly, the North Carolina Center for Student Leadership in
Ethics & Public Service (2009) warns that transformational leaders must be careful not to
mistake passion and confidence for truth and reality. “Whilst it is true that great things have
been achieved through enthusiastic leadership, it is also true that many passionate people
have led the charge right over the cliff and into a bottomless chasm. Just because someone
believes they are right, it does not mean they are right” (para 14).
Finally, recent research by Braun, Peus, and Frey (2012) suggests another potential
limitation to holding transformational leadership as the ideal. Their attempt to test the
interaction effects of leader gender, leader attractiveness, and leadership style on followers’
trust and loyalty found that attractive females using transformational leadership skills
struggled more than less attractive females to gain follower support and trust; the so-called
beauty is beastly effect. The same results did not occur for attractive males. It also did not
occur when transactional leadership skills were used. These study results hold implications
for female leaders, for followers, and for anyone who evaluates leaders and their effectiveness
in organizational contexts. (See Examining the Evidence 2.1.)
Full-Range Leadership Theory
It is this idea that context is an important mediator of transformational leadership that led to
the creation of full-range leadership theory early in the 21st century. This theory, originally
developed by Antonakis, Avolio, and Sivasubramaniam (2003), suggests that there are nine
1. Modeling the way: Requires value clarification and self-awareness so that behavior is congruent
with values.
2. Inspiring a shared vision: entails visioning which inspires followers to want to participate in goal
attainment.
3. Challenging the process: identifying opportunities and taking action.
4. Enabling others to act: Fostering collaboration, trust, and the sharing of power.
5. Encouraging the heart: Recognize, appreciate, and celebrate followers and the achievement of
shared goals.
DISpLAy 2.4 Kouzes and Posner’s Five Practices for Exemplary Leadership
Source: Kouzes, J., & Posner, B. (2007). the leadership challenge (4th ed.). San Francisco, CA: Jossey Bass.
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46 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
factors impacting leadership style and its impact on followers; five are transformational, three
are transactional, and one is a nonleadership or laissez-faire leadership factor (Rowold &
Schlotz, 2009) (see Display 2.5).
Source: Braun, S., Peus, C., & Frey, D. (2012). Is beauty beastly?: Gender-specific effects of leader attractiveness
and leadership style on followers’ trust and loyalty. Zeitschrift Für Psychologie, 220(2), 98–108.
Two hundred and fifty-three undergraduate students (127 female and 126 male) with an average
age of 21.9 years from a german university participated in this study. Leader gender (male versus
female), leader attractiveness (attractive versus unattractive), and leadership style (transformatio-
nal versus transactional) were varied in a 2 × 2 × 2 between-subjects design. participant gender
(male versus female) was accounted for as a quasi-experimental factor. participant evaluations
of trust, loyalty, and ascribed leader communion were collected as measures of dependent and
mediating variables, respectively.
attractive when compared with unattractive female leaders elicited lower levels of trust and
loyalty in their followers when they displayed a transformational leadership style, but not when
they displayed a transactional leadership style. The researchers suggested that these study fin-
dings had important implications in at least four regards: (1) The study raised the awareness
of the potential impact of physical appearance on the ability of female leaders to successfully
employ transformational leadership strategies; (2) to counteract biased evaluations toward
attractive female leaders, leadership assessments must be conducted in a structured manner,
primarily based on behavioral criteria with relevance to their effectiveness as a leader as opposed
to aspects related to candidates’ gender role; (3) the practice of attaching portraits to application
materials challenges the fairness of selection procedures for male and female applications; and
(4) enhanced training of all (future) female leaders and young professionals in general is needed
with regard to the pitfalls of biased perceptions and evaluations based on gender stereotypes in
organizational settings.
Examining the Evidence 2.1
DISpLAy 2.5 Nine Factors of Full-Range Leadership Theory
Factor 1 inspirational motivation transformational
Factor 2 idealized influence (attributed) transformational
Factor 3 idealized influence (behavior) transformational
Factor 4 intellectual stimulation transformational
Factor 5 individualized consideration transformational
Factor 6 Contingent reward transactional
Factor 7 active management-by-exception transactional
Factor 8 Management-by-exception passive transactional
Factor 9 Nonleadership Laissez-faire
In describing these factors, Rowold and Schlotz (2009) suggest that the first factor,
inspirational motivation, is characterized by the leader’s articulation and representation
of vision. Idealized influence (attributed), the second factor, relies on the charisma of the
leader to create emotional ties with followers that build trust and confidence. The third
factor, idealized influence (behavior), results in the leader creating a collective sense of
mission and values and prompting followers to act upon these values. With the fourth factor,
intellectual stimulation, leaders challenge the assumptions of followers’ beliefs as well as
analyze subordinates’ problems and possible solutions. The final transformational factor,

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Chapter 2 Classical Views of Leadership and Management 47
individualized consideration, occurs when the leader is able to individualize his or her
followers, recognizing and appreciating their unique needs, strengths, and challenges.
The first transactional factor, as described by Rowold and Schlotz (2009), is contingent
reward. Here, the leader is task oriented in providing followers with meaningful rewards based
on successful task completion. Active management-by-exception, the second transactional
factor, suggests that the leader watches and searches actively for deviations from rules and
standards and takes corrective actions when necessary. In contrast, the third transactional
factor, management-by-exception passive, describes a leader who intervenes only after errors
have been detected or standards have been violated. Finally, the ninth factor of full-range
leadership theory is the absence of leadership. Thus, laissez-faire is a contrast to the active
leadership styles of transformational and transactional leadership exemplified in the first
eight factors.
Leadership Competencies
Just as Fayol and Gulick identified management functions, contemporary leadership
experts suggest that there are certain competencies (skills, knowledge, and abilities)
health-care leaders need to be successful. The American College of Healthcare Executives,
the American College of Physician Executives, the American Organization of Nurse
Executives, the Healthcare Information and Management Systems Society, the Healthcare
Financial Management Association, and the Medical Group Management Association have
collaborated to identify leadership competencies, which included leadership skills and
behavior; organizational climate and culture; communicating vision; and managing change
(Esparza and Rubino, 2014).
INTEGRATING LEADERSHIp AND MANAGEMENT
Because rapid, dramatic change will continue in nursing and the health-care industry, it
has grown increasingly important for nurses to develop skill in both leadership roles and
management functions. For managers and leaders to function at their greatest potential, the
two must be integrated.
Gardner (1990) asserted that integrated leader-managers possess six distinguishing traits:
1. They think longer term: They are visionary and futuristic. They consider the effect that
their decisions will have years from now as well as their immediate consequences.
2. They look outward, toward the larger organization: They do not become narrowly
focused. They are able to understand how their unit or department fits into the bigger
picture.
3. They influence others beyond their own group: Effective leader-managers rise above an
organization’s bureaucratic boundaries.
4. They emphasize vision, values, and motivation: They understand intuitively the
unconscious and often nonrational aspects that are present in interactions with others.
They are very sensitive to others and to differences in each situation.
5. They are politically astute: They are capable of coping with conflicting requirements
and expectations from their many constituencies.
6. They think in terms of change and renewal: The traditional manager accepts the
structure and processes of the organization, but the leader-manager examines the ever-
changing reality of the world and seeks to revise the organization to keep pace.
Leadership and management skills can and should be integrated as they are learned.
Table 2.3 summarizes the development of leadership theory through the end of the 20th
century. Newer (21st century) and emerging leadership theories are discussed in Chapter 3.
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48 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
In examining leadership and management, it becomes clear that these two concepts have a
symbiotic or synergistic relationship. Every nurse is a leader and manager at some level, and
the nursing role requires leadership and management skills. The need for visionary leaders
and effective managers in nursing preclude the option of stressing one role over the other.
Highly developed management skills are needed to maintain healthy organizations. So too
are the visioning and empowerment of subordinates through an organization’s leadership
team. Because rapid, dramatic change will continue in nursing and the health-care industry,
it continues to be critically important for nurses to develop skill in both leadership roles
and management functions and to strive for the integration of leadership characteristics
throughout every phase of the management process.
TABLE 2.3 Leadership Theorists and Theories
Theorist Theory
aristotle Great Man theory
Lewin and White Leadership styles
Follett Law of the situation
Fiedler Contingency leadership
Blake and Mouton task versus relationship in determining leadership style
hersey and Blanchard Situational leadership theory
tannenbaum and Schmidt Situational leadership theory
Kanter Organizational structure shapes leader effectiveness
Burns transactional and transformational leadership
Bass and avolio transformational leadership
Gardner the integrated leader-manager
KEY CONCEPTS
l Management functions include planning, organizing, staffing, directing, and controlling. these are
incorporated into what is known as the management process.
l Classical, or traditional, management science focused on production in the workplace and on
delineating organizational barriers to productivity. Workers were assumed to be motivated solely by
economic rewards, and little attention was given to worker job satisfaction.
l the human relations era of management science emphasized concepts of participatory and humanistic
management.
l three primary leadership styles have been identified: authoritarian, democratic, and laissez-faire.
l Research has shown that the leader-manager must assume a variety of leadership styles, depending on
the needs of the worker, the task to be performed, and the situation or environment. this is known as
situational or contingency leadership theory.
l Leadership is a process of persuading and influencing others toward a goal and is composed of a wide
variety of roles.
l early leadership theories focused on the traits and characteristics of leaders.
l interactional leadership theory focuses more on leadership as a process of influencing others within an
organizational culture and the interactive relationship of the leader and follower.
l the manager who is committed, has a vision, and is able to empower others with this vision is termed
a transformational leader, whereas the traditional manager, concerned with the day-to-day operations, is
called a transactional leader.
l Full-range leadership theory suggests that context is an important mediator of transformational leadership.
l integrating leadership skills with the ability to carry out management functions is necessary if an
individual is to become an effective leader-manager.

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Chapter 2 Classical Views of Leadership and Management 49
ADDITIONAL LEARNING EXERCISES
LEARNING EXERCISE 2.5
When Culture and Policy Clash
You are the nurse-manager of a medical unit. Recently, your unit admitted a 16-year-old east indian boy
who has been newly diagnosed with insulin-dependent diabetes. the nursing staff has been interested
in his case and has found him to be a delightful young man—very polite and easygoing. however, his
family has been visiting in increasing numbers and bringing him food that he should not have.
the nursing staff has come to you on two occasions and complained about the family’s
noncompliance with visiting hours and unauthorized food. Normally, the nursing staff on your
unit has tried to develop a culturally sensitive nursing care plan for patients with special cultural
needs, so their complaints to you have taken you by surprise.
Yesterday, two of the family members visited you and complained about hospital visitor policies
and what they took to be rudeness by two different staff members. You spent time talking to the
family, and when they left, they seemed agreeable and understanding.
Last night, one of the staff nurses told the family that according to hospital policy only two
members could stay (this is true) and if the other family members did not leave, she would call
hospital security. this morning the boy’s mother and father have suggested that they will take
him home if this matter is not resolved. the patient’s diabetes is still not controlled, and you feel
that it would be unwise for this to happen.
Assignment: Leadership is needed to keep this situation from deteriorating further. Divide into
groups. Develop a plan of action for solving this problem. First, select three desired objectives
for solving the problem and then proceed to determine what you would do that would enable
you to meet your objectives. Be sure that you are clear as to who you consider your followers
to be and what you expect from each of them.
LEARNING EXERCISE 2.6
Delineating Leadership Roles and Management Functions
examine the scenario in Learning exercise 2.5. how would you divide the management
functions and leadership roles in this situation? For example, you might say that having the
nurse-manager adhere to hospital policy was a management function and that counseling staff
was a leadership role.
Assignment: List at least five management functions and five leadership roles that you could
also delineate in this scenario. Share these with your group.
LEARNING EXERCISE 2.7
What Is Your Management Style?
Recall times when you have been a manager. this does not only mean a nursing manager.
Perhaps you were a head lifeguard or an evening shift manager at a fast-food restaurant. During
those times, do you think you were a good manager? Did you involve others in your management
decision making appropriately? how would you evaluate your decision-making ability? Make a
list of your management strengths and a list of management skills that you felt you were lacking.
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50 UNIT I The CriTiCaL Triad: deCision Making, ManageMenT, and Leadership
LEARNING EXERCISE 2.8
Leadership Challenges for Health-Care Leaders
Mary Starmann harrison, President and Chief executive Officer (CeO) of hospital Sisters
health System, was quoted in a recent article by Smith (2012) that the greatest challenge
for health-care leaders today is the transition from volume to value, including a determination
of how best to guide the organization through that transition as well as the timing to do so.
Doug Smith, President and CeO of B.e. Smith, suggests that the greatest challenges for
contemporary health-care leaders are large turnover numbers and an inability or unwillingness
to change. Carol Dozer, CeO of ivinson Memorial hospital, suggests it is the need to cut
costs and preserve resources while bringing in the resources needed to operate under a
value-based system.
Assignment: interview the CeO or top nursing executive at a local health-care agency. ask
them what they perceive to be the top five leadership challenges encountered by health-care
leaders today. then ask them to identify five management challenges. Did these health-care
leaders differentiate between leadership and management challenges? Did they feel that the
leadership or management challenges were greater?
LEARNING EXERCISE 2.9
Quiet at Night?
You are the night shift charge nurse on a busy surgical unit in a large, urban teaching hospital.
Surgeries occur around the clock, and frequently, noise levels are higher than desired because
of the significant number of nurses, physicians, residents, interns, and other health-care workers
who gather at the nurses station or in the halls outside of patient rooms. today, the unit manager
has come to you because the hospital’s score on the Centers for Medicare and Medicaid
Hospital Consumer Assessment of Healthcare Providers and Systems (hCahPS) survey for
the category Always Quiet at Night falls far below the desired benchmark. She has asked you
to devise a plan to address this quality of care issue. the management goal in this situation is to
achieve an hCahPS score on Always Quiet at Night that meets the accepted best practices
benchmark, thus assuring that patients get the rest they need to promote their recovery. the
leadership goal is to foster a shared commitment among all health-care professionals working
on the unit to achieve the Always Quiet at Night goal.
Assignment:
1. identify five management strategies you might use to address the problem of excessive
noise on the unit at night. For example, your list might include structural environmental
changes or work redesign.
2. then identify five leadership strategies you might use to promote buy-in of the Quiet at
Night initiative by all health-care professionals on the unit. how will you inspire these
individuals to work with you in achieving this critically important goal? What incentives
might you use to reward behavior conducive to meeting this goal?
3. Discuss whether you feel this goal could be achieved by employing only the management
strategies you identified. Could it be achieved only with the implementation of leadership
strategies for team building?

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Chapter 2 Classical Views of Leadership and Management 51
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An experimental inquiry. New York, NY: Harper &
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Wolf, G. A., Boland, S., & Aukerman, M. (1994, May).
A transformational model for the practice of
professional nursing. Part 2, Implementation of the
model. Journal of Nursing Administration, 24(5),
38–46.
Wong, C. A. (2012). Advancing a positive leadership orienta-
tion: From problem to possibility. Nursing Leader-
ship, 25(2), 51–55.
Zenger, J., & Folkman, J. (2009). Ten fatal flaws that derail
leaders. Harvard Business Review, 18.

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53
Twenty-First-Century Thinking about
Leadership and Management
… 21st century leaders are less reliant on “how things should be” and instead approach business
challenges and opportunities with an enquiring mind—one that makes room for new possibilities.
—Shirlaws Pty Ltd
… we are not creatures of circumstance; we are creators of circumstance.
—Benjamin Disraeli
CROSSWALK thiS chaPter aDDreSSeS:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential IX: Baccalaureate generalist nursing practice
MSN Essential II: Organizational and systems leadership
MSN Essential IX: advanced generalist nursing practice
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
QSEN Competency: teamwork and collaboration
LEARNING OBJECTIVES The learner will:
l analyze how current and future paradigm shifts in healthcare may affect the leadership skills
needed by nurses in the 21st century
l compare strengths-based leadership, which focuses on the development or empowerment
of workers’ strengths, with the traditional management practices of identifying problems,
improving underperformance, and addressing weaknesses and obstacles
l identify Level 5 Leadership skills (as espoused by Jim collins) which differentiate great
companies from good companies
l identify the characteristics of a servant leader and suggest strategies for encouraging a
service inclination in others
l explore elements of human and social capital which impact resource allocation in organizations
l describe situations where followers (agents) might not be inherently motivated to act in the
best interest of the principal (leader or employer)
l describe components of emotional intelligence which promote the development of productive
work teams
3
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54 UNIT I The CriTiCal Triad: deCision Making, ManageMenT, and leadership
l identify characteristics of authentic leadership and discuss the consequences to the leader–
follower relationship when leaders are not authentic
l identify contemporary nurse-leaders who exemplify thought leadership and the innovative
ideas they have suggested
l describe why quantum leaders need flexibility in responding to the complex relationships that
exist between environment and context in work environments
l describe complexities that exist in the relationship between followers and leaders
l provide examples of the 21st-century shift from industrial age leadership to relationship age leadership
l develop insight into his or her individual leadership strengths
Throughout history, nursing has been required to respond to changing technological and social
forces. In the last decade alone, a growing elderly population, health-care reform, reductions in
federal and state government reimbursement as well as commercial insurance, and new quality
imperatives such as value-based purchasing and pay for performance have resulted in major
redesigns of most health-care organizations. In addition, the locus of care continues to shift
from acute-care hospitals to community and outpatient settings, innovation and technological
advances are transforming the workplace, and organizational cultures are increasingly shifting
to externally regulated, safety-driven, customer-focused care. All of these changes have
brought about a need for leader-managers to learn new roles and develop new skills.
The new managerial responsibilities placed on organized nursing services call for nurse
administrators who are knowledgeable, skilled, and competent in all aspects of management.
Now more than ever, there is a greater emphasis on the business of health care, with managers
being involved in the financial and marketing aspects of their respective departments.
Managers are expected to be skilled communicators, organizers, and team builders and to be
visionary and proactive in preparing for emerging new threats such as domestic terrorism,
biological warfare, and global pandemics.
In addition, the need to develop nursing leadership skills has never been greater. At the
national level, nurse-leaders and nurse-managers are actively involved in implementing
health-care reform and in addressing a potential international nursing shortage. At the
organizational and unit levels, nurse-leaders are being directed to address high turnover rates
by staff, an emerging shortage of qualified top-level nursing administrators, growing trends
toward unionization, and intensified efforts to legislate minimum staffing ratios and eliminate
mandatory overtime, while maintaining cohesive and productive work environments.
Moreover, ensuring successful recruitment, creating shared governance models, and
maintaining high-quality practice depends on successful interprofessional team building,
another critical leadership skill in contemporary health-care organizations. This challenging
and changing health-care system requires leader-managers to use their scarce resources
appropriately and to be visionary and proactive in planning for challenges yet to come.
In confronting these expanding responsibilities and demands, many leader-managers turn
to the experts for tools or strategies to meet these expanded role dimensions. What they have
found is some new and innovative thinking about how best to manage organizations and
lead people as well as some reengineered interactive leadership theories from the later 20th
century. This chapter explores this contemporary thinking about leadership and management,
with specific attention given to emergent 21st-century thinking.
NEW THINKING ABOUT LEADERSHIP AND MANAGEMENT
Japsen (2012) suggests that new leadership will be required to build bridges and find solutions
to the complex health-care problems that will be faced in the next 20 years. This leadership
must embrace community needs and new roles to care and guide individuals across a more
data-driven, accountable US health system.

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Chapter 3 Twenty-First-Century Thinking about leadership and Management 55
Zinni and Koltz (2009) suggest, however, that there is a profound leadership crisis in
America in the 21st century and that contemporary leaders have failed to change with the
times. They argue that this has occurred because the world is changing quickly and the
traditional top-down hierarchical leadership approach has not evolved quickly enough to
match the complexity of the 21st-century world. Single directive approaches to leading will
no longer work and participatory enterprise models, which are not easy to develop, must
replace them (Zinni and Koltz, 2009).
New research on leadership, including full-range leadership theory (see Chapter 2), is
rediscovering the importance of organizational context, levels of analysis, and potential
boundary conditions on transformational leadership. Indeed, many recent leadership and
management concepts focus on the complexity of the relationship between the leader and
the follower and much of the leadership research emerging in the second decade of the 21st
century builds upon the interactive leadership theories developed in the latter part of the 20th
century. As a result, concepts such as strengths-based leadership, Level 5 Leadership, servant
leadership, principal agent theory, human and social capital theory, emotional intelligence
(EI), authentic leadership, quantum leadership, and thought leadership have emerged as part
of the leader-manager’s repertoire for the 21st century.
Strengths-Based Leadership and the Positive Psychology Movement
Strengths-based leadership, which grew out of the positive psychology movement (began in
the late 1990s), focuses on the development or empowerment of workers’ strengths as opposed
to identifying problems, improving underperformance, and addressing weaknesses and
obstacles (Wong, 2012). For example, paying attention to multiple points of view, searching
for common ground, making continuous learning in the workplace a priority, and promoting
collaborative relationships represent strengths-based leadership activities (Wong, 2012). Wong
suggests that strengths-based leadership is part of the development of positive organizational
scholarship, which focuses on successful performance that exceeds the norm and embodies an
orientation toward strengths and developing collective efficacy in organizations.
While the types of activities encompassed in strengths-based leadership may vary, Gottlieb,
Gottlieb, and Shamian (2012) suggest that there are eight strengths-based leadership principles
that create the sustainable changes needed in health care and which provide a vision for current
and future nursing leadership. These eight leadership principles are shown in Display 3.1.
Gottlieb et al. argue that consistently using these leadership principles will allow nurses to step
forward and create a more holistic, humanistic, integrated, health-based, 21st-century health-
care system that focuses on what is best, what works, and what has potential.
DISPLAY 3.1 Principles of Strengths-Based Leadership
STRENGTHS-BASED NURSING LEADERSHIP
l Works with the whole, while appreciating the interrelationships among its parts
l recognizes the uniqueness of staff, nurse-leaders, and the organization
l creates work environments that promote nurses’ health and facilitates their development
l Understands the significance of subjective reality and created meaning
l Values self-determination
l recognizes that person and environment are integral and that nurses function best in environ-
ments where there is a “goodness of fit” that capitalizes on their strengths
l creates environments that promote learning and recognizes the importance of readiness and timing
l invests in collaborative partnerships
Source: Adapted from Gottlieb, L. N., Gottlieb, B., & Shamian, J. (2012). Principles of strengths-based nursing
leadership for strengths-based nursing care: A new paradigm for nursing and healthcare for the 21st century. Nursing
Leadership, 25(2), 38–50.
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56 UNIT I The CriTiCal Triad: deCision Making, ManageMenT, and leadership
Level 5 Leadership
The concept of Level 5 Leadership was developed by Jim Collins and published in his
classic (2001) book, From Good to Great. Collins studied 1,435 companies to determine
what separates great companies from good companies. What he found was that five levels of
leadership skill (see Display 3.2) may be present in any organization. Truly great organizations,
however, typically have leaders who possess the qualities found in all five levels. Thus, not
only do Level 5 leaders have the knowledge to do the job, but they also have team building
skills and can help groups achieve shared goals. They also though demonstrate humility and
seek success for the team, rather than for self-serving purposes, a core component of another
21st-century leadership theory known as Servant Leadership. Level 5 leaders also know when
to ask for help, accept responsibility for the errors they or their team make, and are incredibly
disciplined in their work.
Servant Leadership
Although Greenleaf (1977) developed the idea of servant leadership more than 35 years ago,
it continues to greatly influence leadership thinking in the 21st century. In more than four
decades of working as director of leadership development at AT&T, Greenleaf noticed that
most successful managers lead in a different way from traditional managers. These managers,
which he termed servant leaders, put serving others, including employees, customers, and
the community, as the number-one priority. In addition, servant leaders foster a service
inclination in others that promotes collaboration, teamwork, and collective activism.
Greenleaf argued that to be a great leader, one must be a servant first.
Sutton (2009) notes that many individuals placed in positions of authority become less
mindful of others’ feelings and needs. Meanwhile, their subordinates devote tremendous
energy to watching and interpreting the actions of their leaders and the end result is a toxic
tandem where employees feel underappreciated and overcontrolled. Sutton suggests that good
DISPLAY 3.2 Jim Collin’s Level 5 Leadership
LEVEL 1: HIGHLY CAPABLE INDIVIDUAL
Leader makes high-quality contributions to their work; possesses useful levels of knowledge; and
has the talent and skills needed to do a good job
LEVEL 2: CONTRIBUTING TEAM MEMBER
Leader uses knowledge and skills to help their team succeed; works effectively, productively, and
successfully with other people in their group
LEVEL 3: COMPETENT MANAGER
Leader is able to organize a group effectively to achieve specific goals and objectives
LEVEL 4: EFFECTIVE LEADER
Leader is able to galvanize a department or organization to meet performance objectives and
achieve a vision
LEVEL 5: GREAT LEADER
Leader has all of the abilities needed for the other four levels, plus a unique blend of humility and
will that is required for true greatness
Source: Adapted from Mindtools (1996–2013). Level 5 Leadership. Achieving “greatness” as a leader. Retrieved
May 14, 2013, from http://www.mindtools.com/pages/article/level-5-leadership.htm

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Chapter 3 Twenty-First-Century Thinking about leadership and Management 57
DISPLAY 3.3 Defining Qualities of Servant Leaders
l the ability to listen on a deep level and to truly understand
l the ability to keep an open mind and hear without judgment
l the ability to deal with ambiguity, paradoxes, and complex issues
l the belief that honestly sharing critical challenges with all parties and asking for their input is
more important than personally providing solutions
l Being clear on goals and good at pointing the direction toward goal achievement without
giving orders
l the ability to be a servant, helper, and teacher first and then a leader
l always thinking before reacting
l choosing words carefully so as not to damage those being led
l the ability to use foresight and intuition
l Seeing things whole and sensing relationships and connections
New Thinking about Leaders and Followers
Many contemporary scholars have expanded on Greenleaf ’s work, particularly in terms
of how followers influence the actions of the leader. While the positive effect of followers
on leaders has been fairly well described in most discussions of transformational
leadership, less has been said about potential negative impacts. For example, followers
can and do mislead leaders, whether intentionally or not, as noted in principal agent
leaders find ways to provide employees with more predictability, understanding, control, and
compassion and the reward is long-term employee loyalty. Other defining qualities of servant
leadership are shown in Display 3.3.
LEARNING EXERCISE 3.1
Creating a Service Inclination
an important part of servant leadership is the servant leader’s ability to create a service
inclination in others. in doing so, more leaders are created for the organization.
Assignment: identify servant leaders who you have worked with. Did they motivate followers
to be service oriented? if so, what strategies did they use? Does servant leadership result in
a greater number of leaders within an organization? if so, why do you think that this happens?
LEARNING EXERCISE 3.2
Servant Leadership in Nursing and Medicine
Assignment: Write a one-page essay that addresses the following:
1. Both nursing and medicine are helping, service-oriented professions. Do you believe there
are inherent differences in service inclination between individuals who choose nursing for a
profession rather than medicine?
2. Do you believe that nursing education fosters a greater service inclination than medical
education?
3. Do you believe the female majority (gender) of the nursing profession influences nursing’s
propensity to be service oriented?
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58 UNIT I The CriTiCal Triad: deCision Making, ManageMenT, and leadership
theory. Leaders can counteract this, however, by focusing on vision, cultivating truth
telling, and making sure followers feel they can disagree although this risk can never be
fully overcome.
Followers can and do mislead leaders, both intentionally and unintentionally.
Principal Agent Theory
Principal agent theory, which first emerged in the 1960s and 1970s, is another interactive
leadership theory being actively explored in the 21st century. This theory suggests that not
all followers (agents) are inherently motivated to act in the best interest of the principal
(leader or employer). This is because followers may have an informational (expertise or
knowledge) advantage over the leader as well as their own preferences, which may deviate
from the principal’s preferences. The risk then is that agents will pursue their own objectives
or interests instead of that of their principal.
Principals then must identify and provide agents with appropriate incentives to act in the
organization’s best interest. For example, consumers with good health insurance and small
out-of-pocket expenses may have little motivation to act prudently in accessing health-care
resources, since payment for services used will come primarily from the insurer. The insurer
then must create incentives for agents who access only needed services.
Another example might be end-of-shift overtime. While most employees do not
intentionally seek or want to work overtime after a long and busy shift, the reality is that
doing so typically results in financial rewards. Employers then must either create incentives
that reward employees who are able to complete their work in the allotted shift time or create
disincentives for those who do not.
LEARNING EXERCISE 3.3
The Agent’s Motives
You are a team leader for 10 patients on a busy medical unit. Your team includes Lori, a Licensed
Vocational Nurse (LVN), passing medications and assisting with patient treatments, and tom, an
experienced certified Nurses aid (cNa), who provides basic care such as monitoring vital signs,
ambulating patients, and assisting with hygiene. On several occasions in the past, tom has failed
to report significant changes in patients’ vital signs to you until some time had elapsed or you
discovered them yourself. Despite confronting tom about the need to report these changes and
the specific vital sign parameters that need to be reported, this behavior has continued. You have
become concerned that patient harm might occur if this pattern of behavior is allowed to continue.
Assignment: identify possible motives that tom (the agent) may have for failing to share this
information with you (the principal). What incentives might you employ to modify his behavior?
Human and Social Capital Theory
Human capital refers to the attributes of a person which are productive in some economic
context, although it is normally measured and conceived of as a private return to the
individual as well as a social return (About.com-Economics, 2013). For example, the term
human capital is often used when examining formal educational attainment, “with the
implication that education is an investment whose returns are in the form of wage, salary,
or other compensation” (About.com-Economics, para 1). Human capital can be viewed,
however, from an organizational perspective as well. In this case, human capital would refer
to the collective group knowledge or experience.

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Chapter 3 Twenty-First-Century Thinking about leadership and Management 59
Human capital can refer to a group’s collective knowledge, skills, and abilities.
Human capital theory suggests that individuals and/or organizations will invest in education
and professional development if they believe that such an investment will have a future
payoff. For example, a health-care organization that provides tuition reimbursement for
nurses to go back to school to earn higher degrees is likely doing so in anticipation that a
more highly educated nursing staff will result in increased quality of care and higher retention
rates—both of which should translate into higher productivity and financial return.
This was certainly the case in a landmark 2003 study by Dr. Linda Aiken and her colleagues
at the University of Pennsylvania, which found that “surgical patients have a ‘substantial
survival advantage’ if treated in hospitals with higher proportions of nurses educated at the
baccalaureate or higher degree level and that a 10% increase in the proportion of nurses
holding Bachelor’s of Science (BSN) degrees decreased the risk of patient death and failure
to rescue by 5%” (American Association of Colleges of Nursing, 2013, para 13). Research by
Dr. Aiken and colleagues also showed that hospitals with better care environments, the best
nurse staffing levels, and the most highly educated nurses had the lowest surgical mortality
rates. In fact, the researchers found that every 10% increase in the proportion of nurses on the
hospital staff, with a Bachelor’s of Science (BSN) degree in nursing, was associated with a
4% decrease in the risk of death (Aiken, Clarke, Sloane, Lake, & Cheney, 2008).
Emotional Intelligence
Another leadership theory gaining prominence in the 21st century is that of EI (also known as
EQ). Broadly defined, EI refers to the ability to perceive, understand, and control one’s own
emotions as well as those of others. For example, an individual with higher EI might choose
to feel useful emotions and regulate them in strategic ways, even if they are unpleasant to
experience (Ford & Tamir, 2012).
In their original work on EI in 1990, Mayer and Salovey (1997) suggested that EI develops
with age and that it consists of three mental processes:
• Appraising and expressing emotions in the self and others
• Regulating emotion in self and others
• Using emotions in adaptive ways
In 1997, they further refined EI into four mental abilities: perceiving/identifying emotions,
integrating emotions into thought processes, understanding emotions, and managing emotions.
Goleman (1998), in his 1995 best seller Working with Emotional Intelligence, built upon
this work in his identification of five components of EI: self-awareness, self-regulation,
motivation, empathy, and social skills (Display 3.4). Goleman argued that all individuals
DISPLAY 3.4 Five Components of Emotional Intelligence
1. Self-awareness: the ability to recognize and understand one’s moods, emotions, and drives as
well as their effects on others
2. Self-regulation: the ability to control or redirect disruptive impulses or moods as well as the
propensity to suspend judgment
3. Motivation: a passion to work for reasons that go beyond money or status; a propensity to
pursue goals with energy and commitment
4. Empathy: the ability to understand and accept the emotional makeup of other people
5. Social skills: Proficiency in handling relationships and building networks; an ability to find
common ground
Source: Adapted from Goleman, D. (1998). Working with emotional intelligence. New York, NY: Bantam Books.
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60 UNIT I The CriTiCal Triad: deCision Making, ManageMenT, and leadership
have a rational thinking mind and an emotional feeling mind and that both influence action.
The goal, then, in EI is emotional literacy—being self-aware about one’s emotions and
recognizing how they influence subsequent action. Unlike Mayer and Salovey, however,
Goleman argued that EI could be learned, although he too felt that it improves with age.
While many proponents of EI have suggested that having EI may be even more critical to
leadership success than intellectual intelligence (IQ), Sadri (2012) warns that the concept has
not yet been fully vetted in peer-reviewed research. It is a bit disconcerting then that some
employers and even Schools of Nursing have begun using EI evaluation tools as a criterion
for employability or admission (see Examining the Evidence 3.1).
Authentic Leadership
Another emerging leadership theory for the contemporary leader-manager’s arsenal is that
of authentic leadership (also known as congruent leadership). Authentic leadership suggests
that in order to lead, leaders must be true to themselves and their values and act accordingly.
It is important to remember that authentic or congruent leadership theory differs somewhat
from more traditional transformational leadership theories, which suggest that the leader’s
vision or goals are often influenced by external forces and that there must be at least some
“buy-in” of that vision by followers. In authentic leadership, it is the leaders’ principles and
their conviction to act accordingly that inspire followers. Thus, authentic followers realize
their own true nature.
In authentic leadership, it is the leaders’ principles and their conviction to act accordingly that
inspire followers.
Source: Kendall-Raynor, P. (2012). Prospective nursing students tested for emotional intelligence. Nursing
Standard, 26(24), 5.
The University of dundee in scotland is now using ei assessments as part of its screening crite-
ria for admission to its nursing program. students are asked to look at photographs of people’s
faces and match them with seven emotions—anger, sadness, surprise, disgust, fear, happiness,
and neutrality. in addition, students must complete a self-assessment questionnaire comprising
33 questions about emotions. The university suggests its decision to use ei assessment as a
screening tool is based on research that links ei with high academic performance, lower attrition
rates, and positive clinical practice outcomes. Yet, these same academic administrators note their
concern that some students may be able to answer in a way that they think is correct, without
having any significant degree of ei.
Examining the Evidence 3.1
LEARNING EXERCISE 3.4
Emotions and Decision Making
think back on a recent decision you made that was more emotionally laden than usual. Were
you self-aware about what emotions were influencing your thinking and how your emotions
might have influenced the course(s) of action you chose? Were you able to objectively identify
the emotions that others were experiencing and how these emotions may have influenced
their actions?

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Chapter 3 Twenty-First-Century Thinking about leadership and Management 61
Authentic leadership is not easy. It takes great courage to be true to one’s convictions when
external forces or peer pressure encourages an individual to do something he or she feels
morally would be inappropriate. For example, there is little doubt that some nurse-leaders
experience intrapersonal value conflicts between what they believe to be morally appropriate
and a need to deliver results in a health-care system increasingly characterized by pay for
performance and rewarded by cost containment.
A number of theorists have attempted to further define the theoretical construct of authentic
leadership in the past decade. Shirey (2006) suggests that there are five distinguishing
characteristics of authentic leaders: purpose, values, heart, relationships, and self-discipline
(see Display 3.5). Avolio, Walumbwa, and Weber (2009) suggest, however, that the general
agreement in the literature is that there are four factors that cover the components of authentic
leadership: balanced processing, internalized moral perspective, relational transparency,
and self-awareness. Balanced processing refers to analyzing data rationally before making
decisions. Internalized moral perspective suggests that the authentic leader is guided by
internal moral standards that then guide his or her behavior. Relational transparency refers to
openly sharing feelings and information appropriate to a situation, and self-awareness alludes
to a knowing of self so as to make sense of the world (Avolio et al., 2009). Avolio et al. (2009)
suggest, however, that work on defining and measuring authentic leadership is in its early
stages of development and that further research is needed to assess the validity of this construct.
DISPLAY 3.5 Five Distinguishing Characteristics of the Authentic Leader
1. Purpose: authentic leaders understand their own purposes and passions as a result of ongoing
self-reflection and self-awareness.
2. Values: authentic leaders link between purpose and passion by having congruence in beliefs
and actions.
3. Heart: authentic leaders care for themselves and the people they lead, and their compassion is
genuine.
4. Relationships: authentic leaders value building relationships and establishing connections with
others, not to receive rewards but rather to strengthen the human connection.
5. Self-discipline: authentic leaders practice self-discipline by incorporating balance into their per-
sonal and professional lives.
Source: Shirey, M. R. (2006). Fostering leadership through collaboration. reflections on nursing leadership (3rd quarter).
indianapolis, iN: Sigma Theta Tau International.
LEARNING EXERCISE 3.5
Inconsistency in Word and Action
there are many examples of internationally or nationally recognized leaders who have lost their
followers because of their actions being inconsistent with personally stated convictions. an
example might be a world-class athlete and advocate for healthy lifestyles who is found to be
using steroids to enhance physical performance. Or it might be a political figure who preaches
morality and becomes involved in an extramarital affair or a religious leader who promotes
celibacy and then becomes involved in a sex scandal.
Assignment: think of a leader who espoused one message and then acted in a different
manner. how did it affect the leader’s ability to be an effective leader? how did it change how
you personally felt about that leader? Do you feel that leaders who have lost their “authenticity”
can ever regain the trust of their followers?
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62 UNIT I The CriTiCal Triad: deCision Making, ManageMenT, and leadership
Finally, one must not be so idealistic as to assume that all leaders strive to be authentic.
Indeed, many are flawed, at least at times. Leaders may be deceitful and trustworthy, greedy
and generous, cowardly and brave. To assume that all good leaders are good people is
foolhardy and makes us blind to the human condition. Future leadership theory may well
focus on why leaders behave badly and why followers continue to follow bad leaders.
Thought Leadership
Another relatively new leadership theory to emerge in the 21st century is that of thought
leadership, which applies to a person who is recognized among his or her peers for innovative
ideas and who demonstrates the confidence to promote those ideas. Thus, thought leadership
refers to any situation in which one individual convinces another to consider a new idea,
product, or way of looking at things.
Thought leaders challenge the status quo and attract followers not by any promise
of representation or empowerment, but by their risk taking and vision in terms of being
innovative.
The ideas put forth by thought leaders typically are future oriented and make a significant
impact. In addition, they are generally problem oriented, which increases their value to both
individuals and organizations.
Organizations can also be thought leaders. For example, Blue Cross and Blue Shield were
early thought leaders in the development of private health insurance in the late 1920s. Johnson
and Johnson launched the Discover Nursing campaign earlier this decade to champion the
nursing profession and promote the recruitment and retention of nurses. Thought leaders
in the coming decade will likely focus on enduring issues that continue to be of critical
importance to nursing and health care, and address new, emerging problems of significance.
For example, thought leadership is still greatly needed in identifying and adopting innovative
safety and quality improvement approaches that actually reduce the risk of harm to patients
and health-care workers. In addition, the threat of an international nursing shortage continues
to loom and an inadequate number of innovative solutions have been suggested for addressing
the dire nursing faculty shortage that is expected to occur in the next 5 to 10 years.
LEARNING EXERCISE 3.6
Technological Innovation and Thought Leadership
technological innovations continue to change the face of health care, and the pace of such
innovations continues to increase exponentially. For example, wireless communication,
computerized charting, and the barcode scanning of medications have all greatly affected the
practice of nursing.
Assignment: choose at least one of the following technological innovations, and write a one-
page report on how this technology is expected to impact nursing and health care in the coming
decade. See if you can identify the thought leader(s) credited with developing these technologies
and explore the process that they used to both develop and market their innovations.
● Biometrics to ensure patient confidentiality
● computerized physician order entry
● Point-of-care testing
● Bluetooth technology
● electronic health records
● Nursebots (prototype nurse robots)
● Genetic and genomic testing

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Chapter 3 Twenty-First-Century Thinking about leadership and Management 63
Quantum Leadership
Quantum leadership is another relatively new leadership theory that is being used by leader-
managers to better understand dynamics of environments, such as health care. This theory,
which emerged in the 1990s, builds upon transformational leadership and suggests that leaders
must work together with subordinates to identify common goals, exploit opportunities, and
empower staff to make decisions for organizational productivity to occur. This is especially
true during periods of rapid change and needed transition.
Building on quantum physics, which suggests that reality is often discontinuous and deeply
paradoxical, quantum leadership suggests that the environment and context in which people
work is complex and dynamic and that this has a direct impact on organizational productivity.
The theory also suggests that change is constant. Today’s workplace is a highly fluid, flexible, and
mobile environment, and this calls for an entirely innovative set of interactions and relationships
as well as the leadership necessary to create them (Porter-O’Grady & Malloch, 2011).
Quantum leadership suggests that the environment and context in which people work is
complex and dynamic and that this has a direct impact on organizational productivity.
Because the health-care industry is characterized by rapid change, the potential for intra-
organizational conflict is high. Porter-O’Grady and Malloch (2011) suggest that because the
unexpected is becoming the normative, the quantum leader must be able to address the unsettled
space between present and future and resolve these conflicts appropriately. In addition, they suggest
that the ability to respond to the dynamics of crisis and change is not only an inherent leadership
skill, it must now be inculcated within the very fabric of the organization and its operation.
TRANSITION FROM INDUSTRIAL AGE LEADERSHIP TO RELATIONSHIP
AGE LEADERSHIP
In considering all of these emerging leadership theories, it becomes apparent that a paradigm
shift has taken place early in the 21st century—a transition from industrial age leadership
to relationship age leadership (Scott, 2006). Scott contends that industrial age leadership
focused primarily on traditional hierarchical management structures, skill acquisition,
competition, and control. These are the same skills traditionally associated with management.
Relationship age leadership focuses primarily on the relationship between the leader and
his or her followers, on discerning common purpose, working together cooperatively, and
seeking information rather than wealth (Table 3.1). Servant leadership, authentic leadership,
human and social capital, and EI are all relationship-centered theories that address the
complexity of the leader–follower relationship.
Industrial Age Leadership Relationship Age Leadership
Skills technical skills People skills
Authority command and control invitation and interdependence
Strategy Gaining advantage Discerning purpose
Methodology competition cooperation
Focus Gathering facts Finding meaning
Value What you have (wealth) What you know (information)
Structure hierarchy (top-down) circular (egalitarian)
Meaning of leadership Leadership: position Leadership: trusteeship
Source: Adapted from Scott (2006). © Ki ThoughtBridge, LLC 2000. Author, Katherine Taylor Scott. All rights
reserved. Permission for use in this publication granted by Ki ThoughtBridge.
TABLE 3.1 Comparing Industrial and Relationship Age Leadership
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64 UNIT I The CriTiCal Triad: deCision Making, ManageMenT, and leadership
FIGURE 3.1 • integrated model of leadership. (reproduced with permission from Ki
thoughtBridge & Scott, K. t. (2006, September 29). The gifts of leadership. Keynote
presented at the Sigma theta tau international chapter Leader academy, indianapolis, iN.)
Leader Adaptive
Outer
Inner
Performance Results
Abilities
Character
Technical
Skills
Competence
Authenticity
Influence
A paradigm shift is taking place early in the 21st century−a transition from industrial age
leadership to relationship age leadership.
Covey (2011) concurs, noting that the primary drivers of economic prosperity in the
industrial age were machines and capital—in other words, things. People were necessary, but
replaceable. Covey argues that many current management practices come from the industrial
age where the focus was on controlling workers, fitting them into a slot and using reward
and punishment for external motivation. In contrast, relationship age leadership is all about
leading people who have the power to choose. It is about requiring leaders to embrace the
whole person paradigm (Covey, 2011).
Yet the leader-manager in contemporary health-care organizations cannot and must not
focus solely on relationship building. Ensuring productivity and achieving desired outcomes
are essential to organizational success. The key, then, likely lies in integrating the two
paradigms. Scott (2006) suggests that such integration is possible (Fig. 3.1).
Technical skills and competence seeking must be balanced with the adaptive skills of
influencing followers and encouraging their abilities. Performance and results priorities must be
balanced with authentic leadership and character. In other words, leader-managers must seek the
same tenuous balance between leadership and management that has existed since time began.
LEARNING EXERCISE 3.7
Balancing the Focus between Productivity and Relationships
You are a top-level nursing administrator in a large, urban medical center in california. as in
many acute-care hospitals, your annual nursing turnover rate is more than 25%. at this point,
you have many unfilled licensed nursing positions, and local recruitment efforts to fill these
positions have been largely unsuccessful. the problem has been exacerbated by the recent
passage of legislated minimum licensed staffing ratios in your state.

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Chapter 3 Twenty-First-Century Thinking about leadership and Management 65
LEADERSHIP AND MANAGEMENT FOR NURSING’S FUTURE
Seemingly insurmountable problems, a lack of resources to solve these problems, and
individual apathy have been and will continue to be issues that contemporary leader-
managers face. Effective leadership is absolutely critical to organizational success in the 21st
century. Becoming a better leader-manager begins with a highly developed understanding of
what leadership and management are and how these skills can be developed. The problem is
that these skills are dynamic, and what we know and believe to be true about leadership and
management changes constantly in response to new research and visionary thinking.
Contemporary leader-managers, then, are challenged not only to know and be able to
apply classical leadership and management theory but also to keep abreast of new insights,
new management decision-making tools, and new research in the field. It is more important
than ever that leader-managers be able to integrate leadership roles and management functions
and that some balance be achieved between industrial age leadership and relationship age
leadership skills. Leading and managing in the 21st century promises to be more complex
than ever before, and leader-managers will be expected to have a greater skill set than ever
before. The key to organizational success will likely be having enough highly qualified and
visionary leader-managers to steer the course.
During a meeting with the ceO today, you are informed that the hospital vacancy rate for
licensed nurses is expected to rise to 35% with the implementation of the new minimum staffing
ratios in 3 months. the ceO states that you must reduce turnover or increase recruitment
efforts immediately or the hospital will have to consider closing units or reducing available beds
when the new ratios take effect.
You consider the following “industrial leadership” paradigm options:
1. You could aggressively recruit international nurses to solve at least the immediate staffing
problem.
2. You could increase sign-on bonuses and offer other incentives for recruiting new nurses.
3. You could expand the job description for unlicensed assistive personnel and LVNs to relieve
the registered nurses of some of their duties.
4. You could make newly recruited nurses sign a minimum 2-year contract upon hire.
You also consider the following “relationship leadership” paradigm options:
1. You could hold informal meetings with current staff to determine major variables affecting
their current satisfaction levels and attempt to increase those variables that increase worker
satisfaction.
2. You could develop an open-door policy in an effort to be more accessible to workers who
wish to discuss concerns or issues about their work environment.
3. You could implement a shared governance model to increase worker participation in decision
making on the units in which they work.
4. You could make daily rounds on all the units in an effort to get to know your nursing staff
better on a one-to-one basis.
Assignment: Decide which of the options you would select. rank order them in terms of what
you would do first. then look at your list. Did it reflect more of the industrial leadership paradigm
or a relationship leadership paradigm? What inferences might you draw from your rank ordering
in terms of your leadership skills? Do you think that your rank ordering might change with your
age? Your experience?
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66 UNIT I The CriTiCal Triad: deCision Making, ManageMenT, and leadership
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
KEY CONCEPTS
● Many new leadership and management theories have emerged in the 21st century to explain the
complexity of the leader–follower relationship and the environment in which work is accomplished and
goals are achieved.
● Strengths-based leadership focuses on the development or empowerment of workers’ strengths as
opposed to identifying problems, improving underperformance, and addressing weaknesses and
obstacles.
● Level 5 leadership is characterized by knowledge, team building skills, the ability to help groups achieve
goals, humility, and the empowerment of others through servant leadership.
● Servant leadership is a contemporary leadership model that puts serving others as the first priority.
● Followers can and do influence leaders in both positive and negative ways.
● Principal agent theory suggests that followers may have an informational (expertise or knowledge)
advantage over the leader as well as their own preferences, which may deviate from those of the
principal. this may lead to a misalignment of goals.
● Human capital represents the capability of the individual. Social capital represents what a group can
accomplish together.
● Emotional intelligence refers to the ability to use emotions effectively and is considered by many to be
critical to leadership and management success.
● Authentic leadership suggests that in order to lead, leaders must be true to themselves and their values
and act accordingly.
● Thought leadership refers to any situation whereby one individual convinces another to consider a new
idea, product, or way of looking at things.
● thought leaders attract followers not by any promise of representation or empowerment but by their risk
taking and vision in terms of being innovative.
● Quantum leadership suggests that the environment and context in which people work is complex and
dynamic and that this has a direct impact on organizational productivity.
● a transition has occurred in the 21st-century from industrial age leadership to relationship age leadership.
LEARNING EXERCISE 3.8
Reflecting on Emotional Intelligence in Self
Do you feel that you have emotional intelligence? Do you express appropriate emotions such as
empathy when taking care of patients? are you able to identify and control your own emotions
when you are in an emotionally charged situation?
Assignment: Describe a recent emotional experience. Write two to four paragraphs
reporting how you responded in this experience. Were you able to read the emotions of
the other individuals involved? how did you respond, and were you later able to reflect on
this incident?

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Chapter 3 Twenty-First-Century Thinking about leadership and Management 67
REFERENCES
LEARNING EXERCISE 3.10
Human and Social Capital
examine the institution in which you work or go to school. assess both the human capital
and social capital present. Which is greater? Which do you believe contributes most to this
institution in being able to accomplish its stated mission and goals?
About.com-Economics. (2013). Definition of human capital.
Retrieved May 14, 2013, from http://economics.about
.com/cs/economicsglossary/g/human_capital.htm
Aiken, L., Clarke, S. P., Sloane, D. M., Lake, E. T., &
Cheney, T. (2008, May). Effects of hospital
care environment on patient mortality and nurse
outcomes. Journal of Nursing Administration,
38(5), 223–229.
American Association of Colleges of Nursing. (2013). Fact
sheet. Creating a more highly qualified nursing
workforce. Retrieved May 13, 2013, from, http://www
.aacn.nche.edu/Media/FactSheets/NursingWrkf.htm
Avolio, B., Walumbwa, F., & Weber, T. (2009). Leadership:
Current theories, research, and future directions.
Annual Review of Psychology, 60, 421–449.
Collins, J. (2001). Good to great: Why some companies make the
leap … and others don’t. New York, NY: Harper Collins.
Covey, S. (2011, September). Lighthouse principles and
leadership. UC Morning in America (adaptation from
a speech presented at University of the Cumberlands
on April 8, 2008, in the “Principle-Centered
Leadership Series” sponsored by the Forcht Group
of Kentucky Center for Excellence in Leadership).
Retrieved May 14, 2013, from http://www
.ucumberlands.edu/academics/history/downloads/
MorningInAmericaVol2i3
Ford, B., & Tamir, M. (2012). When getting angry is smart:
Emotional preferences and emotional intelligence.
Emotion, 12(4), 685–689.
Goleman, D. (1998). Working with emotional intelligence.
New York, NY: Bantam Books.
Gottlieb, L.N., Gottlieb, B., & Shamian, J. (2012). Principles
of strengths-based nursing leadership for strengths-
based nursing care: A new paradigm for nursing and
healthcare for the 21st century. Nursing Leadership,
25(2), 38–50.
Greenleaf, R. K. (1977). Servant leadership: A journey in the
nature of legitimate power and greatness. New York,
NY: Paulist.
Japsen, B. (2012, June 22). Health leaders look to 2032 for
opportunities to improve the health of the nation.
Robert Wood Johnson Foundation. Retrieved February
25, 2013, from http://www.rwjf.org/en/about-rwjf/
newsroom/newsroom-content/2012/06/health-leaders
-look-to-2032-for-opportunities-to-improve-the-hea.html
Kendall-Raynor, P. (2012). Prospective nursing students tested
for emotional intelligence. Nursing Standard, 26(24), 5.
Mayer, J. D., & Salovey, P. (1997). What is emotional
intelligence? In P. Salovey & D. Sluyter (Eds.),
Emotional development and emotional intelligence:
Implications for educators (pp. 3–31). New York,
NY: Basic Books.
LEARNING EXERCISE 3.9
Self-Regulation and Emotional Intelligence
You have just come from your 6-month performance evaluation as a new charge nurse. While
your supervisor stated that he was very pleased in general with how you are performing in this
new role, one area that he suggested you work on was to learn to be calmer in hectic clinical
situations. he suggested that your anxiety could be transmitted to coworkers and subordinates
who look to you to be their role model. he feels that you are especially anxious when staffing is
short and that at times you vent your frustrations to your staff, which only adds to the general
anxiety level on the unit.
Assignment: create a specific plan of 6 to 10 things you can do to bolster your emotional
intelligence in terms of self-regulation during stressful times.
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http://www.aacn.nche.edu/Media/FactSheets/NursingWrkf.htm

http://www.ucumberlands.edu/academics/history/downloads/MorningInAmericaVol2i3

http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2012/06/health-leaders-look-to-2032-for-opportunities-to-improve-the-hea.html

http://economics.about.com/cs/economicsglossary/g/human_capital.htm

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68 UNIT I The CriTiCal Triad: deCision Making, ManageMenT, and leadership
Mindtools (1996–2013). Level 5 leadership. Achieving
“greatness” as a leader. Retrieved Sept. 26, 2013,
from http://www.mindtools.com/pages/article/level-5
-leadership.htm
Porter-O’Grady, T., & Malloch, K. (2011). Quantum
leadership: Advancing information, transforming
healthcare (3rd ed.). Sudbury, MA: Jones & Bartlett.
Sadri, G. (2012). Emotional intelligence and leadership
development. Public Personnel Management, 41(3),
535–548.
Scott, K. T. (2006, September 29). The gifts of leadership.
Keynote presented at the Sigma Theta Tau International
Chapter Leader Academy, Indianapolis, IN.
Shirey, M. R. (2006). Promoting sustainability through
collaboration. Reflections on nursing leadership
(3rd quarter) Indianapolis, IN:.
Sutton, R. I. (2009, June). How to be a good boss in a bad
economy. Harvard Business Review, 42–50.
Wong, C. A. (2012). Advancing a positive leadership
orientation: From problem to possibility. Nursing
Leadership, 25(2), 51–55.
Zinni, T., & Koltz, T. (2009). Leading the charge:
Leadership lessons from the battlefield
to the boardroom. New York, NY:
Palgrave Macmillan.

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Foundation for Effective
Leadership and Management
Ethics, Law, and Advocacy
UNIT II
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70
Ethical Issues
… when organizations and their leaders become fixated on the bottom line and ignore values, an
environment conducive to ethics failure is nurtured.
—J. G. Bruhn
… All my growth and development led me to believe that if you really do the right thing, and if you
play by the rules, and if you’ve got good enough, solid judgment and common sense, that you’re
going to be able to do whatever you want to do with your life.
—Barbara Jordan
CROSSWALK this chapter addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VIII: Professionalism and professional values
BSN Essential IX: Baccalaureate generalist nursing practice
MSN Essential II: Organizational and systems leadership
MSN Essential VI: Health policy and advocacy
MSN Essential IX: Advanced generalist nursing practice
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: Professionalism
QSEN Competency: Patient-centered care
LEARNING OBJECTIVES The learner will:
l define ethics and ethical dilemmas
l compare and contrast the utilitarian, duty-based, rights-based, and intuitionist frameworks for
ethical decision making
l identify and define six different principles of ethical reasoning
l use a systematic problem-solving or decision-making model to determine appropriate action
for select ethical problems
l describe the limitations of using outcome as the sole criterion for the evaluation of ethical
decision making
l distinguish between legal and ethical obligations in decision making
l describe how differences in personal, organizational, subordinate, and patient obligations
increase the risk of intrapersonal conflict in ethical decision making
l demonstrate self-awareness regarding the ethical frameworks and ethical principles that
most strongly influence his or her personal decision making.
l role model ethical decision making congruent with the American Nurses Association (ANA)
Code of Ethics and Interpretive Statements and professional standards
4

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Chapter 4 Ethical Issues 71
Unit II examines ethical, legal, and legislative issues affecting leadership and management
as well as professional advocacy. This chapter focuses on applied ethical decision making
as a critical leadership role for mangers. Chapter 5 examines the impact of legislation and
the law on leadership and management and Chapter 6 focuses on advocacy for patients and
subordinates and for the nursing profession in general.
Ethics is the systematic study of what a person’s conduct and actions should be with regard
to self, other human beings, and the environment; it is the justification of what is right or good
and the study of what a person’s life and relationships should be, not necessarily what they
are. Ethics is a system of moral conduct and principles that guide a person’s actions in regard
to right and wrong and in regard to oneself and society at large.
Ethics is concerned with doing the right thing and with being a certain kind of person, in terms
of conduct and character (Gallagher & Hodge, 2012).
Applied ethics requires application of normative ethical theory to everyday problems. The
normative ethical theory for each profession arises from the purpose of the profession. The
values and norms of the nursing profession, therefore, provide the foundation and filter
from which ethical decisions are made. The nurse-manager, however, has a different ethical
responsibility than the clinical nurse and does not have as clearly defined a foundation to use
as a base for ethical reasoning.
In addition, because management is a discipline and not a profession, it does not have
a defined purpose, such as medicine and the law; therefore, it lacks a specific set of norms
to guide ethical decision making. Instead, the organization reflects norms and values to
the manager, and the personal values of managers are reflected through the organization.
The manager’s ethical obligation is tied to the organization’s purpose, and the purpose of
the organization is linked to the function that it fills in society and the constraints society
places on it. So, the responsibilities of the nurse-manager emerge from a complex set of
interactions. Society helps define the purposes of various institutions, and the purposes, in
turn, help ensure that the institution fulfills specific functions. However, the specific values
and norms in any particular institution determine the focus of its resources and shape its
organizational life. The values of people within institutions influence actual management
practice. In reviewing this set of complex interactions, it becomes evident that arriving at
appropriate ethical management decisions is a difficult task.
Not only are nursing management ethics distinct from clinical nursing ethics, they are also
distinct from other areas of management. Although there are many similar areas of responsibility
between nurse-managers and non-nurse-managers, many leadership roles and management
functions are specific to nursing. These differences require the nurse-manager to deal with
unique obligations and ethical dilemmas that are not encountered in non-nursing management.
In addition, because personal, organizational, subordinate, and consumer responsibilities
differ, there is great potential for nursing managers to experience intrapersonal conflict about
the appropriate course of action. Multiple advocacy roles and accountability to the profession
further increase the likelihood that all nurse-managers will be faced with ethical dilemmas
in their practice. Nurses often find themselves viewed simultaneously as advocates for
physicians, patients, and the organization—all of whose needs and goals may be dissimilar.
Nurses are often placed in situations where they are expected to be agents for patients,
physicians, and the organization simultaneously, all of which may have conflicting needs, wants,
and goals.
To make appropriate ethical decisions then, the manager must have knowledge of ethical
principles and frameworks, use a professional approach that eliminates trial and error and
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72 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
focuses on proven decision-making models, and use available organizational processes to assist
in making such decisions. Such organizational processes include institutional review boards
(IRBs), ethics committees, and professional codes of ethics. Using both a systematic approach
and proven ethical tools and technology allows managers to make better decisions and increases
the probability that they will feel confident about the decisions they have made. Leadership
roles and management functions involved in management ethics are shown in Display 4.1.
LEADERSHIP ROLES
1. Is self-aware regarding own values and basic beliefs about the rights, duties, and goals of human
beings.
2. Accepts that some ambiguity and uncertainty must be a part of all ethical decision making.
3. Accepts that negative outcomes occur in ethical decision making despite high-quality problem
solving and decision making.
4. Demonstrates risk taking in ethical decision making.
5. Role models ethical decision making, which is congruent with the American Nurses Association
(ANA) Code of Ethics and Interpretive Statements and professional standards.
6. Clearly communicates expected ethical standards of behavior.
7. Role models behavior that eliminates theory–practice–ethics gaps.
MANAGEMENT FUNCTIONS
1. Uses a systematic approach to problem solving and decision making when faced with manage-
ment problems with ethical ramifications.
2. Identifies outcomes in ethical decision making that should always be sought or avoided.
3. Uses established ethical frameworks to clarify values and beliefs.
4. Applies principles of ethical reasoning to define what beliefs or values form the basis for decision
making.
5. Is aware of legal precedents that may guide ethical decision making and is accountable for pos-
sible liabilities should they go against the legal precedent.
6. Continually reevaluates the quality of personal ethical decision making, based on the process of
decision making or problem solving used.
7. Recognizes and rewards ethical conduct of subordinates.
8. Takes appropriate action when subordinates use unethical conduct.
DISPLAY 4.1 Leadership Roles and Management Functions Associated with Ethics
TYPES OF ETHICAL ISSUES
There are many terms used to describe moral issues faced by nurses, including moral
indifference, moral uncertainty, moral conflict, moral distress, moral outrage, and ethical
dilemmas. Moral indifference occurs when an individual questions why morality in practice
is even necessary. Moral uncertainty or moral conflict occurs when an individual is unsure
which moral principles or values apply and may even include uncertainty as to what the moral
problem is.
On the other hand, moral distress occurs when the individual knows the right thing to
do but organizational constraints make it difficult to take the right course of action. Pauly,
Varcoe, and Storch (2012) suggest that moral distress in health care is a growing concern and
that it impacts satisfaction, the recruitment and retention of health-care providers, as well as
the delivery of safe and competent quality patient care. Nalley (2013) agrees, suggesting that
the intense patient situations (e.g., end-of-life care), lack of collaboration, and disrespectful
communication that are often a part of nursing can lead to emotional exhaustion, increased
absenteeism, low morale, chronic discontent, and job dissatisfaction.

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Chapter 4 Ethical Issues 73
To identify which influencers nurses perceived as having the greatest impact on their
ethical beliefs and moral distress, Davis, Schrader, and Belcheir (2012) surveyed 1144
Idaho nurses. Approximately 35% of the nurses reported experiencing moral distress in the
workplace at least once a month and 27.7% reported leaving a job due to moral distress.
Nurses with strong religious beliefs had significantly higher moral distress than those who
identified the nurses’ Code of Ethics, family values, or work/life experiences as the compass
for their ethical beliefs. The researchers concluded that because religion and spiritual
beliefs may pose additional moral distress for nurses in dealing with ethical dilemmas (see
Examining the Evidence 4.1).
Moral outrage occurs when an individual witnesses the immoral act of another but feels
powerless to stop it. For example, in a high-profile whistle-blower case in New Mexico, six
nurses at Memorial Medical Center in Las Cruces independently voiced concerns to their
nurse-managers over a 6-year period, regarding inadequate and inappropriate care being
given by an osteopathic physician on staff (Bitoun Blecher, 2001–2013). In addition, the
nurses brought the alleged shortcomings of this particular doctor to the attention of other
physicians. The doctor in this case was later accused of negligence and incompetence after
one of her patients died from sepsis and another suffered a serious injury.
But for reasons that are still unclear, the hospital allegedly failed to act on the nurses’
complaints. Instead, the hospital challenged the nurses’ actions and disciplined them,
citing state regulations that forbid sharing patient information for any reason. The hospital
also retaliated after the case was filed and the nurses agreed to testify against the doctor.
“Sometimes the atmosphere in a hospital is set up so that you cannot work through the
system, and that’s what happened here—the system failed” (Bitoun Blecher, 2001–2013,
para 28).
Source: Davis, S., Schrader, V., & Belcheir, M. (2012). Influencers of ethical beliefs and the impact on moral distress
and conscientious objection. Nursing Ethics, 19(6), 738–749.
The aim of this exploratory study was to identify influencers that had the greatest impact on the
development of nurses’ ethical beliefs and to determine whether these influencers might impact
levels of moral distress and the potential for conscientious objection. One thousand one hundred
forty-four registered nurses from throughout Idaho participated in this study by completing a
30-item survey on the Idaho State Board of Nursing online license renewal website.
Thirty-four percent of the sample claimed that their work and/or life experience was the
most important influence in the development of their ethical beliefs, followed by religious beliefs
(29.4%), family values (24%), and the Nursing Code of Ethics (9%). A small percentage of
the sample claimed to have developed their ethical beliefs from governing laws (3.2%), and
even fewer from political views (0.3%). The religious beliefs group had significantly higher moral
distress scores compared with those who identified the nurses’ Code of Ethics, family values, or
work/life experiences as influencing the development of their ethical beliefs. Those who chose
governing laws or political views had a mean which did not differ from any other group.
This study supported previous findings that nurses’ ethical beliefs are influenced less by their
professional codes of ethics and more by work or life experiences, religious beliefs, and family
values. The researchers noted that how one’s ethical beliefs are influenced may determine how
they will react to ethical dilemmas and that religion and spiritual beliefs often influence how nur-
ses and health-care providers in general make ethical decisions. Because these values are often
strongly engrained from childhood, the authors concluded that it may be unrealistic to expect
nurses to ignore these belief systems when faced with ethical dilemmas.
Examining the Evidence 4.1
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74 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
Lastly, the most difficult of all moral issues is termed a moral or ethical dilemma, which
may be described as being forced to choose between two or more undesirable alternatives.
For example, a nurse might experience a moral or ethical dilemma if he or she was required
to provide care or treatments, which were in conflict with his or her own religious beliefs. In
this case, the nurse would likely experience an intrapersonal moral conflict about whether his
or her values, needs, and wants can or should supersede those of the patient. Because ethical
dilemmas are so difficult to resolve, many of the learning exercises in this chapter are devoted
to addressing this type of moral issue.
Individual values, beliefs, and personal philosophy play a major role in the moral or ethical
decision making that is part of the daily routine of all managers.
How do managers decide what is right and what is wrong? What does the manager do if no
right or wrong answer exists? What if all solutions generated seem to be wrong? Remember
that the way managers approach and solve ethical issues is influenced by their values and basic
beliefs about the rights, duties, and goals of all human beings. Self-awareness, then, is a vital
leadership role in ethical decision making, just as it is in so many other aspects of management.
No rules, guidelines, or theories exist that cover all aspects of the ethical problems that
managers face. However, it is the manager’s responsibility to understand the ethical problem-
solving process, to be familiar with ethical frameworks and principles, and to know ethical
professional codes. It is these tools that will assist managers in effective problem solving and
prevent ethical failure within their organization. Critical thinking occurs when managers are
able to engage in an orderly process of ethical problem solving to determine the rightness or
wrongness of courses of action.
ETHICAL FRAMEWORKS FOR DECISION MAKING
Ethical frameworks guide individuals in solving ethical dilemmas. These frameworks do not
solve the ethical problem but assist the manager in clarifying personal values and beliefs.
Four of the most commonly used ethical frameworks are utilitarianism, duty-based reasoning,
rights-based reasoning, and intuitionism (Table 4.1).
Ethical frameworks do not solve ethical problems but do assist decision makers in clarifying
personal values and beliefs.
The teleological theory of ethics is also called utilitarianism or consequentialist theory.
Using an ethical framework of utilitarianism encourages decision making based on what
provides the greatest good for the greatest number of people. In doing so, the needs and
wants of the individual are diminished. Utilitarianism also suggests that the end can justify
the means. For example, a manager using a utilitarian approach might decide to use travel
budget money to send many staff to local workshops rather than to fund one or two people
to attend a national conference. Another example would be an insurance program that meets
TABLE 4.1 Ethical Frameworks
Framework Basic Premise
Utilitarian (teleological) Provide the greatest good for the greatest number of people
Rights based (deontological) Individuals have basic inherent rights that should not be interfered with
Duty based (deontological) A duty to do something or to refrain from doing something
Intuitionist (deontological) Each case weighed on a case-by-case basis to determine relative
goals, duties, and rights

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Chapter 4 Ethical Issues 75
the needs of many but refuses coverage for expensive organ transplants. As illustrated in
Learning Exercise 4.5, the organization uses utilitarianism to justify lying to employee
applicants because their hiring would result in good for many employees by keeping several
units in the hospital open.
Deontological ethical theory judges whether the action is right or wrong regardless of the
consequences and is based on the philosophy of Emanuel Kant in the 18th century. Primarily,
this theory uses both duty-based reasoning and rights-based reasoning as the basis for its
philosophy. Duty-based reasoning is an ethical framework stating that some decisions must
be made because there is a duty to do something or to refrain from doing something. In
Learning Exercise 4.5, the supervisor feels a duty to hire the most qualified person for the
job, even if the personal cost is high.
Rights-based reasoning is based on the belief that some things are a person’s just due (i.e.,
each individual has basic claims, or entitlements, with which there should be no interference).
Rights are different from needs, wants, or desires. The supervisor in Learning Exercise
4.5 believes that both applicants have the right to fair and impartial consideration of their
application. In Learning Exercise 4.6, Sam believes that all people have the right to truth and,
in fact, that he has the duty to be truthful.
The intuitionist framework allows the decision maker to review each ethical problem or
issue on a case-by-case basis, comparing the relative weights of goals, duties, and rights.
This weighting is determined primarily by intuition—what the decision maker believes is
right for that particular situation. Recently, some ethical theorists have begun questioning
the appropriateness of intuitionism as an ethical decision-making framework because of the
potential for subjectivity and bias. All of the cases solved in this chapter involve some degree
of decision making by intuition.
Other more recent theories of ethical philosophy include ethical relativism and ethical
universalism. Ethical relativism suggests that individuals make decisions based only on what
seems right or reasonable according to their value system or culture. Conversely, universalism
holds that ethical principles are universal and constant and that ethical decision making
should not vary as a result of individual circumstances or cultural differences.
PRINCIPLES OF ETHICAL REASONING
Both teleological and deontological theorists have developed a group of moral principles
that are used for ethical reasoning. These principles of ethical reasoning further explore and
define what beliefs or values form the basis for decision making. Respect for people is the
most basic and universal ethical principle. The major ethical principles stemming from this
basic principle are discussed in Display 4.2.
The most fundamental universal principle is respect for people.
Autonomy: Promotes self-determination and freedom of choice
Beneficence: Actions are taken in an effort to promote good
Nonmaleficence: Actions are taken in an effort to avoid harm
Paternalism: One individual assumes the right to make decisions for another
Utility: The good of the many outweighs the wants or needs of the individual
Justice: Seek fairness; treat “equals” equally and treat “unequals” according to their differences
Veracity: Obligation to tell the truth
Fidelity: Need to keep promises
Confidentiality: Keep privileged information private
DISPLAY 4.2 Ethical Principles
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76 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
Autonomy (Self-Determination)
A form of personal liberty, autonomy, is also called freedom of choice or accepting the
responsibility for one’s choice. The legal right of self-determination supports this moral
principle. The use of progressive discipline recognizes the autonomy of the employee.
The employee, in essence, has the choice to meet organizational expectations or to
be disciplined further. If the employee’s continued behavior warrants termination, the
principle of autonomy says that the employee has made the choice to be terminated by
virtue of his or her actions, not by that of the manager. Therefore, nurse-managers must be
cognizant of the ethical component present whenever an individual’s decisional capacity is
in question. To take away a person’s right to self-determination is a serious but sometimes
necessary action.
Beneficence (Doing Good)
This principle states that the actions one takes should be done in an effort to promote good.
The concept of nonmaleficence, which is associated with beneficence, says that if one cannot
do good, then one should at least do no harm. For example, if a manager uses this ethical
principle in planning performance appraisals, he or she is much more likely to view the
performance appraisal as a means of promoting employee growth.
Paternalism
This principle is related to beneficence in that one person assumes the authority to make a
decision for another. Because paternalism limits freedom of choice, most ethical theorists
believe that paternalism is justified only to prevent a person from coming to harm.
Unfortunately, some managers use the principle of paternalism in subordinates’ career
planning. In doing so, managers assume that they have greater knowledge of what an
employee’s short- and long-term goals should be than the employee does.
Utility
This principle reflects a belief in utilitarianism—what is best for the common good outweighs
what is best for the individual. Utility justifies paternalism as a means of restricting individual
freedom. Managers who use the principle of utility need to be careful not to become so
focused on desired group outcomes that they become less humanistic.
Justice (Treating People Fairly)
This principle states that equals should be treated equally and that unequals should be treated
according to their differences. This principle is frequently applied when there are scarcities
or competition for resources or benefits. The manager who uses the principle of justice will
work to see that pay raises reflect performance and not just time of service.
Woods (2012) notes that in the last few decades, a growing number of commentators have
questioned the appropriateness of the “justice view” of ethics as a suitable approach in health-
care ethics, and most certainly in nursing. Woods noted that nurses do not readily adopt the
high degree of impartiality and objectivity that is associated with a justice view; instead their
moral practices are more accurately reflected through the use of alternative approaches such
as relational or care-based ethics. This observation suggests the need for a more ethically
refined nursing response to an increasingly complex set of sociocultural inequalities such as
a combined social justice and relational care-based approach. Woods maintains that such an
approach is not only possible, but crucial if nurses are to realize their full potential as ethical
agents for individual and social good.

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Chapter 4 Ethical Issues 77
Veracity (Truth Telling)
This principle is used to explain how people feel about the need for truth telling or the
acceptability of deception. A manager who believes that deception is morally acceptable if it
is done with the objective of beneficence may tell all rejected job applicants that they were
highly considered whether they had been or not.
LEARNING EXERCISE 4.1
Are Some More Equal than Others
Research suggests that individuals with health insurance in this country have better access to
health-care services and better health-care outcomes than those who do not. This does not
mean, however, that all individuals with health insurance receive “equal treatment.” Medicaid
recipients (the financially indigent) often complain that although they have public insurance,
many private providers refuse to accept them as patients. Patients enrolled in managed care
suggest that their treatment options are more limited than traditional private insurance because
of the use of gatekeepers, required authorizations, and queuing. Even individuals with private
insurance suggest that copayments and out-of-pocket costs for deductibles place the cost of
care beyond the reach of many.
Assignment: Using the ethical principle of justice, determine whether health care in this country
should be a right or a privilege. Are the uninsured and the insured “unequals” that should be
treated according to their differences? Does the type of health insurance that one has also create
a system of “unequals”? If so, are the unequals being treated according to their differences?
LEARNING EXERCISE 4.2
Weighing Veracity versus Nonmaleficence
You are a second-year nursing student. During the first year of the nursing program, you formed
a close friendship with Susan, another nursing student, and the two of you spend many of your
free evenings and weekends together doing fun things. The only thing that drives you a bit crazy
about your friend is that she is incredibly messy. When you go to her home, you usually see dirty
dishes piled in the sink, dog hair over all the furniture, clothing strewn all over the apartment,
and uneaten pizza or other half spoiled food sitting on the floor. You attempt to limit your time
at her apartment since it is so bothersome to you, so it has not been a factor in your friendship.
Today, when Susan and you are sitting at the dining table in your apartment, your current
roommate tells you that she is unexpectedly vacating her lease at the end of the month. Susan
becomes excited and shares that her lease will end at the end of this month as well and
suggests how much fun it would be if the two of you could move in together. She immediately
begins talking about when she could move in, where she would locate her furniture in the
apartment, and where her dog might stay when the two of you are in clinical. While you value
Susan’s friendship and really enjoy the time you spend together, the idea of living with someone
as untidy as Susan is not something you want to do. Unfortunately, your current lease does not
preclude pets or subleases.
Assignment: Decide how you will respond to Susan. Will you tell her the truth? Are your values
regarding veracity stronger or weaker than your desire to cause no harm to Susan’s feelings
(nonmaleficence)?
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78 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
Fidelity (Keeping Promises)
Fidelity refers to the moral obligation that individuals should be faithful to their commitments
and promises. Breaking a promise is believed by many ethicists to be wrong regardless of the
consequences. In other words, even if there were no far-reaching negative results of the broken
promise, it is still wrong because it would render the making of any promise meaningless.
However, there are times when keeping a promise (fidelity) may not be in the best interest of
the other party, as discussed below under confidentiality. Although nurses have multiple fidelity
duties (patient, physician, organization, profession, and self) that at times may be in conflict, the
ANA Code of Ethics is clear that the nurse’s primary commitment is to the patient (ANA, 2001).
Confidentiality (Respecting Privileged Information)
The obligation to observe the privacy of another and to hold certain information in strict
confidence is a basic ethical principle and a foundation of both medical and nursing
ethics. However, as in deception, there are times when the presumption against disclosing
information must be overridden. For example, health-care managers are required by law to
report certain cases, such as drug abuse in employees, elder abuse, and child abuse.
LEARNING EXERCISE 4.3
Family Values
You are the evening shift charge nurse of the recovery room. You have just admitted a 32-year-
old woman who 2 hours ago was thrown from a Jeep in which she was a passenger. She was
rushed to the emergency department and subsequently to surgery, where cranial burr holes
were completed and an intracranial monitor was placed. No further cranial exploration was
attempted because the patient sustained extensive and massive neurologic damage. She will
probably not survive your shift. The plan is to hold her in the recovery room for 1 hour and, if she
is still alive, transfer her to the intensive care unit.
Shortly after receiving the patient in the recovery room, you are approached by the evening
house supervisor, who says that the patient’s sister is pleading to be allowed into the recovery
room. Normally, visitors are never allowed into the recovery room but occasionally exceptions are
made. Tonight, the recovery room is empty except for this patient. You decide to bend the rules
and allow the young woman’s sister into the recovery room. The visiting sister is near collapse;
it is obvious that she had been the driver of the Jeep. As the visitor continues to speak to the
comatose patient, her behavior and words make you begin to wonder if she is indeed the sister.
Within 15 minutes, the house supervisor returns and states, “I have made a terrible mistake. The
patient’s family just arrived, and they say that the visitor we just allowed into the recovery room
is not a member of the family but is the patient’s lover. They are very angry and demand that this
woman not be allowed to see the patient.”
You approach the visitor and confront her in a kindly manner regarding the information that you
have just received. She looks at you with tears streaming down her face and says, “Yes, it is true.
Mary and I have been together for 6 years. Her family disowned her because of it, but we were
everything to each other. She has been my life, and I have been hers. Please, please let me stay.
I will never see her again. I know the family will not allow me to attend the funeral. I need to say
my goodbyes. Please let me stay. It is not fair that they have the legal right to be family when I
have been the one to love and care for Mary.”
Assignment: You must decide what to do. Recognize that your own value system will play a
part in your decision. List several alternatives that are available to you. Identify which ethical
frameworks or principles most affected your decision making.

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Chapter 4 Ethical Issues 79
AMERICAN NURSES ASSOCIATION CODE OF ETHICS AND PROFESSIONAL
STANDARDS
“Professional ethics relates to the values and standards of a particular profession, which
are generally made explicit in professional codes of conduct or practice” (Grob, Leng, &
Gallagher, 2012, p. 36). A professional code of ethics is a set of principles, established by
a profession, to guide the individual practitioner. The first Code of Ethics for Nurses was
adopted by the ANA in 1950 and has been revised five times since then. The ANA Center
for Ethics and Human Rights again began seeking public input in the review of the Code
of Ethics for Nurses with Interpretative Statements (the Code) in early 2013 with suggested
revisions again in 2013.
This code outlines the important general values, duties, and responsibilities that flow from
the specific role of being a nurse. While not legally binding, the code functions as a guide to the
highest ethical practice standards for nurses and as an aid for moral thinking. See Display 4.3.
The ANA House of Delegates approved these nine provisions of the new Code of Ethics for Nurses
at its June 30, 2001, meeting in Washington, DC. In July 2001, the Congress of Nursing Practice
and Economics voted to accept the new language of the interpretive statements, resulting in a fully
approved revised Code of Ethics for Nurses with Interpretive Statements.
1. The nurse, in all professional relationships, practices with compassion and respect for the inher-
ent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or
economic status, personal attributes, or the nature of health problems.
2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the
patient.
4. The nurse is responsible and accountable for individual nursing practice and determines the appro-
priate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
5. The nurse owes the same duties to self as to others, including the responsibility to preserve integ-
rity and safety, to maintain competence, and to continue personal and professional growth.
6. The nurse participates in establishing, maintaining, and improving health-care environments and
conditions of employment conducive to the provision of quality health care and consistent with the
values of the profession through individual and collective action.
7. The nurse participates in the advancement of the profession through contributions to practice,
education, administration, and knowledge development.
8. The nurse collaborates with other health professionals and the public in promoting community,
national, and international efforts to meet health needs.
9. The profession of nursing, as represented by associations and their members, is responsible for
articulating nursing values, for maintaining the integrity of the profession and its practice, and for
shaping social policy.
DISPLAY 4.3 American Nurses Association Code of Ethics for Nurses
Professional codes of ethics function as a guide to the highest standards of ethical practice for
nurses. They are not legally binding.
The 2001 Code of Ethics for Nurses departs from previous versions in several important
ways. The newest code returns to the use of the term patient rather than client, as patient
more accurately reflects what the majority of nurses do—care for individuals with health
problems. The code also explicitly details that the nurse’s most fundamental accountability
is to the patient, whether an individual, family, group, or community (No. 2). The 2001 code
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80 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
also addresses the responsibility of the nurse for assuring that the work environment is safe,
even in an era of cutting costs and reduced revenues (No. 6). Finally, there is a provision
(No. 5) that addresses duties of nurses to themselves.
Another document that may be helpful specifically to the nurse-manager in creating and
maintaining an ethical work environment is The Scope and Standards of Practice of Nursing
Administration Practice published by the ANA. These standards, revised in 2009, specifically
delineate professional standards in management ethics, and these appear in Display 4.4.
STANDARD 12. ETHICS
The nurse administrator integrates ethical provisions in all areas of practice.
MEASUREMENT CRITERIA
1. Incorporates Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) to guide practice.
2. Assures the preservation and protection of the autonomy, dignity, and rights of individuals.
3. Maintains confidentiality within legal and regulatory parameters.
4. Assures a process to identify and address ethical issues within nursing and the organization.
5. Participates on multidisciplinary and interdisciplinary teams that address ethical risks, benefits,
and outcomes.
6. Demonstrates a commitment to practicing self-care, managing stress, and connecting with self
and others.
Source: American Nurses Association. (2009). Nursing administration: Scope and standards of practice. Silver Springs,
MD: American Nurses Publishing.
DISPLAY 4.4 Standards of Practice for Nurse Administrators
ETHICAL PROBLEM SOLVING AND DECISION MAKING
“Cutting edge medical research, coupled with rapid advances in the delivery of health care,
has far surpassed society’s ability to predict, comprehend, and/or resolve the ethical dilemmas
confronting modern health care. These dilemmas resist fast and easy solutions” (Alichnie,
2012, p. 3). Therefore, ethical concepts and their utility in clinical practice must be taught
along with the problem-solving skills that are a part of all decision making.
Some of the difficulty people have in making ethical decisions can be attributed to a lack
of formal education about problem solving. Other individuals lack the thinking skills or risk
taking needed to solve complex ethical problems. Still other nurses erroneously use decision-
making outcomes as the sole basis for determining the quality of the decision making.
Although decision makers should be able to identify desirable and undesirable outcomes,
outcomes alone cannot be used to assess the quality of the problem solving. Many variables
affect outcome, and some of these are beyond the control or foresight of the problem solver.
Even the most ethical courses of action can have undesirable and unavoidable consequences.
The quality of ethical problem solving should be evaluated in terms of the process used to
make the decision. The best possible decisions stem from structured problem solving, adequate
data collection, and examination of multiple alternatives—even if outcomes are poor.
If a structured approach to problem solving is used, data gathering is adequate, and multiple
alternatives are analyzed, even with a poor outcome, the nurse should accept that the best
possible decision was made at that time with the information and resources available.
In addition, Mortell (2012) suggests that some decision making by nurses reflects a theory–
practice–ethics gap despite the moral obligation nurses have to ensure theory and practice

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Chapter 4 Ethical Issues 81
are integrated. For example, Mortell notes that noncompliance exists in hand hygiene among
practitioners despite ongoing infection prevention education and training; easy access to
facilities such as wash basins; antiseptic/alcohol hand gels that are convenient, effective, and
skin- and user-friendly; and organizational recognition and support for clinicians in hand
washing and hand gel practices. Thus, despite nurses having knowledge of best practices
based on current research, they continue to fail to achieve the required and desired compliance
in hand hygiene. Mortell concludes that more emphasis should be placed on clinicians’ moral
and ethical obligations as part of training and orientation and that organizations must continue
to emphasize the duty of care toward patients in nurses’ decision making.
Kearney and Penque (2012) provide another example of a theory–practice–ethics gap in
their suggestion that while nurses recognize that checklists can reduce episodes of patient
harm by ensuring that procedures are being carried out appropriately, that some providers
will indicate that an intervention has been undertaken when it has not. This occurs because of
the mantra “If it wasn’t documented, it wasn’t done” and an increasing emphasis and reliance
on documentation that demands that “all boxes must be ticked” to ensure complete care has
been provided. Kearney and Penque suggest then that checklists present a context for ethical
decision making in that when providers do not take ethics into account, checklists could
actually perpetuate rather than prevent unsafe practices or errors.
The Traditional Problem-Solving Process
Although not recognized specifically as an ethical problem-solving model, one of the oldest
and most frequently used tools for problem solving is the traditional problem-solving process.
This process, which is discussed in Chapter 1, consists of seven steps, with the actual decision
being made at step 5 (review the seven steps under “Traditional Problem-Solving Process”
in Chapter 1). Although many individuals use at least some of these steps in their decision
making, they frequently fail to generate an adequate number of alternatives or to evaluate the
results—two essential steps in the process.
LEARNING EXERCISE 4.4
A Nagging Uneasiness
You are a nurse on a pediatric unit. One of your patients is a 15-month-old girl with a diagnosis
of failure to thrive. The mother says that the child is emotional, cries a lot, and does not like to
be held. You have been taking care of the infant for 2 days since her admission, and she has
smiled and laughed and held out her arms to everyone. She has eaten well. There is something
about the child’s reaction to the mother’s boyfriend that bothers you. The child appears to draw
away from him when he visits. The mother is very young and seems to be rather immature but
appears to care for the child.
This is the second hospital admission for this child. Although you were not on duty for the first
admission 6 weeks ago, you check the records and see that the child was admitted with the
same diagnosis. While you are on duty today, the child’s father calls and inquires about her
condition. He lives several hundred miles away and requests that the child be hospitalized until
the weekend (it is Wednesday) so that he can “check things out.” He tells you that he believes
the child is mistreated. He says he is also concerned about his ex-wife’s 4-year-old child from
another marriage and is attempting to gain custody of that child in addition to his own child.
From what little the father said, you are aware that the divorce was bitter and that the mother
has full custody.
(Continued)
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82 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
The Nursing Process
Another problem-solving model not specifically designed for ethical analysis but appropriate
for it is the nursing process. Most nurses are aware of the nursing process and the cyclic
nature of its components of assessment, diagnosis, planning, implementation, and evaluation
(see Fig. 1.2). However, most nurses do not recognize its use as a decision-making tool. The
cyclic nature of the process allows for feedback to occur at any step. It also allows the cycle to
repeat until adequate information is gathered to make a decision. It does not, however, require
clear problem identification. Learning Exercise 4.4 shows how the nursing process might be
used as an ethical decision-making tool.
You talk with the physician at length. He says that after the last hospitalization, he requested that
the community health agency and Child Protective Services call on the family. Their subsequent
report to him was that the 4-year-old child appeared happy and well and that the 15-month-old
child appeared clean, although underweight. There was no evidence to suggest child abuse.
However, the community health agency plans to continue following the children. He says that
the mother has been good about keeping doctor appointments and has kept the children’s
immunizations up to date. The pediatrician proceeds to write an order for discharge. He says
that although he also feels somewhat uneasy, continued hospitalization is not justified, and the
state medical aid will not pay for additional days. He also says that he will follow up once again
with Child Protective Services to make another visit.
When the mother and her boyfriend come to take the baby home, the baby clings to you and
refuses to go to the boyfriend. She also seems reluctant to go to the mother. All during the
discharge, you are extremely uneasy. When you see the car drive away, you feel very sad.
After returning to the unit, you talk with your supervisor, who listens carefully and questions
you at length. Finally, she says, “It seems as if you have nothing concrete on which to act and
are only experiencing feelings. I think you would be risking a lot of trouble for yourself and the
hospital if you acted rashly at this time. Accusing people with no evidence and making them go
through a traumatic experience is something I would hesitate to do.”
You leave the supervisor’s office still troubled. She did not tell you that you must do nothing, but
you believe that she would disapprove of further action on your part. The doctor also felt strongly
that there was no reason to do more than was already being done. The child will be followed by
community health nurses. Perhaps the ex-husband was just trying to make trouble for his ex-wife
and her new boyfriend. You would certainly not want anyone to have reported you or created
problems regarding your own children. You remember how often your 5-year-old bruised himself
when he was that age. He often looked like an abused child. You go about your duties and try
to shake off your feeling. What should you do?
Assignment:
1. Solve the case in small groups by using the traditional problem-solving process. Identify the
problem and several alternative solutions to solve this ethical dilemma. What should you do
and why? What are the risks? How does your value system play a part in your decision?
Justify your solution. After completing this assignment, solve Part 2.
2. Assume that this was a real case. Twenty-four hours after the child’s discharge, she is
readmitted with critical head trauma. Police reports indicate that the child suffered multiple
skull fractures after being thrown up against the wall by her mother’s boyfriend. The child
is not expected to live. Does knowing the outcome change how you would have solved the
case? Does the outcome influence how you feel about the quality of your group’s problem
solving?

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Chapter 4 Ethical Issues 83
LEARNING EXERCISE 4.5
One Applicant Too Many
The reorganization of the public health agency has resulted in the creation of a new position
of community health liaison. A job description has been written, and the job opening has been
posted. As the chief nursing executive of this agency, it will be your responsibility to select
the best person for the position. Because you are aware that all hiring decisions have some
subjectivity, you want to eliminate as much personal bias as possible. Two people have applied
for the position; one of them is a close personal friend.
Analysis
Assess: As the nursing executive, you have a responsibility to make personnel decisions as
objectively as you can. This means that the hiring decision should be based solely on which
employee is best qualified for the position. You do recognize, however, that there may be a
personal cost in terms of the friendship.
Diagnose: You diagnose this problem as a potential intrapersonal conflict between your
obligation to your friend and your obligation to your employer.
Plan: You must plan how you are going to collect your data. The tools you have selected are
applications, resumes, references, and personal interviews.
Implement: Both applicants are contacted and asked to submit resumes and three letters
of reference from recent employers. In addition, both are scheduled for structured formal
interviews with you and two of the board members of the agency. Although the board
members will provide feedback, you have reserved the right to make the final hiring decision.
Evaluate: As a result of your plan, you have discovered that both candidates meet the minimal
job requirements. One candidate, however, clearly has higher-level communication skills,
and the other candidate (your friend) has more experience in public health and is more
knowledgeable regarding the resources in your community. Both employees have complied
with the request to submit resumes and letters of reference; they are of similar quality.
Assess: Your assessment of the situation is that you need more information to make the best
possible decision. You must assess whether strong communication skills or public health
experience and familiarity with the community would be more valuable in this position.
Plan: You plan how you can gather more information about what the employee will be doing in
this newly created position.
Implement: If the job description is inadequate in providing this information, it may be necessary to
gather information from other public health agencies with a similar job classification.
Evaluate: You now believe that excellent communication skills are essential for the job. The
candidate who had these skills has an acceptable level of public health experience and
seems motivated to learn more about the community and its resources. This means that your
friend will not receive the job.
Assess: Now you must assess whether a good decision has been made.
Plan: You plan to evaluate your decision in 6 months, basing your criteria on the established
job description.
Implement: You are unable to implement your plan because this employee resigns unexpectedly
4 months after she takes the position. Your friend is now working in a similar capacity in
another state. Although you correspond infrequently, the relationship has changed as a result
of your decision.
(Continued)
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84 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
THE MORAL DECISION-MAKING MODEL
Crisham (1985) developed a model for ethical decision making incorporating the nursing
process and principles of biomedical ethics. This model is especially useful in clarifying
ethical problems that result from conflicting obligations. This model is represented by
the mnemonic MORAL as shown in Display 4.5. Learning Exercise 4.6 demonstrates the
MORAL modeling in solving an ethical issue.
Evaluate: Did you make a good decision? This decision was based on a carefully thought-out
process, which included adequate data gathering and a weighing of alternatives. Variables
beyond your control resulted in the employee’s resignation, and there was no apparent reason
for you to suspect that this would happen. The decision to exclude or minimize personal bias was
a conscious one, and you were aware of the possible ramifications of this choice. The decision
making appears to have been appropriate.
Massage the dilemma: Collect data about the ethical problem and who should be involved in the
decision-making process.
Outline options: Identify alternatives, and analyze the causes and consequences of each.
Review criteria and resolve: Weigh the options against the values of those involved in the decision.
This may be done through a weighting or grid.
Affirm position and act: Develop the implementation strategy.
Look back: Evaluate the decision making.
Source: Crisham, P. (1985). MORAL: How can I do what is right? Nursing Management, 16(3), 42A–42N.
DISPLAY 4.5 The MORAL Decision-Making Model
LEARNING EXERCISE 4.6
Little White Lies
Sam is the nurse recruiter for a metropolitan hospital that is experiencing an acute nursing
shortage. He has been told to do or say whatever is necessary to recruit professional nurses so
that the hospital will not have to close several units. He also has been told that his position will
be eliminated if he does not produce a substantial number of applicants in the nursing career
days to be held the following week. Sam loves his job and is the sole provider for his family.
Because many organizations are experiencing severe personnel shortages, the competition for
employees is keen. After his third career day without a single prospective applicant, he begins
to feel desperate. On the fourth and final day, Sam begins making many promises to potential
applicants regarding shift preference, unit preference, salary, and advancement that he is not
sure he can keep. At the end of the day, Sam has a lengthy list of interested applicants but also
feels a great deal of intrapersonal conflict.

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Chapter 4 Ethical Issues 85
Massage the Dilemma
In a desperate effort to save his job, Sam finds he has taken action that has resulted in
high intrapersonal value conflict. Sam must choose between making promises he cannot
keep and losing his job. This has far-reaching consequences for all involved. Sam has the
ultimate responsibility for knowing his values and acting in a manner that is congruent with
his value system. The organization is, however, involved in the value conflict in that its values
and expectations conflict with those of Sam. Sam and the organization have some type of
responsibility to these applicants, although the exact nature of this responsibility is one of
the values in conflict. Because this is Sam’s problem and an intrapersonal conflict, he must
decide the appropriate course of action. His primary role is to examine his values and act in
accordance.
Outline Options
Option 1. Quit his job immediately. This would prevent future intrapersonal conflict, provided
that Sam becomes aware of his value system and behaves in a manner consistent with that
value system in the future. It does not, however, solve the immediate conflict about the action
Sam has already taken. This action takes away Sam’s livelihood.
Option 2. Do nothing. Sam could choose not to be accountable for his own actions. This
will require Sam to rationalize that the philosophy of the organization is in fact acceptable or
that he has no choice regarding his actions. Thus, the responsibility for meeting the needs
and wants of the new employees is shifted to the organization. Although Sam will have no
credibility with the new employees, there will be only a negligible impact on his ability to
recruit at least on a short-term basis. Sam will continue to have a job and be able to support
his family.
Option 3. If after value clarification Sam has determined that his values conflict with the
organization’s directive to do or say whatever is needed to recruit employees, he could
approach his superior and share these concerns. Sam should be very clear about what his
values are and to what extent he is willing to compromise them. He also should include in this
meeting what, if any, action should be taken to meet the needs of the new employees. Sam
must be realistic about the time and effort usually required to change the values and beliefs of
an organization. He also must be aware of his bottom line if the organization is not willing to
provide a compromise resolution.
Option 4. Sam could contact each of the applicants and tell them that certain recruitment
promises may not be possible. However, he will do what he can to see that the promises are
fulfilled. This alternative is risky. The applicants will probably be justifiably suspicious of both
the recruiter and the organization, and Sam has little formal power at this point to fulfill their
requests. This alternative also requires a time and energy commitment by Sam and does not
prevent the problem from recurring.
Review the Options
In value clarification, Sam discovered that he valued truth telling. Alternative 3 allows Sam to
present a recruiting plan to his supervisor that includes a bottom line that this value will not be
violated.
Affirm Position and Act
Sam approached his superior and was told that his beliefs were idealistic and inappropriate in
an age of severe worker shortages. Sam was terminated. Sam did, however, believe that he
made an appropriate decision. He did become self-aware regarding his values and attempted to
communicate these values to the organization in an effort to work out a mutually agreeable plan.
(Continued)
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86 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
WORKING TOWARD ETHICAL BEHAVIOR AS THE NORM
The concerns about ethical conduct in American institutions are documented by many news
articles in the national press. Many individuals believe that organizational and institutional
ethical failure has become the norm. Governmental agencies, both branches of Congress,
the stock exchange, oil companies, and savings and loan institutions have all experienced
problems with unethical conduct. Many members of society wonder what has gone wrong.
Nurse-managers, then, have a responsibility to create a climate in their organizations in which
ethical behavior is not only the expectation but the norm.
In an era of markedly limited physical, human, and fiscal resources, nearly all decision
making by nurse-managers will involve some ethical component. Indeed, the following
forces ensure that ethics will become an even greater dimension in management decision
making in the future: increasing technology, regulatory pressures, and competitiveness
among health-care providers; workforce shortages; an imperative to provide better care at less
cost; spiraling costs of supplies and salaries; and the public’s increasing distrust of the health-
care delivery system and its institutions. The following actions, as shown in Display 4.6, can
help the manager in ethical problem solving.
Look Back
Although Sam was terminated, he knew that he could find some type of employment to meet
his immediate fiscal needs. He did become self-aware regarding his values and used what he
had learned in this decision-making process, in that he planned to evaluate more carefully the
recruitment philosophy of the organization in relation to his own value system before accepting
another job.
1. Separate legal and ethical issues
2. Collaborate through ethics committees
3. Use IRBs appropriately
4. Foster an ethical work environment
DISPLAY 4.6 Strategies Leader-Managers Can Use to Promote Ethical Behavior as the Norm
Separate Legal and Ethical Issues
Although they are not the same, separating legal and ethical issues is sometimes difficult.
Legal controls are generally clear and philosophically impartial; ethical controls are much less
clear and individualized. In many ethical issues, courts have made a decision that may guide
managers in their decision making. Often, however, these guidelines are not comprehensive,
or they differ from the manager’s own philosophy. Managers must be aware of established
legal standards and cognizant of possible liabilities and consequences for actions that go
against the legal precedent.
In general, legal controls are clearer and philosophically impartial; ethical controls are much less
clear and individualized.

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Chapter 4 Ethical Issues 87
Legal precedents are frequently overturned later and often do not keep pace with the changing
needs of society. In addition, certain circumstances may favor an illegal course of action as
the “right” thing to do. If a man were transporting his severely ill wife to the hospital, it might
be morally correct for him to disobey traffic laws. Therefore, the manager should think of the
law as a basic standard of conduct, whereas ethical behavior requires a greater examination
of the issues involved.
The manager may confront several particularly sensitive legal–ethical issues, including
termination or refusal of treatment, durable power of attorney, abortion, sterilization, child
abuse, and human experimentation. Most health-care organizations have legal counsel
to assist managers in making decisions in such sensitive areas. Because legal aspects
of management decision making are so important, Chapter 5 is devoted exclusively to
this topic.
Collaborate Through Ethics Committees
The new manager must consult with others when solving sensitive legal–ethical questions
because a person’s own value system may preclude examining all possible alternatives.
Many institutions have ethics committees to assist with problem solving in ethical issues.
These ethics committees typically are interprofessional and are organized to consciously
and reflectively consider significant and often difficult or ambiguous value issues related to
patient care or organizational activities. Ethics committees are a core element of collaborative
ethical decision making and should include representatives of all stakeholders, including
patients when they are involved in the ethical issue.
Use Institutional Review Boards Appropriately
IRBs are primarily formed to protect the rights and welfare of research subjects. They provide
oversight to ensure that individuals conducting research adhere to ethical principles that were
articulated by the National Commission for the Protection of Human Subjects of Biomedical
and Behavioral Research. The primary role of the manager regarding IRBs is to make sure that
such a board is in place in the organization where the manager works and that any research
performed within his or her sphere of responsibility has been approved by such a board.
Foster an Ethical Work Environment
Perhaps the most important thing a leader-manager can do to foster an ethical work
environment, however, is to role model ethical behavior. Silén, Kjellström, Christensson,
Sidenvall, and Svantesson (2012) note this can be done as simply as meeting the needs of
patients and next of kin in a considerate way, as well as receiving and giving support and
information within the work group. Likewise, working as a team with a standard for behavior
can promote a positive ethical climate. Other important interventions include encouraging
staff to openly discuss ethical issues that they face daily in their practice. This allows
subordinates to gain greater perspective on complex issues and provides a mechanism for
peer support.
Sorbello (2008), however, notes the challenge faced by some nurse administrators in
both retaining the essence of nurses who “live caring” at the same time they are “challenged
to make wise and ethical decisions for what is best for the organization” (p. 48). She
recommends that nurse-leaders seek to balance the competing demands for resources within
the organization within the context of the ethical problems they face. She also suggests
that in sharing these challenges with staff, managers are often able to nurture meaningful
relationships, foster honest dialogue, and role model caring.
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88 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
ETHICAL DIMENSIONS IN LEADERSHIP AND MANAGEMENT
The need for ethical decisions occurs in every phase of the management process, and many
of the learning exercises in this book have an ethical component that must be considered in
problem solving. In fact, each section in this book could appropriately include a section on
ethical issues, such as the following:
Unit III
• At what point do the needs of the organization become more important than those of
the individual worker?
• Should employees ever be coerced into changing their stated values so that they more
closely align with those of the organization?
• How can managers fairly allocate resources when virtually all resources are limited?
Unit IV
• Should quality or cost be the final determinant when selecting the most appropriate
type of patient care delivery system?
• Should licensed vocational nurses and licensed professional nurses be allowed to
function in the primary nursing role?
• How should the manager protect clients from an inadequately trained nurse?
• Which should be more important to the organization—human relations or productivity?
• Which is more corrupting—power or powerlessness?
Unit V
• At what point does short staffing become unsafe?
• Should shift scheduling be used as a means of reward and punishment?
• Is luring or recruiting employees from other agencies ever ethical?
• How far can the truth be stretched in recruitment advertising before it becomes
deceptive?
• Should preemployment testing be required as a condition of employment?
• Is it ethical for employees to take a position in an organization if they know that they
are planning to leave in a short time?
• Is it ever justified for an employee to lie in an interview?
• Who has the responsibility for socializing the new graduate into the professional
nursing role—the nursing school, the hospital, or is it a joint process?
• What commitment does the organization have to the nurse who is reentering the
profession after not practicing for many years?
Unit VI
• To whom do managers owe their primary allegiance—the organization or their
subordinates?
• When is it appropriate to use money as the primary motivator?
• If employees are producing at acceptable or higher levels, what new rewards and
incentives should be introduced?

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Chapter 4 Ethical Issues 89
• Is it ethical to promote antiunion organizers to management roles to reduce the
possibility of union formation?
• Is affirmative action hiring to compensate for past discrimination ethically justifiable,
or does it promote reverse discrimination?
• Is it ethical for nurses to strike?
• Should the national nursing organization also be a collective bargaining agent?
Unit VII
• Is it necessary for each employee to be assisted to achieve at optimal levels? Can the
manager be selective in determining which employees are assisted to reach optimal
productivity?
• At what point does the power to evaluate the work of others become dangerous?
• Should the individual be allowed total self-determination in short- and long-term
career planning?
• Is it ethical to promote or transfer a less-qualified person to keep a valuable employee
on a unit?
• Does the organization have an obligation to reemploy the chemically impaired
employee who seeks rehabilitation?
• When does the employee’s right to privacy regarding drug or alcohol use stop and the
manager’s right to that information begin?
• Is it ever ethical to file a grievance against another person for the purpose of
harassment?
• Can discipline administered in anger ever be fair?
• In pursuing beneficence, is it more appropriate to discipline marginal employees
progressively or to terminate them?
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN ETHICS
Leadership roles in ethics focus on the human element involved in ethical decision making.
Leaders are self-aware regarding their values and basic beliefs about the rights, duties, and
goals of human beings. As self-aware and ethical people, they role model confidence in their
decision making to subordinates. They also are realists and recognize that some ambiguity
and uncertainty must be a part of all ethical decision making. Leaders are willing to take risks
in their decision making despite the fact that negative outcomes can occur even with quality
decision making.
In ethical issues, the manager is often the decision maker. Because ethical decisions are
so complex and the cost of a poor decision may be high, management functions focus on
increasing the chances that the best possible decision will be made at the least possible cost
in terms of fiscal and human resources. This usually requires that the manager becomes expert
at using systematic approaches to problem solving or decision making, such as theoretical
models, ethical frameworks, and ethical principles. By developing expertise, the manager can
identify universal outcomes that should be sought or avoided.
The integrated leader-manager recognizes that ethical issues pervade every aspect of
leadership and management. Rather than being paralyzed by the complexity and ambiguity of
these issues, the leader-manager seeks counsel as needed, accepts his or her limitations, and
makes the best possible decision at that time with the information and resources available.
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90 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
KEY CONCEPTS
l Ethics is the systematic study of what a person’s conduct and actions should be with regard to self,
other human beings, and the environment; it is the justification of what is right or good and the study of
what a person’s life and relationships should be—not necessarily what they are.
l In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by
nurse-managers involves some ethical component. Multiple advocacy roles and accountability to the
profession further increase the likelihood that managers will be faced with ethical dilemmas in their practice.
l Many systematic approaches to ethical problem solving are appropriate. These include the use of
theoretical problem-solving and decision-making models, ethical frameworks, and ethical principles.
l Outcomes should never be used as the sole criterion for assessing the quality of ethical problem
solving, because many variables affect outcomes that have no reflection on whether the problem solving
was appropriate. Quality, instead, should be evaluated both by the outcome and the process used to
make the decision. If a structured approach to problem solving is used, data gathering is adequate, and
multiple alternatives are analyzed, then, regardless of the outcome, the manager should feel comfortable
that the best possible decision was made at that time with the information and resources available.
l Four of the most commonly used ethical frameworks for decision making are utilitarianism, duty-based
reasoning, rights-based reasoning, and intuitionism. These frameworks do not solve the ethical problem
but assist individuals involved in the problem solving to clarify their values and beliefs.
l Principles of ethical reasoning explore and define what beliefs or values form the basis for our decision
making. These principles include autonomy, beneficence, nonmaleficence, paternalism, utility, justice,
fidelity, veracity, and confidentiality.
l Professional codes of ethics and standards for practice are guides to the highest standards of ethical
practice for nurses.
l Sometimes it is very difficult to separate legal and ethical issues, although they are not the same. Legal
controls are generally clear and philosophically impartial. Ethical controls are much more unclear and
individualized.
LEARNING EXERCISE 4.7
The Impaired Employee
Beverly, a 35-year-old, full-time nurse on the day shift, has been with your facility for 10 years.
There are rumors that she comes to work under the influence of alcohol. Staff report the smell of
alcohol on her breath, unexcused absences from the unit, and an increase in medication errors.
Although the unit supervisor suspected that Beverly was chemically impaired, she was unable
to observe directly any of these behaviors.
After arriving at work last week, the supervisor walked into the nurses’ lounge and observed
Beverly covertly drinking from a dark-colored flask in her locker. She immediately confronted
Beverly and asked her if she was drinking alcohol while on duty. Beverly tearfully admitted that
she was drinking alcohol but stated this was an isolated incident and begged her to forget it.
She promised never to consume alcohol at work again.

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Chapter 4 Ethical Issues 91
In an effort to reduce the emotionalism of the event and to give herself time to think, the
supervisor sent Beverly home and scheduled a conference with her for later in the day. At this
conference, Beverly was defensive and stated, “I do not have a drinking problem, and you are
overreacting.” The supervisor shared data that she had gathered supporting her impression that
Beverly was chemically impaired. Beverly offered no explanation for these behaviors.
The plan for Beverly was a referral to the State Board of Nursing Diversion Program and a
requirement that she complete the program as they direct her. Beverly again became very tearful
and begged the supervisor to reconsider. She stated that she was the sole provider for her four
small children and that her frequent sick days had taken up all available vacation and sick pay.
The supervisor stated that she believed her decision was appropriate and again encouraged
Beverly to seek guidance for her drinking. Four days later, the supervisor read in the newspaper
that Beverly committed suicide the day after this meeting.
Assignment: Evaluate the problem solving of the supervisor. Would your actions have differed
if you were the manager? Are there conflicting legal and ethical obligations? To whom does the
manager have the greatest obligation—patients, subordinates, or the organization? Could the
outcome have been prevented? Does this outcome reflect on the quality of the problem solving?
LEARNING EXERCISE 4.8
Everything Is Not What It Seems
You are a perinatal unit coordinator at a large teaching hospital. In addition to your management
responsibilities, you have been asked to fill in as a member of the hospital promotion committee,
which reviews petitions from clinicians for a step-level promotion on the clinical specialist ladder.
You believe that you could learn a great deal on this committee and could be an objective and
contributing member.
The committee has been convened to select the annual winner of the Outstanding Clinical
Specialist Award. In reviewing the applicant files, you find that one file from a perinatal clinical
specialist contains many overstatements and several misrepresentations. You know for a fact
that this clinician did not accomplish all that she has listed, because she is a friend and close
colleague. She did not, however, know that you would be a member of this committee and thus
would be aware of this deception.
When the entire committee met, several members commented on this clinician’s impressive
file. Although you were able to dissuade them covertly from further considering her nomination,
you are left with many uneasy feelings and some anger and sadness. You recognize that she
did not receive the nomination and thus there is little real danger regarding the deceptions in
the file being used inappropriately at this time. However, you will not be on this committee next
year, and if she were to submit an erroneous file again, she could be highly considered for the
award. You also recognize that even with the best of intentions and the most therapeutic of
communication techniques, confronting your friend with her deception will cause her to lose
face and will probably result in an unsalvageable friendship. Even if you do confront her, there
is little you can do to stop her from doing the same in future nomination processes other than
formally reporting her conduct.
Assignment: Determine what you will do. Do the potential costs outweigh the potential
benefits? Be realistic about your actions.
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92 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
LEARNING EXERCISE 4.9
The Valuable Employee
Gina has been the supervisor of a 16-bed intensive care unit/critical care unit (ICU/CCU) in a
200-bed urban hospital for 8 years. She is respected and well liked by her staff. Her unit’s staff
retention level and productivity are higher than any other unit in the hospital. For the last 6 years,
Gina has relied heavily on Mark, her permanent charge nurse on the day shift. He is bright and
motivated and has excellent clinical and managerial skills. Mark seems satisfied and challenged
in his current position, although Gina has not had any formal career planning meetings with
him to discuss his long-term career goals. It would be fair to say that Mark’s work has greatly
increased Gina’s scope of power and has enhanced the reputation of the unit.
Recently, one of the physicians approached Gina about a plan to open an outpatient cardiac
rehabilitation program. The program will require a strong leader and manager who is self-
motivated. It will be a lot of work but also provides many opportunities for advancement. He
suggests that Mark would be an excellent choice for the job, although he has given Gina full
authority to make the final decision.
Gina is aware that Lynn, a bright and dynamic staff nurse from the open-heart surgery floor, also
would be very interested in the job. Lynn has been employed at the hospital for only 1 year but
has a proven track record and would probably be very successful in the job. In addition, there is
a staffing surplus right now on the open-heart surgery floor because two of the surgeons have
recently retired. It would be difficult and time-consuming to replace Mark as charge nurse in
the ICU/CCU.
Assignment: What process should this supervisor pursue to determine who should be hired
for the position? Should the position be posted? When does the benefit of using transfers/
promotions as a means of reward outweigh the cost of reduced productivity?
LEARNING EXERCISE 4.10
To See or Not to See
For the last few days, you have been taking care of Mr. Cole, a 28-year-old patient with end-
stage cystic fibrosis. You have developed a caring relationship with Mr. Cole and his wife. They
are both aware of the prognosis of his disease and realize that he has only a short time left to live.
When Dr. Jones made rounds with you this morning, she told the Coles that Mr. Cole could
be discharged today if his condition remains stable. They were both excited about the news
because they had been urging the doctor to let him go home to enjoy his remaining time
surrounded by things he loves.
When you bring in Mr. Cole’s discharge orders to his room in order to review his medications and
other treatments, you find Mrs. Cole assisting Mr. Cole as he coughs up bright red blood. When you
confront them, they both beg you not to tell the doctor or chart the incident because this is the first
time this has happened. They believe that it is their right to go home and let Mr. Cole die surrounded
by his family. They said that they know that they can leave against their physician’s wishes and go
home AMA (against medical advice), but if they do, their insurance will not pay for home care.
Assignment: What is your duty in this case? What are Mr. Cole’s rights? Is it ever justified to
withhold information from the physician? Will you chart the incident and will you report it to
anyone? Solve this case, justifying your decision by using ethical principles.

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Chapter 4 Ethical Issues 93
REFERENCES
Alichnie, C. (2012). Ethics and nursing. Pennsylvania Nurse,
67(2), 5–26.
American Nurses Association. (2001). Code of ethics for
nurses with interpretive statements. Washington, DC:
American Nurses Publishing.
American Nurses Association. (2009). Nursing
administration: Scope and standards of
practice. Silver Springs, MD: American Nurses
Publishing.
Bitoun Blecher, M. (2001–2013). What color is your
whistle? Minoritynurse.com. Retrieved February
24, 2013, from http://www.minoritynurse.com/
workplace-issues/what-color-your-whistle
Crisham, P. (1985). MORAL: How can I do what is right?
Nursing Management, 16(3), 42A–42N.
Davis, S., Schrader, V., & Belcheir, M. (2012). Influencers
of ethical beliefs and the impact on moral distress
and conscientious objection. Nursing Ethics, 19(6),
738–749.
Gallagher, A., & Hodge, S. (Eds.) (2012). Ethics, law and
professional issues: A practice-based approach
for health professionals. Basingstoke: Palgrave
MacMillan.
Grob, C., Leng, J., & Gallagher, A. (2012). Educational
responses to unethical healthcare practice. Nursing
Standard, 26(41), 35–41.
Kearney, G., & Penque, S. (2012). Ethics of everyday
decision making. Nursing Management – UK, 19(1),
32–36.
Mortell, M. (2012). Hand hygiene compliance: Is there
a theory-practice-ethics gap? British Journal of
Nursing, 21(17), 1011–1014.
Nalley, C. (2013, February 8). Moral distress takes toll on
nurses. Advance for nurses. Retrieved February 25,
2013, from http://nursing.advanceweb.com/Features/
Articles/Moral-Distress-Takes-Toll-on-Nurses.aspx
Pauly, B. M., Varcoe, C., & Storch, J. (2012, March).
Framing the issues. Moral distress in health care.
HEC Forum, 24(1), 1–11.
Silén, M., Kjellström, S., Christensson, L., Sidenvall, B.,
& Svantesson, M. (2012). What actions promote a
positive ethical climate? A critical incident study of
nurses’ perceptions. Nursing Ethics, 19(4), 501–512.
Sorbello, B. (2008, December). The nurse administrator as
caring person: A synoptic analysis applying caring
philosophy, Ray’s ethical theory of existential
authenticity, the ethic of justice, and the ethic of care.
International Journal for Human Caring,
12(1), 44–49.
Woods, M. (2012). Exploring the relevance of social justice
within a relational nursing ethic. Nursing Philosophy,
13(1), 56–65.
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94
Legal and Legislative Issues
… It may seem a strange principle to enunciate as the very first requirement in a hospital that it
should do the sick no harm.
—Florence Nightingale
… Laws or ordinances unobserved, or partially attended to, had better never have been made.
—George Washington, letter to James Madison, March 31, 1787
CROSSWALK this chapter addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential V: health-care policy, finance, and regulatory environments
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential VI: health policy and advocacy
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency V: Business skills
QSEN Competency: safety
LEARNING OBJECTIVES The learner will:
l correlate the legal authority of nursing practice and the nursing process
l select appropriate legal nursing actions in sensitive clinical situations
l explain how increased consumer awareness of patient rights has affected the actions of the
health-care team
l evaluate the significance of professional and institutional licensure
l describe appropriate methods of ensuring informed consent
l analyze the impact of civil law on nursing practice
l differentiate between legal and ethical accountability
5
Chapter 4 presented ethics as an internal control of human behavior and nursing practice.
Therefore, ethics has to do with actions that people should take, not necessarily actions that
they are legally required to take. On the other hand, ethical behavior written into law is no
longer just desired, it is mandated. This chapter focuses on the external controls of legislation
and law. Since the first mandatory Nurse Practice Act was passed in North Carolina in 1903,
nursing has been legislated, directed, and controlled to some extent.
The primary purpose of law and legislation is to protect the patient and the nurse. Laws
and legislation define the scope of acceptable practice and protect individual rights. Nurses
who are aware of their rights and duties in legal matters are better able to protect themselves
against liability or loss of professional licensure.
This chapter has five sections. The first section presents the primary sources of law and
how each affects nursing practice. The nurse’s responsibility to be proactive in establishing

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Chapter 5 Legal and Legislative Issues 95
and revising laws affecting nursing practice is emphasized. The second section presents the
types of legal cases in which nurses may be involved and differentiates between the burden
of proof and the consequences for each if the nurse is found to have broken the law. The third
section identifies specific doctrines used by the courts to define legal boundaries for nursing
practice. The role of state boards in professional licensure and discipline is examined. The fourth
section deals with the components of malpractice for the individual practitioner and the manager
or supervisor. Legal terms are defined. The fifth and final section discusses issues such as
informed consent, medical records, intentional torts, the Patient Self-Determination Act (PSDA),
the Good Samaritan Act, and the Health Insurance Portability and Accountability Act (HIPAA).
This chapter is not meant to be a complete legal guide to nursing practice. There are many
excellent legal textbooks and handbooks that accomplish that function. The primary function
of this chapter is to emphasize the widely varying and rapidly changing nature of laws and
the responsibility that each manager has to keep abreast of legislation and laws affecting both
nursing and management practice. Leadership roles and management functions inherent in
legal and legislative issues are shown in Display 5.1.
DISpLAy 5.1 Leadership Roles and Management Functions Associated with Legal
and Legislative Issues
LEADERSHIP ROLES
1. serves as a role model by providing nursing care that meets or exceeds accepted standards of care.
2. Updates knowledge and skills in the field of practice and seeks professional certification to
increase expertise in a specific field.
3. reports substandard nursing care to appropriate authorities following the established chain of
command.
4. Fosters nurse–patient relationships that are respectful, caring, and honest, thus reducing the
possibility of future lawsuits.
5. creates an environment that encourages and supports diversity and sensitivity.
6. prioritizes patient rights and patient welfare in decision making.
7. demonstrates vision, risk taking, and energy in determining appropriate legal boundaries for
nursing practice, thus defining what nursing is and what should be in the future.
MANAGEMENT FUNCTIONS
1. increases knowledge regarding sources of law and legal doctrines that affect nursing practice.
2. delegates to subordinates wisely, looking at the manager’s scope of practice and that of the
individuals he or she supervises.
3. Understands and adheres to institutional policies and procedures.
4. Minimizes the risk of product liability by assuring that all staff are appropriately oriented to the
appropriate use of equipment and products.
5. Monitors subordinates to ensure they have a valid, current, and appropriate license to practice
nursing.
6. Uses foreseeability of harm in delegation and staffing decisions.
7. increases staff awareness of intentional torts and assists them in developing strategies to reduce
their liability in these areas.
8. provides educational and training opportunities for staff on legal issues affecting nursing practice.
SOURCES OF LAW
The US legal system can be somewhat confusing because there are not only four sources of the law
but also parallel systems at the state and federal levels. The sources of law include constitutions,
statutes, administrative agencies, and court decisions. A comparison is shown in Table 5.1.
A constitution is a system of fundamental laws or principles that govern a nation, society,
corporation, or other aggregate of individuals. The purpose of a constitution is to establish the
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96 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
basis of a governing system for the future and the present. The U.S. Constitution establishes
the general organization of the federal government and grants and limits its specific powers.
Each state also has a constitution that establishes the general organization of the state
government and grants and limits its powers.
The second source of law is statutes—laws that govern. Legislative bodies, such as the
U.S. Congress, state legislatures, and city councils, make these laws. Statutes are officially
enacted (voted on and passed) by the legislative body and are compiled into codes, collections
of statutes, and ordinances. The 51 Nurse Practice Acts representing the 50 states and the
District of Columbia are examples of statutes. These Nurse Practice Acts define and limit
the practice of nursing, thereby stating what constitutes authorized practice as well as what
exceeds the scope of authority. Although Nurse Practice Acts may vary among states, all must
be consistent with provisions or statutes established at the federal level.
The 51 Nurse Practice Acts (one for each state and the District of Columbia) define and limit the
practice of nursing, thereby stating what constitutes authorized practice as well as what exceeds
the scope of authority.
Administrative agencies, the third source of law, are given authority to act by the legislative
bodies and create rules and regulations that enforce statutory laws. For example, State Boards
of Nursing are administrative agencies set up to implement and enforce the state Nurse
Practice Act by writing rules and regulations and by conducting investigations and hearings
to ensure the law’s enforcement. Administrative laws are valid only to the extent that they are
within the scope of the authority granted to them by the legislative body.
The fourth source of law is court decisions. Judicial or decisional laws are made by the
courts to interpret legal issues that are in dispute. Depending on the type of court involved,
judicial or decisional law may be made by a single justice, with or without a jury, or by a
panel of justices. Generally, initial trial courts have a single judge or magistrate, intermediary
appeal courts have three justices, and the highest appeal courts have nine justices.
TypES OF LAWS AND COURTS
Although most nurses worry primarily about being sued for malpractice, they may actually be
involved in three different types of court cases: criminal, civil, and administrative (Table 5.2).
The court in which each is tried, the burden of proof required for conviction, and the resulting
punishment associated with each is different.
TABLE 5.1 Sources of Law
Origin of Law Use Involvement with Nursing Practice
the
constitution
the highest law in the United states; interpreted
by the U.s. supreme court; gives authority to
other three sources of the law
Little direct involvement in the area of
malpractice
statutes also called statutory law or legislative law; laws
that are passed by the state or federal legislators
and that must be signed by the president or
governor
Before 1970s, very few state or federal
laws dealt with malpractice. since the
malpractice crisis, many statutes affect
malpractice
administrative
agencies
the rules and regulations established by
appointed agencies of the executive branch of
the government (governor or president)
some of these agencies, such as the
National Labor relations Board and
health and safety boards, can affect
nursing practice
court
decisions
also called tort law; this is court mode law
and the courts interpret the statutes and set
precedents; in the United states, there are two
levels of court: trial court and appellate court
Most malpractice law is addressed by the
courts

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Chapter 5 Legal and Legislative Issues 97
In criminal cases, the individual faces charges generally filed by the state or federal
attorney general for crimes committed against an individual or society. In criminal cases,
the individual is always presumed to be innocent unless the state can prove his or her guilt
beyond a reasonable doubt. Incarceration and even death are possible consequences for being
found guilty in criminal matters. Nurses found guilty of intentionally administering fatal
doses of drugs to patients would be charged in a criminal court.
In civil cases, one individual sues another for money to compensate for a perceived loss.
The burden of proof required to be found guilty in a civil case is described as a preponderance
of the evidence. In other words, the judge or jury must believe that it was more likely
than not that the accused individual was responsible for the injuries of the complainant.
Consequences of being found guilty in a civil suit are monetary. Most malpractice cases are
tried in civil court.
In administrative cases, an individual is sued by a state or federal governmental agency
assigned the responsibility of implementing governmental programs. State Boards of
Nursing are one such governmental agency. When an individual violates the state Nurse
Practice Act, the Boards of Nursing may seek to revoke licensure or institute some form of
discipline. The burden of proof in these cases varies from state to state. When the clear and
convincing standard is not used, the preponderance of the evidence standard may be used.
Clear and convincing involves higher burdens of proof than preponderance of evidence but
significantly lower burdens of proof than beyond a reasonable doubt.
The burden of proof required for conviction as well as the type of punishment given differs in
criminal, civil, and administrative cases.
TABLE 5.2 Types of Laws and Courts
Type Burden of Proof Required for Guilty Verdict Likely Consequences of a Guilty
Verdict
criminal Beyond a reasonable doubt incarceration, probation, and fines
civil Based on a preponderance of the evidence Monetary damages
administrative clear and convincing standard suspension or loss of licensure
LEARNING EXERCISE 5.1
Both Guilty and Not Guilty
think of celebrated cases where defendants have been tried in both civil and criminal courts.
What were the verdicts in both cases? if the verdicts were not the same, analyze why this
happened. do you agree that taking away an individual’s personal liberty by incarceration should
require a higher burden of proof than assessing for monetary damages?
Assignment: also complete a literature search to see if you can find cases where a nurse faced
both civil and administrative charges. Were you able to find cases where the nurse was found
guilty in a civil court but did not lose his or her license? did you find the opposite?
LEGAL DOCTRINES AND THE pRACTICE OF NURSING
Two important legal doctrines frequently guide all three courts in their decision making. The
first of these, stare decisis, means to let the decision stand. Stare decisis uses precedents as
a guide for decision making. This doctrine gives nurses insight into ways that the court has
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98 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
previously fixed liability in given situations. However, the nurse must avoid two pitfalls in
determining if stare decisis should apply to a given situation.
Precedent is often used as a guide for legal decision making.
The first is that the previous case must be within the jurisdiction of the court hearing the
current case. For example, a previous Florida case decided by a state court does not set
precedent for a Texas appellate court. Although the Texas court may model its decision after
the Florida case, it is not compelled to do so. The lower courts in Texas, however, would rely
on Texas appellate decisions.
The other pitfall is that the court hearing the current case can depart from the precedent
and set a landmark decision. Landmark decisions generally occur because societal needs have
changed, technology has become more advanced, or following the precedent would further
harm an already injured person. Roe versus Wade, the 1973 landmark decision to allow a
woman to seek and receive a legal abortion during the first two trimesters of pregnancy, is
an example. Given the influence of politics and varying societal views about abortion, this
precedent may change again in the future.
The second doctrine that guides courts in their decision making is res judicata, which
means a “thing or matter settled by judgment.” It applies only when a competent court has
decided a legal dispute and when no further appeals are possible. This doctrine keeps the
same parties in the original lawsuit from retrying the same issues that were involved in the
first lawsuit.
When using doctrines as a guide for nursing practice, the nurse must remember that all
laws are fluid and subject to change. An example of changing law regarding professional
nursing occurred in an Illinois Supreme Court case just over a decade ago when the law
finally recognized nursing as an independent profession with its own unique body of
knowledge. In this case (Sullivan versus Edward Hospital, 2004), the Illinois Supreme Court
decided that physicians could not serve as expert witnesses regarding nursing standards (Find
Law for Legal Professionals, 2013). This demonstrates how the law is ever evolving. Laws
cannot be static; they must change to reflect the growing autonomy and responsibility desired
by nurses. It is critical that all nurses be aware of and sensitive to rapidly changing laws and
legislation that affect their practice. Nurses must also recognize that state laws may differ
from federal laws and that legal guidelines for nursing practice in the organization may differ
from state or federal guidelines.
Boundaries for practice are defined in the Nurse Practice Act of each state. These
acts are general in most states to allow for some flexibility in the broad roles and varied
situations in which nurses practice. Because this allows for some interpretation, many
employers have established guidelines for nursing practice in their own organization. These
guidelines regarding scope of practice cannot, however, exceed the requirements of the state
Nursing Practice Acts. Managers need to be aware of their organization’s specific practice
interpretations and ensure that subordinates are aware of the same and follow established
practices. All nurses must understand the legal controls for nursing practice in their state.
pROFESSIONAL NEGLIGENCE
Historically, physicians were the health-care providers most likely to be held liable for
nursing care. As nurses have gained authority, autonomy, and accountability, they have
assumed responsibility, accountability, and liability for their own practice. As roles have
expanded, nurses have begun performing duties traditionally reserved for medical practice.
As a result of an increased scope of practice, many nurses now carry individual malpractice
insurance. This is a double-edged sword. Nurses need malpractice insurance in basic practice

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Chapter 5 Legal and Legislative Issues 99
as well as in expanded practice roles. They do incur a greater likelihood of being sued,
however, if they have malpractice insurance, since injured parties will always seek damages
from as many individuals with financial resources as possible.
In addition, some nurses count on their employer-provided professional liability policies to
protect them from malpractice claims, but such policies often have limitations. For example,
employers may not provide coverage once an employee has terminated their employment,
even if the situation which led to the complaint occurred while the nurse was employed there
and some employer-provided policies have inadequate limits of liability for the individual
employee. Nurses then are advised to obtain their own personal liability policy.
Unfortunately, both the enhanced role of nurses and the increase in the number of insured
nurses have led to a great increase in the number of liability suits seeking damages from
nurses as individuals over the past few decades. In particular, malpractice has become of great
concern to advanced practice nurses such as nurse practitioners and nurse midwives. Nurse
practitioners are not only paying high costs for their insurance premiums, they generally are
subject to strict professional liability (malpractice) insurance requirements.
Elements of Malpractice
All liability suits involve a plaintiff and a defendant. In malpractice cases, the plaintiff is
the injured party and the defendant is the professional who is alleged to have caused the
injury. Negligence is the omission to do something that a reasonable person, guided by the
considerations that ordinarily regulate human affairs, would do—or as doing something that
a reasonable and prudent person would not do. Reasonable and prudent generally means
the average judgment, foresight, intelligence, and skill that would be expected of a person
with similar training and experience. Malpractice—the failure of a person with professional
training to act in a reasonable and prudent manner—also is called professional negligence.
Five elements must be present for a professional to be held liable for malpractice (Table 5.3).
First, a standard of care must have been established that outlines the level or degree of
quality considered adequate by a given profession. Standards of care outline the duties a
defendant has to a plaintiff or a nurse to a client. These standards represent the skills and
learning commonly possessed by members of the profession and generally are the minimal
requirements that define an acceptable level of care. Standards of care, which guarantee
clients safe nursing care, include organizational policy and procedure statements, job
descriptions, and student guidelines.
TABLE 5.3 Components of Professional Negligence
Elements of Liability Explanation Example: Giving Medications
1. duty to use due care
(defined by the
standard of care)
the care that should be given under the
circumstances (what the reasonably
prudent nurse would have done)
a nurse should give medications
accurately, completely, and on time
2. Failure to meet standard
of care (breach of duty)
Not giving the care that should be given
under the circumstances
a nurse fails to give medications
accurately, completely, or on time
3. Foreseeability of harm the nurse must have reasonable access
to information about whether the
possibility of harm exists
the drug handbook specifies that the
wrong dosage or route may cause injury
4. a direct relationship
between failure to meet
the standard of care
(breach) and injury
can be proved
patient is harmed because proper care
is not given
Wrong dosage causes the patient to
have a convulsion
5. injury actual harm results to the patient convulsion or other serious complication
occurs
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100 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
Second, after the standard of care has been established, it must be shown that the standard
was violated—there must have been a breach of duty. This breach is shown by calling other
nurses who practice in the same specialty area as the defendant to testify as expert witnesses.
Third, the nurse must have had the knowledge or availability of information that not meeting
the standard of care could result in harm. This is called foreseeability of harm. If the average,
reasonable person in the defendant’s position could have anticipated the plaintiff’s injury as
a result of his or her actions, then the plaintiff’s injury was foreseeable. Ignorance is not an
excuse, but lack of information may have a negative effect on the ability to foresee harm.
Being ignorant is not a justifiable excuse, but not having all the information in a situation may
impede one’s ability to foresee harm.
For example, a charge nurse assigns another registered nurse (RN) to care for a critically ill
patient. The assigned RN makes a medication error that injures the patient in some way. If
the charge nurse had reason to believe that the RN was incapable of adequately caring for the
patient or failed to provide adequate supervision, foreseeability of harm is apparent, and the
charge nurse also could be held liable. If the charge nurse was available as needed and had good
reason to believe that the RN was fully capable, he or she would probably not be held liable.
A number of malpractice cases have hinged on whether the nurse was persistent enough in
attempting to notify health-care providers of changes in a patient’s conditions or to convince
the providers of the seriousness of a patient’s condition. Because the nurse has foreseeability of
harm in these situations, the nurse who is not persistent can be held liable for failure to intervene
because the intervention was below what was expected of him or her as a patient advocate.
The fourth element is that failure to meet the standard of care must have the potential to
injure the patient. There must be a provable correlation between improper care and injury to
the patient.
The final element is that actual patient injury must occur. This injury must be more than
transitory. The plaintiff must show that the action of the defendant directly caused the injury
and that the injury would not have occurred without the defendant’s actions. It is important
to remember here, however, that not taking action is an action.
LEARNING EXERCISE 5.2
Who Is Responsible for Harm to This Patient? You Decide
You are a surgical nurse at Memorial hospital. at 4 pm, you receive a patient from the recovery
room who has had a total hip replacement. You note that the hip dressings are saturated with
blood but are aware that total hip replacements frequently have some postoperative oozing from
the wound. there is an order on the chart to reinforce the dressing as needed, and you do so.
When you next check the dressing at 6 pm, you find the reinforcements saturated and drainage
on the bed linen. You call the physician and tell her that you believe the patient is bleeding
too heavily. the physician reassures you that the amount of bleeding you have described is
not excessive but encourages you to continue to monitor the patient closely. You recheck the
patient’s dressings at 7 and 8 pm. You again call the physician and tell her that the bleeding still
looks too heavy. she again reassures you and tells you to continue to watch the patient closely.
at 10 pm, the patient’s blood pressure becomes nonpalpable, and she goes into shock. You
summon the doctor, and she comes immediately.
Assignment: What are the legal ramifications of this case? Using the components of
professional negligence outlined in table 5.3, determine who in this case is guilty of malpractice.
Justify your answer. at what point in the scenario should each character have altered his or her
actions to reduce the probability of a negative outcome?

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Chapter 5 Legal and Legislative Issues 101
AVOIDING MALpRACTICE CLAIMS
Interactions between nurses and clients that are less businesslike and more personal are more
satisfying to both. It has been shown that despite technical competence, nurses who have
difficulty establishing positive interpersonal relationships with patients and their families
are at greater risk for being sued. Communication that proceeds in a caring and professional
manner has been shown repeatedly to be a major reason that people do not sue, despite
adequate grounds for a successful lawsuit.
In addition, many experts have suggested a need to create safer environments for care so
that less patients are injured during the course of their care. This has especially been true since
the 1999 release of To Err Is Human by the Institute of Medicine (IOM), a congressionally
chartered independent organization. The IOM report indicated that errors are simply a part
of the human condition and that the health-care system itself needs to be redesigned so that
fewer errors can occur. For example, even though there are unit-dose systems in play, nurse-
leaders often look the other way when staff dump all the medications into a soufflé cup and
hand them to patients, thus increasing the possibility of medication errors.
Strategies recommended by the Joint Commission, in its 2005 seminal report, Healthcare in the
Crossroads, can be viewed in Display 5.2. The three major areas of focus in the call to action are
to prevent injuries, improve communication, and examine mechanisms for injury compensation.
Nurses then can reduce the risk of malpractice claims by taking the following actions:
• Practice within the scope of the Nurse Practice Act.
• Observe agency policies and procedures.
• Model practice after established standards by using evidence-based practice.
• Always put patient rights and welfare first.
• Be aware of relevant law and legal doctrines and combine such with the biological,
psychological, and social sciences that form the basis of all rational nursing decisions.
• Practice within the area of individual competence.
• Upgrade technical skills consistently by attending continuing education programs and
seeking specialty certification.
Nurses should also purchase their own liability insurance and understand the limits of their
policies. Although this will not prevent a malpractice suit, it should help protect a nurse from
financial ruin should there be a malpractice claim.
LEARNING EXERCISE 5.3
Discussing Lawsuits and Liability
in small groups, discuss the following questions:
1. do you believe that there are unnecessary lawsuits in the health-care industry? What criteria
can be used to distinguish between appropriate and unnecessary lawsuits?
2. have you ever advised a friend or family member to sue to recover damages that you believed
they suffered as a result of poor-quality health care? What motivated you to encourage them
to do so?
3. do you think that you will make clinical errors in judgment as a nurse? if so, what types of
errors should be considered acceptable (if any), and what types are not acceptable?
4. do you believe that the recent national spotlight on medical error identification and prevention
will encourage the reporting of medical errors when they do occur?
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102 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
EXTENDING THE LIABILITy
In recent years, the concept of joint liability, in which the nurse, physician, and
employing organization are all held liable, has become the current position of the legal
system. This probably more accurately reflects the higher level of accountability now
present in the nursing profession. Before 1965, nurses were rarely held accountable for
their own acts, and hospitals were usually exempt due to charitable immunity. However,
following precedent-setting cases in the 1960s, employers are now held liable for the
nurse’s acts under a concept known as vicarious liability. One form of vicarious liability
is called respondeat superior, which means “the master is responsible for the acts of
his servants.” The theory behind the doctrine is that an employer should be held legally
liable for the conduct of employees whose actions he or she has a right to direct or
control.
1. Pursue patient safety initiatives that prevent medical injury by:
l strengthening oversight and accountability mechanisms to better ensure the competencies
of physicians and nurses
l encouraging appropriate adherence to clinical guidelines to improve quality and reduce
liability risk
l supporting team development through team training
l continuing to leverage patient safety initiatives through regulatory and oversight bodies
l Building an evidence-based information and technology system that impacts patient safety
and pursue proposals to offset implementation costs
l promoting the creation of cultures of patient safety in health-care organizations
l establishing a federal leadership locus for advocacy of patient safety and health-care quality
l pursuing “pay-for-performance” strategies that provide incentives to improve patient safety
and health-care quality
2. Promote open communication between patients and practitioners by:
l involving health-care consumers as active members of the health-care team
l encouraging open communication between practitioners and patients when adverse events
occur
l pursuing legislation that protects disclosure and apology from being used as evidence
against practitioners in litigation
l encouraging nonpunitive reporting of errors to third parties that promote information and data
analysis as a basis for developing safety improvement
l enacting federal safety legislation that provides legal protection for when information is
reported to patient safety organizations
3. Create an injury compensation system that is patient centered and serves the common good by:
l conducting demonstration projects of alternatives to medical liability that promote patient
safety and transparency and provide swift compensation for injured patients
l encouraging continued development of mediation and early-offer initiatives
l prohibiting confidential settlements that prevent learning from events
l redesigning the National practitioner data Bank
l advocating for court-appointed, independent expert witnesses to mitigate bias in expert wit-
ness testimony
Source: Joint Commission on Accreditation of Healthcare Organizations. (2005). health care in the crossroads: strat-
egies for improving the medical liability system and preventing patient injury. Oakbrook Terrace, IL: Author.
DISpLAy 5.2 Summary of Recommendations from the Executive Summary of “Healthcare
in the Crossroads: Strategies for Improving the Medical Liability System and
Preventing Injury”

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Chapter 5 Legal and Legislative Issues 103
The difficulty in interpreting respondeat superior is that many exceptions exist. The first
and most important exception is related to the state in which the nurse practices. In some
states, the doctrine of charitable immunity applies, which holds that a charitable (nonprofit)
hospital cannot be sued by a person who has been injured as a result of a hospital employee’s
negligence. Thus, liability is limited to the employee.
Another exception to respondeat superior occurs when the state or federal government
employs the nurse. The common-law rule of governmental immunity provides that
governments cannot be held liable for the negligent acts of their employees while carrying out
government activities. Some states have changed this rule by statute, however, and in these
particular jurisdictions, respondeat superior continues to apply to the acts of nurses employed
by the state government.
Nurses must remember that the purpose of respondeat superior is not to shift the burden
of blame from the employee to the organization but rather to share the blame, increasing the
possibility of larger financial compensation to the injured party. Some nurses erroneously
assume that they do not need to carry malpractice insurance because their employer will in
all probability be sued as well and thus will be responsible for financial damages. Under the
doctrine of respondeat superior, any employer required to pay damages to an injured person
because of an employee’s negligence may have the legal right to recover or be reimbursed
that amount from the negligent employee.
One rule that all nurses must know and understand is that of personal liability, which says
that every person is liable for his or her own conduct. The law does not permit a wrongdoer
to avoid legal liability for his or her own wrongdoing, even though someone else also may be
sued and held legally liable. For example, if a manager directs a subordinate to do something
that both know to be improper, the injured party can recover damages against the subordinate
even if the supervisor agreed to accept full responsibility for the delegation at the time. In the
end, each nurse is always held liable for his or her own negligent practice.
Managers are not automatically held liable for all acts of negligence on the part of those
they supervise, but they may be held liable if they were negligent in the supervision of
those employees at the time that they committed the negligent acts. Liability for negligence
is generally based on the manager’s failure to determine which of the patient needs can be
assigned safely to a subordinate or the failure to supervise a subordinate adequately for the
assigned task (Huston, 2014a). Both the abilities of the staff member and the complexity of
the task assigned must be considered when determining the type and amount of direction and
supervision warranted.
Hospitals have also been found liable for assigning personnel who were unqualified to
perform duties as shown by their evaluation reports. Managers, therefore, need to be cognizant
of their responsibilities in assigning and appointing personnel because they could be found
liable for ignoring organizational policies or for assigning employees duties that they are not
capable of performing. In such cases, though, the employee must provide the supervisor with
the information that he or she is not qualified for the assignment. The manager does have the
right to reassign employees as long as they are capable of discharging the anticipated duties
of the assignment.
In addition, there has been a push to have more in-depth background checks when health-
care employees are hired, with some states already mandating such checks. For example,
California, as of 2009, determined that it would no longer issue temporary or permanent
licenses to nurses without a criminal background check. Indeed, many states are now
requiring a criminal background check on all license renewals, and federal legislation has
recently been introduced along these lines.
At present, except in a few states, personnel directors in hospitals (those making hiring
decisions) are required to request information from the National Practitioner Data Bank for
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104 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
those individuals who seek clinical privileges, and many states now require nursing students
to be fingerprinted before they are allowed to work with vulnerable populations. In the future,
hiring someone without an adequate background check, who later commits a crime involving
a patient, could be another area of liability for the manager. This is an example of the type
of pending legislation with which a manager must keep abreast so that if it becomes law, its
impact on future management practices will be minimized.
LEARNING EXERCISE 5.4
Understanding Limitations and Rules
have you ever been directed in your nursing practice to do something that you believed might
be unsafe or that you felt inadequately trained or prepared to do? What did you do? Would
you act differently if the situation occurred now? What risks are inherent in refusing to follow
the direct orders of a physician or superior? What are the risks of performing a task that you
believe may be unsafe?
INCIDENT REpORTS
Incident reports or adverse event forms are records of unusual or unexpected incidents that
occur in the course of a client’s treatment. Because attorneys use incident reports to defend
the health agency against lawsuits brought by clients, the reports are generally considered
confidential communications and cannot be subpoenaed by clients or used as evidence in
their lawsuits in most states. (Be sure, however, that you know the law for the state in which
you live, as this does vary.) However, incident reports that are inadvertently disclosed to the
plaintiff are no longer considered confidential and can be subpoenaed in court. Thus, a copy
of an incident report should not be left in the chart. In addition, no entry should be made in
the patient’s record about the existence of an incident report. The chart should, however,
provide enough information about the incident or occurrence so that appropriate treatment
can be given.
INTENTIONAL TORTS
Torts are legal wrongs committed against a person or property, independent of a contract,
that render the person who commits them liable for damages in a civil action. Whereas
professional negligence is considered to be an unintentional tort, assault, battery, false
imprisonment, invasion of privacy, defamation, and slander are intentional torts. Intentional
torts are a direct invasion of someone’s legal rights. Managers are responsible for seeing
that staff members are aware of and adhere to laws governing intentional torts. In addition,
the manager must clearly delineate policies and procedures about these issues in the work
environment.
Nurses can be sued for assault and battery. Assault is conduct that makes a person fearful
and produces a reasonable apprehension of harm. Essentially then, assault is “threatening a
person, with the present ability to carry out the threat” (Frederick, 2012, para 1). Battery is
an intentional and wrongful physical contact with a person that entails an injury or offensive
touching. “If there was a threat but no physical contact, the charge is simple assault. When
there is a physical injury, no matter how slight, the charge is simple assault and battery”
(Frederick, 2012, para 1).

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Chapter 5 Legal and Legislative Issues 105
Unit managers must be alert to patient complaints of being handled in a rough manner
or complaints of excessive force in restraining patients. In fact, performing any treatment
without patient’s permission or without receiving an informed consent might constitute
both assault and battery. In addition, many battery suits have been won based on the use of
restraints when dealing with confused patients.
The use of physical restraints also has led to claims of false imprisonment. False
imprisonment is the restraint of a person’s liberty of movement by another party who lacks
the legal authority or justification to do so (Criminal Law Lawyers Source, 2003–2013).
Practitioners are liable for false imprisonment when they unlawfully restrain the movement
of their patients. Physical restraints should be applied only with a physician’s direct order.
Likewise, the patient who wishes to sign out against medical advice should not be held
against his or her will. This tort also is frequently applicable to involuntary commitments to
mental health facilities. Managers in mental health settings must be careful to institutionalize
patients in accordance with all laws governing commitment.
Another intentional tort is defamation. Defamation is communicating to a third party, false
information that injures a person’s reputation. When defamation is written, it is called libel.
When it is spoken, it is called slander.
OTHER LEGAL RESpONSIBILITIES OF THE MANAGER
Managers also have some legal responsibility for the quality control of nursing practice at
the unit level, including such duties as reporting dangerous understaffing, checking staff
credentials and qualifications, and carrying out appropriate discipline. Health-care facilities
may also be held responsible for seeing that staff know how to operate equipment safely.
Sources of liability for managers vary from facility to facility and from position to position.
For example, standards of care as depicted in policies and procedures may pose a liability
for the nurse if such policies and procedures are not followed. The chain of command in
reporting inadequate care by a physician is another area in which management liability may
occur if employees are not taught proper protocols. Managers have a responsibility to see
that written protocols, policies, and procedures are followed in order to reduce liability. In
addition, the manager, like all professional nurses, is responsible for reporting improper or
substandard medical care, child and elder abuse, and communicable diseases, as specified by
the Centers for Disease Control and Prevention.
Individual nurses also may be held liable for product liability. When a product is
involved, negligence does not have to be proved. This strict liability is a somewhat gray
area of nursing practice. Essentially, strict liability holds that a product may be held to a
higher level of liability than a person. In other words, if it can be proved that the equipment
or product had a defect that caused an injury, then it would be debated in court by using all
the elements essential for negligence, such as duty and breach. Therefore, equipment and
other products fall within the scope of nursing responsibility. In general, if they are aware
that equipment is faulty, nurses have a duty to refuse to use the equipment. If the fault in
the equipment is not readily apparent, risks are low that the nurse will be found liable for
the results of its use.
Informed Consent
Many nurses erroneously believe that they have obtained informed consent when they
witness a patient’s signature on a consent form for surgery or procedure. Strictly speaking,
informed consent (Display 5.3) can be given only after the patient has received a complete
explanation of the surgery, procedure, or treatment and indicates that he or she understands
the risks and benefits related to it.
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106 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
Informed consent is obtained only after the patient receives full disclosure of all pertinent
information regarding the surgery or procedure and only if the patient understands the potential
benefits and risks associated with doing so.
The information must be in a language that the patient can understand and should be
conveyed by the individual who will be performing the procedure. Patients must be invited
to ask questions and have a clear understanding of the options as well.
Only a competent adult can legally sign the form that shows informed consent. To be
considered competent, patients must be capable of understanding the nature and consequences
of the decision and of communicating their decision. Spouses or other family members cannot
legally sign unless there is an approved guardianship or conservatorship or unless they hold a
durable power of attorney for health care. If the patient is younger than 16 years (18 in some
states), a parent or guardian must generally give consent.
In an emergency, the physician can invoke implied consent, in which the physician states
in the progress notes of the medical record that the patient is unable to sign but that treatment
is immediately needed and is in the patient’s best interest. Usually, this type of implied
consent must be validated by another physician.
Nurses frequently seek express consent from patients by witnessing patients sign a
standard consent form. In express consent, the role of the nurse is to be sure that the patient
has received informed consent and to seek remedy if he or she has not.
Informed consent does pose ethical issues for nurses. Although nurses are obligated
to provide teaching and to clarify information given to patients by their physicians,
nurses must be careful not to give new information that contradicts information given
by the physician, thus interfering in the physician–patient relationship. The nurse is
not responsible for explaining the procedure to be performed. The role, rather, is to
be a patient advocate by determining their level of understanding and seeing that the
appropriate person answers their questions. At times, this can be a cloudy issue both
legally and ethically.
Informed Consent for Clinical Research
The intent of informed consent in clinical research is to give patients adequate information,
through a full explanation of a proposed treatment, including any possible harms, so they
can make an informed decision. Studies, however, repeatedly suggest that participants often
have incomplete understanding of various features of clinical trials and issues associated with
written informed consent are common. (See Examining the Evidence 5.1.)
THE PERSON(S) GIVING CONSENT MUST FULLY COMPREHEND:
1. the procedure to be performed
2. the risks involved
3. expected or desired outcomes
4. expected complications or side effects that may occur as a result of treatment
5. alternative treatments that are available
CONSENT MAY BE GIVEN BY:
1. a competent adult
2. a legal guardian or individual holding durable power of attorney
3. an emancipated or married minor
4. Mature minor (varies by state)
5. parent of a minor child
6. court order
DISpLAy 5.3 Guidelines for Informed Consent

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Chapter 5 Legal and Legislative Issues 107
Banner and Zimmer (2012) also underscore the importance of nurses understanding and
applying ethical principles for obtaining a valid informed consent in research. This includes
the clear and accurate disclosure of information, assessment of decisional capacity, and
the promotion of voluntarism. Understanding and responding to these issues and criteria
are important in maintaining client safety, dignity, and respect and are essential to the
development of high-quality, ethically sound research that improves health outcomes.
Source: Braude, H., & Kimmelman, J. (2012). The ethics of managing affective and emotional states to improve
informed consent: Autonomy, comprehension, and voluntariness. Bioethics, 26(3), 149–156.
An individual’s right to self-determination and autonomy is a core consideration in research.
Braude and Kimmelman, however, argue that surveys consistently show that patient-subjects
involved in clinical research frequently harbor inflated expectations of benefit (therapeutic overe-
stimation) or conflate trial participation with care (therapeutic misconception). Many commenta-
tors argue that such misunderstandings raise important concerns about consent validity.
In addition, Braude and Kimmelman suggest that while consent should be free from undue
influence, that some correction, persuasion, or manipulation often exists. Both directive and non-
directive affective interventions raise similar ethical concerns regarding the manipulation of con-
sent practices. A paradoxical tension exists in that affective interventions intended to enhance
autonomy may achieve their end through bypassing conscious cognition. Thus, the increasing
impact of affective interventions on the lives of researchers and subjects, who experience real
affect and emotions in considering difficult decisions, is a phenomenon that requires continued
rigorous and sophisticated moral reflection.
Examining the Evidence 5.1
LEARNING EXERCISE 5.5
Is It Really Informed Consent?
You are a staff nurse on a surgical unit. shortly after reporting for duty, you make rounds
on all your patients. Mrs. Jones is a 36-year-old woman scheduled for a bilateral salpingo-
oophorectomy and hysterectomy. in the course of conversation, Mrs. Jones comments that she
is glad she will not be undergoing menopause as a result of this surgery. she elaborates by
stating that one of her friends had surgery that resulted in “surgical menopause” and that it was
devastating to her. You return to the chart and check the surgical permit and doctor’s progress
notes. the operating room permit reads “bilateral salpingo-oophorectomy and hysterectomy,”
and it is signed by Mrs. Jones. the physician has noted “discussed surgery with patient” in the
progress notes.
You return to Mrs. Jones’s room and ask her what type of surgery she is having. she states, “i’m
having my uterus removed.” You phone the physician and relate your information to the surgeon
who says, “Mrs. Jones knows that i will take out her ovaries if necessary; i’ve discussed it with
her. she signed the permit. Now, please get her ready for surgery—she is the next case.”
Assignment: discuss what you should do at this point. Why did you select this course of
action? What issues are involved here? Be able to discuss legal ramifications of this case.
Medical Records
One source of information that people seek to help them make decisions about their health
care is their medical record. Nurses have a legal responsibility for accurately recording
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108 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
appropriate information in the client’s medical record. The alteration of medical records can
result in license suspension or revocation.
Although the patient owns the information in that medical record, the actual record
belongs to the facility that originally made the record and is storing it. Although patients
must have “reasonable access” to their records, the method for retrieving the record varies
greatly from one institution to another. Generally, a patient who wishes to inspect his or
her records must make a written request and pay reasonable clerical costs to make such
records available. The health-care provider generally permits such inspection during business
hours within several working days of the inspection request. Nurses should be aware of
the procedure for procuring medical records for patients at the facilities where they work.
Often, a patient’s attempt to procure medical records results from a lack of trust or a need for
additional teaching and education. Nurses can do a great deal to reduce this confusion and
foster an open, trusting relationship between the patient and his or her health-care providers.
Collaboration between health-care providers and patients, and documentation thereof, is a
good indication of well-provided clinical care.
If it is not documented in the health-care record. … it did not happen.
LEARNING EXERCISE 5.6
Mrs. Brown’s Chart
Mrs. Brown has been diagnosed with invasive cancer. she has been having daily radiation
treatments. her husband is a frequent visitor and seems to be a devoted husband. they are
both very interested in her progress and prognosis. although they have asked many questions
and you have given truthful answers, you know little because the physician has not shared much
with the staff. today, you walk into Mrs. Brown’s room and find Mr. Brown sitting at Mrs. Brown’s
bedside reading her chart. the radiation orderly had inadvertently left the chart in the room when
Mrs. Brown returned from the X-ray department.
Assignment: identify several alternatives that you have. discuss what you would do and why. is
there a problem here? What follow-up is indicated? attempt to solve this problem on your own
before reading the sample analysis that follows.
Analysis
the nurse needs to determine the most important goal in this situation. possible goals include
(a) getting the chart away from Mr. Brown as soon as possible, (b) protecting the privacy of Mrs.
Brown, (c) gathering more information, or (d) becoming an advocate for the Browns.
in solving the case, it is apparent that not enough information has been gathered. Mr. Brown
now has the chart, and it seems pointless to take it away from him. Usually, the danger in
patients’ families reading the chart lies in the direction of their not understanding the chart and
thereby obtaining confusing information or the patient’s privacy being invaded because the
patient has not consented to family members’ access to the chart.
Using this as the basis for rationale, the nurse should use the following approach:
1. clarify that Mr. Brown has Mrs. Brown’s permission to read the chart by asking her directly.
2. ask Mr. Brown if there is anything in the chart that he did not understand or anything that
he questions. You may even ask him to summarize what he has read. clarify the things
that are appropriate for the nurse to address, such as terminology, procedures, and
nursing care.

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Chapter 5 Legal and Legislative Issues 109
The Patient Self-Determination Act
The PSDA, enacted in 1991, required health-care organizations that received federal funding
(Medicare and Medicaid) to provide education for staff and patients on issues concerning
treatment and end-of-life issues. This education included the use of advance directives (ADs),
written instructions regarding desired end-of-life care. Most ADs address the use of dialysis
and respirators; if you want to be resuscitated if breathing or heartbeat stops; tube feeding;
and organ or tissue donation (Medline Plus, 2013). They also likely include a durable power
of attorney for health care, which names your health-care proxy, someone you trust to make
health decisions if you are unable to do so (Medline Plus).
The PSDA requires acute care facilities to document on the medical record whether a
patient has an AD and to provide written information to patients who do not. However,
despite mechanisms within most health-care institutions to provide this information, the AD
completion rate remains low and many patients do not understand what is included in the AD
or whether this is something important they should have. Examining the Evidence 5.2 reveals
evidence found in one study.
3. refer questions that are inappropriate for the nurse to answer to the physician, and let
Mr. Brown know that you will help him in talking with the physician regarding the medical plan
and prognosis.
4. When finished talking with Mr. Brown, the nurse should request the chart and place it in the
proper location. the incident should be reported to the immediate supervisor.
5. the nurse should follow through by talking with the physician about the incident and
Mr. Brown’s concerns and by assisting the Browns to obtain the information that they have
requested.
Conclusion
the nurse first gathered more information before becoming the adversary or advocate. it is
possible that the Browns had only simple questions to ask and that the problem was a lack of
communication between staff and their patients rather than a physician–patient communication
deficit. Legally, patients have a right to understand what is happening to them, and that should
be the basis for the decisions in this case.
Source: Johnson, R. W., Zhao, Y., Newby, L., Granger, C. B., & Granger, B. B. (2012). Reasons for noncompletion of
advance directives in a cardiac intensive care unit. american Journal of critical care, 21(5), 311–320.
This semistructured cross-sectional study asked all (n = 505) eligible patients 18 years or older
admitted to the cardiac intensive care unit at Duke University Medical Center, Durham, North
Carolina, the standard question required by the PSDA—Do you have an AD?—and three open-
ended questions to ascertain the patient’s understanding of ADs. Most patients (64.4%; n = 325)
did not have an AD before admission to the unit. Of the patients who initially declined the oppor-
tunity to complete an AD (n = 213), 33.8% (n = 72) said they did not understand the question
when initially asked and therefore just said no.
The researchers concluded that simply asking patients if they have an AD does not elicit an
accurate reflection of a patient’s understanding of ADs and that confusion about ADs makes it
difficult for patients to communicate their end-of-life wishes to the appropriate person. The resear-
chers suggest a need to restructure the current implementation of the PSDA and to move beyond
simply checking a box to providing more meaningful discussion with each patient and their family.
Examining the Evidence 5.2
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110 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
Good Samaritan Laws
Nurses are not required to stop and provide emergency services as a matter of law although
most health-care workers feel ethically compelled to stop if they believe they can help. Good
Samaritan laws suggest that health-care providers are typically protected from potential
liability if they volunteer their nursing skills away from the workplace (generally limited
to emergencies), provided that actions taken are not grossly negligent and if the health-care
worker does not exceed his or her training or scope of practice in performing the emergency
services. Hasley (2012) warns, however, that not being paid for your services alone will
not provide Good Samaritan law protection. For example, nurses who volunteer at clinics
or summer camps would typically not be covered since this does not constitute emergency
assistance.
Good Samaritan laws apply only if the health-care worker does not exceed his or her training or
scope of practice in performing the emergency services.
Protection under Good Samaritan laws varies tremendously from state to state. In some states,
the law grants immunity to RNs but does not protect licensed vocational nurses (LVNs)
or licensed professional nurses (LPNs). Other states offer protection to anyone who offers
assistance, even if they do not have a health-care background. Nurses should be familiar with
the Good Samaritan laws in their state.
Health Insurance Portability and Accountability Act of 1996
Another area of the law that nurses must understand is the right to confidentiality. Unautho-
rized release of information or photographs in medical records may make the person who
discloses the information civilly liable for invasion of privacy, defamation, or slander. Written
authorization by the patient to release information is needed to allow such disclosure.
Many nurses have been caught unaware by the telephone call requesting information about
a patient’s condition. It is extremely important that the nurse does not give out unauthorized
information, regardless of the urgency of the person making the request. In addition, nurses
must be careful not to discuss patient information in venues where it can be inadvertently
overheard, read, transmitted, or otherwise unintentionally disclosed. For example, nurses
talking in elevators, the hospital gift shop, or in a restaurant for lunch need to be aware of their
surroundings and remain alert about not revealing any patient information in a public place.
Efforts to preserve patient confidentiality increased tremendously with the passage of
the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (also known as
the Kassebaum–Kennedy Act). HIPAA gave Congress a deadline of August 1999 to pass
legislation protecting the privacy of health information and to improve the portability and
continuity of health insurance coverage. When this did not happen, the Department of Health
and Human Services stepped in and issued the appropriate regulations. The first version of
the privacy rule was issued in December 2000 under the Clinton administration, but it was
modified by the Bush administration before it was ever implemented, and it continues to be
modified on a regular basis.
HIPAA essentially represents two areas for implementation. The first is the Administrative
Simplification plan, and the second area includes the Privacy Rules. The Administrative
Simplification plan is directed at restructuring the coding of health information to simplify the
digital exchange of information among health-care providers and to improve the efficiency of
health-care delivery. The privacy rules are directed at ensuring strong privacy protections for
patient without threatening access to care.
The Privacy Rule applies to health plans, health-care clearinghouses, and health-care
providers. It also covers all patient records and other individually identifiable health

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Chapter 5 Legal and Legislative Issues 111
information. Although there are many components to HIPAA, key components of the
Privacy Rule are that direct treatment providers must make a good faith effort to obtain
written acknowledgment of the notice of privacy rights and practices from patients. In
addition, health-care providers must disclose protected health information to patients
requesting their own information or when oversight agencies request the data. Reasonable
efforts must be taken, however, to limit the disclosure of personal health information to the
minimum information necessary to complete the transaction. There are situations, however,
when limiting the information is not required. For example, a minimum of information is
not required for treatment purposes, since it is clearly better to have too much information
than too little. The HIPAA Privacy Rule and Common Rule also require that individuals
participating in research studies should be assured privacy, particularly regarding personal
health information.
The Privacy Rule attempts to balance the need for the protection of personal health information
with the need for disclosure of that information for patient care.
Because of the complexity of the HIPAA regulations, it is not expected that a nursing manager
would be responsible for compliance alone. Instead, it is most important that the manager
work with the administrative team to develop compliance procedures. For example, managers
must ensure that unauthorized people do not have access to patient charts or medical records
and that unauthorized people are not allowed to observe procedures.
It is equally important that managers remain cognizant of ongoing changes to the
guidelines and are aware of how rules governing these issues may differ in the state in which
they are employed. Some provisions of the Privacy Rules mention “reasonable efforts”
toward achieving compliance, but being reasonable is provision specific. The American
Recovery and Reinvestment Act (ARRA) applies several of HIPAA’s security and privacy
requirements to business associates and changes data restrictions, disclosure, and reporting
requirements.
LEGAL CONSIDERATIONS OF MANAGING A DIVERSE WORKFORCE
Diversity has been defined as the differences among groups or between individuals and comes
in many forms, including age, gender, religion, customs, sexual orientation, physical size,
physical and mental capabilities, beliefs, culture, ethnicity, and skin color (Huston, 2014b).
Demographic data from the U.S. Census Bureau continue to show increased diversification
of the US population, a trend that began almost 35 years ago.
As will be discussed in later chapters, a primary area of diversity is language, including
word meanings, accents, and dialects. Problems arising from this could be misunderstanding
or reluctance to ask questions. Staff from cultures in which assertiveness is not promoted
may find it difficult to disagree with or question others. How the manager handles these
manifestations of cultural diversity is of major importance. If the manager’s response is
seen as discriminatory, the employee may file a complaint with one of the state or federal
agencies that oversee civil rights or equal opportunity enforcement. Such things as overt or
subtle discrimination are prohibited by Title VII (Civil Rights Act of 1964). Managers have a
responsibility to be fair and just. Lack of promotions and unfair assignments may occur with
minority employees just because they are different.
In addition, English-only rules in the workplace may be viewed as discriminatory under
Title VII. Such rules may not violate Title VII if employers require English only during
certain periods of time. Even in these circumstances, the employees must be notified of the
rules and how they are to be enforced.
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112 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
Clearly, managers should be taught how to deal sensitively and appropriately with an
increasingly diverse workforce. Enhancing self-awareness and staff awareness of personal
cultural biases, developing a comprehensive cultural diversity program, and role modeling
cultural sensitivity are some of the ways that managers can effectively avoid many legal
problems associated with discriminatory issues. However, it is hoped that future goals for the
manager would go beyond compliance with Title VII and move toward understanding of and
respect for other cultures.
pROFESSIONAL VERSUS INSTITUTIONAL LICENSURE
In general, a license is a legal document that permits a person to offer special skills and
knowledge to the public in a particular jurisdiction when such practice would otherwise be
unlawful. Licensure establishes standards for entry into practice, defines a scope of practice,
and allows for disciplinary action. Currently, licensing for nurses is a responsibility of State
Boards of Nursing or State Boards of Nurse Examiners, which also provide discipline as
necessary. The manager, however, is responsible for monitoring that all licensed subordinates
have a valid, appropriate, and current license to practice.
Professional licensure is a privilege and not a right.
All nurses must safeguard the privilege of licensure by knowing the standards of care
applicable to their work setting. Deviation from that standard should be undertaken only
when nurses are prepared to accept the consequences of their actions, in terms of both liability
and loss of licensure.
Nurses who violate specific norms of conduct, such as securing a license by fraud,
performing specific actions prohibited by the Nurse Practice Act, exhibiting unprofessional
or illegal conduct, performing malpractice, and abusing alcohol or drugs, may have their
licenses suspended or revoked by the licensing boards in all states. Frequent causes of license
revocation are shown in Display 5.4.
l professional negligence
l practicing medicine or nursing without a license
l Obtaining a nursing license by fraud or allowing others to use your license
l Felony conviction for any offense substantially related to the function or duties of an rN
l participating professionally in criminal abortions
l Not reporting substandard medical or nursing care
l providing patient care while under the influence of drugs or alcohol
l Giving narcotic drugs without an order
l Falsely holding oneself out to the public or to any health-care practitioner as a “nurse practitioner”
DISpLAy 5.4 Common Causes of Professional Nursing License Suspension or Revocation
Typically, suspension and revocation proceedings are administrative. Following a
complaint, the Board of Nursing completes an investigation. Most of these investigations
reveal no grounds for discipline. If the investigation supports the need for discipline, nurses
are notified of the charges and are allowed to prepare a defense. At the hearing, which is
very similar to a trial, the nurse is allowed to present evidence. Based on the evidence,
an administrative law judge makes a recommendation to the State Board of Nursing,

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Chapter 5 Legal and Legislative Issues 113
which makes the final decision. The entire process, from complaint to final decision,
may take up to 2 years.
Some professionals have advocated shifting the burden of licensure, and thus accountability,
from individual practitioners to an institution or agency. Proponents for this move believe that
institutional licensure would provide more effective use of personnel and greater flexibility.
Most professional nursing organizations oppose this move strongly because they believe that
it has the potential for diluting the quality of nursing care.
An alternative to institutional licensure has been the development of certification
programs by the American Nurses Association (ANA). By passing specifically prepared
written examinations, nurses are able to qualify for certification in most nurse practice
areas. This voluntary testing program represents professional organizational certification.
In addition to ANA certification, other specialties, such as cardiac care, offer their own
certification examinations. Many nursing leaders today strongly advocate professional
certification as a means of enhancing the profession. However, certification is really only
helpful in determining a nurse’s continued competence if that nurse is functioning in the areas
of his or her certified competence (Huston, 2014c).
INTEGRATING LEADERSHIp ROLES AND MANAGEMENT FUNCTIONS
IN LEGAL AND LEGISLATIVE ISSUES
Legislative and legal controls for nursing practice have been established to clarify the
boundaries of nursing practice and to protect clients. The leader uses established legal
guidelines to role model nursing practice that meets or exceeds accepted standards of care.
Leaders also are role models in their efforts to expand expertise in their field and to achieve
specialty certification. Perhaps the most important leadership roles in law and legislation are
those of vision, risk taking, and energy. The leader is active in professional organizations and
groups that define what nursing is and what it should be in the future. This is an internalized
responsibility that must be adopted by many more nurses if the profession is to be a
recognized and vital force in the political arena.
Management functions in legal and legislative issues are more directive. Managers
are responsible for seeing that their practice and the practice of their subordinates are
in accord with current legal guidelines. This requires that managers have a working
knowledge of current laws and legal doctrines that affect nursing practice. Because laws
are not static, this is an active and ongoing function. The manager has a legal obligation
to uphold the laws, rules, and regulations affecting the organization, the patient, and
nursing practice.
Managers have a responsibility to be fair and nondiscriminatory in dealing with all
members of the workforce, including those whose culture differs from their own. The
effective leader goes beyond merely preventing discriminatory charges and instead strives to
develop sensitivity to the needs of a culturally diverse staff.
The integrated leader-manager reduces the personal risk of legal liability by creating
an environment that prioritizes patient needs and welfare. In addition, caring, respect,
and honesty as part of nurse–patient relationships are emphasized. If these functions
and roles are truly integrated, the risks of patient harm and nursing liability are greatly
reduced.
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114 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
ADDITIONAL LEARNING EXERCISES AND AppLICATIONS
KEY CONCEPTS
l sources of law include constitutions, statutes, administrative agencies, and court decisions.
l the burden of proof required to be found guilty and the punishment for the crime varies significantly
between criminal, civil, and administrative courts.
l Nurse practice acts define and limit the practice of nursing in each state.
l professional organizations generally espouse standards of care that are higher than those required by
law. these voluntary controls often are forerunners of legal controls.
l Legal doctrines such as stare decisis and res judicata frequently guide courts in their decision making.
l currently, licensing for nurses is a responsibility of state Boards of Nursing or state Boards of Nurse
examiners. these state boards also provide discipline as necessary.
l some professionals have advocated shifting the burden of licensure, and thus accountability, from individual
practitioners to an institution or agency. Many professional nursing organizations oppose this move.
l Malpractice or professional negligence is the failure of a person with professional training to act in a
reasonable and prudent manner. Five components must be present for an individual to be found guilty of
malpractice.
l employers of nurses can now be held liable for an employee’s acts under the concept of vicarious liability.
l each person, however, is liable for his or her own tortuous conduct.
l Managers are not automatically held liable for all acts of negligence on the part of those they supervise,
but they may be held liable if they were negligent in supervising those employees at the time that they
committed the negligent acts.
l While professional negligence is considered to be an unintentional tort, assault, battery, false
imprisonment, invasion of privacy, defamation, and slander are intentional torts.
l consent can be informed, implied, or expressed. Nurses need to understand the differences between
these types of consents and use the appropriate one.
l although the patient owns the information in a medical record, the actual record belongs to the facility
that originally made it and is storing it.
l it has been shown that despite good technical competence, nurses who have difficulty establishing
positive interpersonal relationships with clients and their families are at greater risk for being sued.
l each nurse should be aware of how laws such as Good samaritan immunity or legal access to incident
reports are implemented in the state in which they live.
l New legislation pertaining to confidentiality (hipaa) and patient rights (e.g., psda) continues to shape
nurse–client interactions in the health-care system.
LEARNING EXERCISE 5.7
Where Does Your Responsibility Lie?
Mrs. shin is a 68-year-old patient with liver cancer. she has been admitted to the oncology unit at
Memorial hospital. her admitting physician has advised chemotherapy, even though she believes
that there is little chance of it working. the patient asks her doctor, in your presence, if there is
an alternative treatment to chemotherapy. she replies, “Nothing else has proved to be effective.
everything else is quackery, and you would be wasting your money.” after the doctor leaves, the
patient and her family ask you if you know anything about alternative treatments. When you indicate
that you do have some current literature available, they beg you to share your information with them.

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Chapter 5 Legal and Legislative Issues 115
Assignment: What do you do? What is your legal responsibility to your patient, the doctor,
and the hospital? Using your knowledge of the legal process, the Nurse practice act, patients’
rights, and legal precedents (look for the case tuma versus Board of Nursing, 1979), explain
what you would do, and defend your decision.
LEARNING EXERCISE 5.8
Legal Ramifications for Exceeding One’s Duties
You have been the evening charge nurse in the emergency department at Memorial hospital for
the last 2 years. Besides yourself, you have two LVNs and four rNs working in your department.
Your normal staffing is to have two rNs and one LVN on duty Monday through thursday and
one LVN and three rNs on during the weekend.
it has become apparent that one of the LVNs, Maggie, resents the recently imposed limitations of LVN
duties because she has had 10 years of experience in nursing, including a tour of duty as a medic
in the first Gulf War. the emergency department physicians admire her and are always asking her to
assist them with any major wound repair. Occasionally, she has exceeded her job description as an
LVN in the hospital, although she has done nothing illegal of which you are aware. You have given her
satisfactory performance evaluations in the past, even though everyone is aware that she sometimes
pretends to be a “junior physician.” You also suspect that the physicians sometimes allow her to
perform duties outside her licensure, but you have not investigated this or actually seen it yourself.
tonight, you come back from supper and find Maggie suturing a deep laceration while the
physician looks on. they both realize that you are upset, and the physician takes over the
suturing. Later, the doctor comes to you and says, “don’t worry! she does a great job, and i’ll
take the responsibility for her actions.” You are not sure what you should do. Maggie is a good
employee, and taking any action will result in unit conflict.
Assignment: What are the legal ramifications of this case? discuss what you should do, if
anything. What responsibility and liability exist for the physician, Maggie, and yourself? Use
appropriate rationale to support your decision.
LEARNING EXERCISE 5.9
To Float or Not to Float
You have been an obstetrical staff nurse at Memorial hospital for 25 years. the obstetrical unit
census has been abnormally low lately, although the patient census in other areas of the hospital
has been extremely high. When you arrive at work today, you are told to float to the thoracic surgery
critical care unit. this is a highly specialized unit, and you feel ill prepared to work with the equipment
on the unit and the type of critically ill patients who are there. You call the staffing office and ask to
be reassigned to a different area. You are told that the entire hospital is critically short staffed, that
the thoracic surgery unit is four nurses short, and that you are at least as well equipped to handle
that unit as the other three staff who also are being floated. Now your anxiety level is even higher.
You will be expected to handle a full rN patient load. You also are aware that more than half of the
staff on the unit today will have no experience in thoracic surgery. You consider whether to refuse to
float. You do not want to place your nursing license in jeopardy, yet you feel conflicting obligations.
Assignment: to whom do you have conflicting obligations? You have little time to make this
decision. Outline the steps that you use to reach your final decision. identify the legal and ethical
ramifications that may result from your decision. are they in conflict?
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116 UNIT II FOUNDATION FOR EFFECTIVE LEADERSHIP
REFERENCES
Banner, D. D., & Zimmer, L. L. (2012). Informed consent in
research: An overview for nurses. Canadian Journal
of Cardiovascular Nursing, 22(1), 26–30.
Braude, H., & Kimmelman, J. (2012). The ethics of
managing affective and emotional states to improve
informed consent: Autonomy, comprehension, and
voluntariness. Bioethics, 26(3), 149–156.
Criminal Law Lawyers Source. (2003–2013). Terms. False
imprisonment. Retrieved February 5, 2013, from

Terms

false-imprisonment.html
Find Law for Legal Professionals. (2013). Docket No.
95409-Agenda 9-November 2003. JUANITA
SULLIVAN, Indiv. and as Special Adm’r of the Estate
of Burns Sullivan, Deceased, Appellant, v. EDWARD
HOSPITAL et al. Appellees. Opinion filed February 5,
2004. Retrieved February 4, 2013, from http://caselaw
.findlaw.com/il-supreme-court/1367447.html
Frederick, B. G. (2012). Assault and battery. Retrieved
February 4, 2013, from http://www.grandstrandlaw
.com/lawyer-attorney-1266243.html
Hasley, J. (2012). Good Samaritan Law: Am I covered?
ASBN Update, 16(1), 16.
Huston, C. J. (2014a). Unlicensed assistive personnel and the
registered nurse. In C. J. Huston (Ed.), Professional
issues in nursing (2nd ed.). Philadelphia, PA:
Lippincott Williams & Wilkins 107–120.
Huston, C. J. (2014b). Diversity in the nursing workforce.
In C. J. Huston (Ed.), Professional issues in nursing
(2nd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins 136–155.
Huston, C. J. (2014c). Assuring provider competence through
licensure, continuing education and certification. In
C. J. Huston (Ed.), Professional issues in nursing
(2nd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins 292–307.
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Organizations. (2005). Health care in the crossroads:
Strategies for improving the medical liability system
and preventing patient injury. Oakbrook Terrace, IL:
Author.
Johnson, R. W., Zhao, Y., Newby, L., Granger, C. B., &
Granger, B. B. (2012). Reasons for noncompletion
of advance directives in a cardiac intensive care
unit. American Journal of Critical Care, 21(5),
311–320.
Medline Plus. (2013). Advance directives. Retrieved
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117
Patient, Subordinate, and Professional
Advocacy
… to see what is right, and not do it, is want of courage, or of principles.
—Confucius
… in our imperfect state of conscience and enlightenment, publicity and the collision resulting from
publicity are the best guardians of the interest in the sick.
—Florence Nightingale
CROSSWALK this chapter addresses:
BsN essential ii: Basic organizational and systems leadership for quality care and patient safety
BsN essential V: Health-care policy, finance, and regulatory environments
BsN essential Vi: Interprofessional communication and collaboration for improving patient health
outcomes
BsN essential Viii: Professionalism and professional values
MsN essential ii: Organizational and systems leadership
MsN essential Vi: Health policy and advocacy
aONe Nurse executive competency ii: A knowledge of the health-care environment
aONe Nurse executive competency iii: Leadership
aONe Nurse executive competency i: Professionalism
QseN competency: Patient-centered care
QseN competency: Teamwork and collaboration
LEARNING OBJECTIVES The learner will:
l differentiate between the manager’s responsibility to advocate for patients, subordinates, the
organization, the profession, and for self
l identify values central to advocacy
l differentiate between controlling patient choices and assisting patients to choose
l select an appropriate response that exemplifies advocacy in given situations
l identify how the Patient’s Bill of Rights protects patients
l describe ways a manager can advocate for subordinates
l identify ways individual nurses can become advocates for the profession
l identify both the risks and potential benefits of becoming a whistleblower
l specify both direct and indirect strategies to influence legislation
l describe strategies nurses can use to successfully interact with the media
6
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118 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
Advocacy—helping others to grow and self-actualize—is a critically important leadership
role. Many of the leadership skills that will be described in the following chapters, such as
risk taking, vision, self-confidence, ability to articulate needs, and assertiveness, are used in
the advocacy role.
Managers, by virtue of their many roles, must be advocates for the profession, subordinates,
and patients. The actions of an advocate are to inform others of their rights and to ascertain
that they have sufficient information on which to base their decisions. The term advocacy can
be stated in its simplest form as protecting and defending what one believes in for both self
and others (The Free Dictionary, 2013). Nurses often are expected to advocate for patients
when they are unable to speak for themselves. Indeed, advocacy has been recognized as
one of the most vital and basic roles of the nursing profession since the time of Florence
Nightingale.
Nurses may act as advocates by helping others make informed decisions, by acting as an
intermediary in the environment, or by directly intervening on behalf of others.
This chapter examines the processes through which advocacy is learned as well as the ways in
which leader-managers can advocate for their patients, subordinates, and the profession. The
role of “whistleblower” as an advocacy role is discussed. Specific suggestions for interacting
with legislators and the media to influence health policy are also included. Leadership roles
and management functions essential for advocacy are shown in Display 6.1.
BECOMING AN ADVOCATE
Although advocacy is present in all clinical practice settings, the nursing literature contains
only limited descriptions of how nurses learn the advocacy role and some experts have
even questioned whether advocacy can be taught at all. Some students learn about the
advocacy role as part of ethics or policy content in their nursing education, and while most
undergraduate and graduate programs likely include some type of advocacy instruction, the
extent or impact of this education is largely unknown.
Leadership rOLes
1. Creates a climate where advocacy and its associated risk taking are valued.
2. Seeks fairness and justice for individuals who are unable to advocate for themselves.
3. Seeks to strengthen patient and subordinate support systems to encourage autonomous, well-
informed decision making.
4. Influences others by providing information necessary to empower them to act autonomously.
5. Assertively advocates on behalf of patients and subordinates when an intermediary is necessary.
6. Participates in professional nursing organizations and other groups that seek to advance the
profession of nursing.
7. Role models proactive involvement in health-care policy through both formal and informal interac-
tions with the media and legislative representatives.
8. Works to establish the creation of a national, legally binding Bill of Rights for Patients.
9. Speaks up when appropriate to advocate for health-care practices necessary for safety and qual-
ity improvement.
10. Advocates for social justice in addition to individual patient advocacy.
11. Appropriately differentiates between controlling patient choices (domination and dependence)
and in assisting patient choices (allowing freedom).
DISpLAy 6.1 Leadership roles and Management Functions associated with advocacy

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chapter 6 Patient, Subordinate, and Professional Advocacy 119
Regardless of how or when advocacy is learned, there are nursing values central
to advocacy. These values emphasize caring, autonomy, respect, and empowerment
(Display 6.2).
The nursing values central to advocacy emphasize caring, autonomy, respect, and empowerment.
MaNaGeMeNt FUNctiONs
1. Assures that subordinates and patients have adequate information to make informed decisions.
2. Prioritizes the rights and values of patients.
3. Seeks appropriate consultation when advocacy results in intrapersonal or interpersonal conflict.
4. Promotes and protects the workplace safety and health of subordinates and patients.
5. Encourages subordinates to bring forth concerns about the employment setting and seeks impu-
nity for whistleblowers.
6. Demonstrates the skills needed to interact appropriately with the media and legislators regarding
nursing and health-care issues.
7. Is aware of current legislative efforts affecting nursing practice and organizational and unit man-
agement.
8. Assures that the work environment is both safe and conducive to professional and personal
growth for subordinates.
9. Creates work environments that promote subordinate empowerment so that workers have the
courage to speak up for patients, themselves, and their profession.
10. Takes immediate action when illegal, unethical, or inappropriate behavior occurs that can endan-
ger or jeopardize the best interests of the patient, the employee, or the organization.
1. Each individual has a right to autonomy in deciding what course of action is most appropriate to
meet his or her health-care goals.
2. Each individual has a right to hold personal values and to use those values in making health-care
decisions.
3. All individuals should have access to the information they need to make informed decisions and
choices.
4. The nurse must act on behalf of patients who are unable to advocate for themselves.
5. Empowerment of patients and subordinates to make decisions and take action on their own is the
essence of advocacy.
DISpLAy 6.2 Nursing Values central to advocacy
LEARNING EXERCISE 6.1
Values and advocacy
How important a role do you believe advocacy to be in nursing? Do you believe that your
willingness to assume this role is a learned value? Were the values of caring and service
emphasized in your family and/or community when you were growing up? Have you identified
any role models in nursing who actively advocate for patients, subordinates, or the profession?
What strategies might you use as a new nurse to impart the need for advocacy to your peers
and to the student nurses who work with you?
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120 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
pATIENT ADVOCACy
Standard VII of the American Nurses Association (ANA) Scope and Standards of Practice
(2010) states that the registered nurse practices ethically. As such, the registered nurse is
expected to take appropriate action regarding instances of illegal, unethical, and inappropriate
behavior that can endanger or jeopardize the best interests of the health-care consumer or
situation; speak up when appropriate to question health-care practice when necessary for
safety and quality improvement; and advocate for equitable health-care consumer care.
This patient advocacy is necessary because disease almost always results in decreased
independence, loss of freedom, and interference with the ability to make choices autonomously.
In addition, aging, as well as physical, mental, or social disability, may make individuals
more vulnerable and in need of advocacy. This certainly was the case in research conducted
by Jenkins (2012) who found that advocacy has a role in the prevention and detection of
abuse in safeguarding vulnerable adults as well as ensuring that those abused can achieve
justice. Thus, advocacy becomes the foundation and essence of nursing, and nurses have a
responsibility to promote human advocacy.
Managers also must advocate for patients with regard to distribution of resources and the
use of technology. The advances in science and limits of financial resources have created new
problems and ethical dilemmas. For example, although diagnosis-related groupings may have
eased the strain on government fiscal resources, they have created ethical problems, such as
patient dumping, premature patient discharge, and inequality of care.
O’Mahony Paquin (2011) agrees, suggesting that nurses must advocate for social justice
in addition to individual patient advocacy. When nurses focus their assessment and advocacy
skills solely at the individual level, they risk overlooking the underlying systematic problems
and injustices which lead to disease and thus implementing limited interventions that provide
only Band-Aid solutions. Common areas in which nurses must advocate for patients are
shown in Display 6.3.
1. End-of-life decisions
2. Technological advances
3. Health-care reimbursement
4. Access to health care
5. Provider–patient conflicts regarding expectations and desired outcomes
6. Withholding of information or blatant lying to patients
7. Insurance authorizations, denials, and delays in coverage
8. Medical errors
9. Patient information disclosure (privacy and confidentiality)
10. Patient grievance and appeals processes
11. Cultural and ethnic diversity and sensitivity
12. Respect for patient dignity
13. Inadequate consents
14. Incompetent health-care providers
15. Complex social problems including AIDS (acquired immunodeficiency syndrome), teenage preg-
nancy, violence, and poverty
16. Aging population
DISpLAy 6.3 common areas requiring Nurse–patient advocacy
Yet at times, individual rights must be superseded to ensure the safety of all parties
involved. It is important, however, for the patient advocate to know the difference between
controlling patient choices and assisting patients to choose. Lavelle and Tusaie (2011) note

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chapter 6 Patient, Subordinate, and Professional Advocacy 121
that the assumption that health-care professionals are the best judges of what treatment would
be most effective is actually very narcissistic and, in fact, this assumption may strip patients
of their right to self-determination. Nurses must not use paternalism as a means to reduce
patient autonomy.
it is important for the patient advocate to be able to differentiate between controlling patient choices
(domination and dependence) and in assisting patient choices (allowing freedom).
LEARNING EXERCISE 6.2
culture and decisions
You are a staff nurse on a medical unit. One of your patients, Mr. Dau, is a 56-year-old Hmong
immigrant to the United States. He has lived in the United States for 4 years and became
a citizen 2 years ago. His English is marginal, although he understands more than he can
verbalize. He was admitted to the hospital with sepsis resulting from urinary tract infection. His
condition is now stable.
Today, Mr. Dau’s physician informed him that his computed tomography scan shows a large
tumor in his prostrate that is likely cancer. The physician wants to do immediate follow-up testing
and surgical resection of the tumor to relieve his symptoms of hesitancy and urinary retention.
Although the tumor is probably cancerous, the physician believes that it will respond well to
traditional oncology treatments. The expectation is that Mr. Dau should recover fully.
One hour later, when you go in to check on Mr. Dau, you find him sitting on his bed with
his suitcase packed, waiting for a ride home. He informs you that he is checking out of
the hospital. He states that he believes he can make himself better at home with herbs
and through prayers by the Hmong shaman. He concludes by telling you, “if I am meant to
die, there is little anyone can do.” When you reaffirm the hopeful prognosis reported by his
physician that morning, Mr. Dau says “The doctor is just trying to give me false hope. I need
to go home and prepare for my death.”
assignment: What should you do? How can you best advocate for this patient? Is the problem
a lack of information? How does culture play a role in the patient’s decision? Does a lack of
understanding on this patient’s part justify paternalism?
pATIENT RIGHTS
Until the 1960s, patients had few rights; in fact, patients often were denied basic human
rights during a time when they were most vulnerable. This changed with the adoption of
the Consumer Bill of Rights and Responsibilities, also known as the Patient’s Bill of Rights
in 1998. This document had three key goals: (1) to help patients feel more confident in the
US healthcare system, (2) to stress the importance of a strong relationship between patients
and their health-care providers, and (3) to stress the key role patients play in staying healthy
by laying out rights and responsibilities for all patients and health-care providers (American
Cancer Society, 2013).
Since that time, the National League for Nursing, the American Hospital Association,
and many other organizations have created documents outlining the rights of patients. While
not legally binding, these documents do guide health-care organizations and practitioners in
terms of professional expectations for patient advocacy. Some federal laws do exist though in
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122 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
terms of patient rights such as the right to get a copy of one’s medical records, and the right
to keep them private (Medline Plus, 2013).
In addition, with the passage of the Affordable Care Act in 2010, a new Patient’s Bill of
Rights was established to give new patient protections in dealing with insurance companies
(American Cancer Society, 2013). These protections, which phase in between 2010 and
2014, include the elimination of annual and lifetime coverage limits; provide for choice of
physician from a plan’s network; allow children to get health insurance in spite of existing
medical conditions; allow children to stay on a parent’s policy until age 26 if they meet other
requirements; and restrict health insurance companies from being able to rescind (take back)
health coverage because of honest mistakes on insurance applications.
The government, in its role as the single largest insurer of health care, has also influenced
the protection of patient rights by linking reimbursement with patient right provisions. For
example, in 2011, the Department of Health and Human Services mandated that all hospitals
that receive Medicare and Medicaid funding must protect the visitation rights of lesbian,
gay, bisexual, and transgendered (LGBT) patients (Gallagher, Hernandez, & Walker, 2012).
Learning Exercise 6.3 addresses the rights of LGBT patients.
LEARNING EXERCISE 6.3
advocating for a transgendered patient
You are the charge nurse on a medical unit. Today, during walking rounds, a transgendered
patient tells you that she hears the staff whispering and making fun of her in the hallway outside
her room. She says this is hurtful and that while the staff may lack clarity about her gender
identity, she does not, and that becoming a woman is all she ever wanted. She said that friends
who have come to visit her have also been made to feel uncomfortable.
assignment:
1. How best can you advocate for this patient?
2. What leadership roles could you employ to address the lack of compassion and advocacy
for this patient with the staff?
3. What policies should be created to assure compliance with the Department of Health
and Human Services mandate to protect the visitation rights of this patient’s friends and
significant others?
There has also been significant progress in patient rights related to the privacy of health-
care information, including the Health Insurance Portability and Accountability Act of 1996
(HIPAA). In addition, new legislation—The American Recovery and Reinvestment Act of
2009 (ARRA)—maintains and expands HIPAA guidelines as they are related to patient health
information privacy and security protections.
States have also created bills of rights. In 1994, the Illinois General Assembly established a
Medical Patient Rights Act that established certain rights for medical patients and provided a
penalty for violations of these rights (Illinois General Assembly, n.d.). California has adopted
a similar Patient Guide pertaining to health-care rights and remedies (see Display 6.4). These
guidelines, however, are not legally binding, although they may influence federal or state
funding and certainly should be considered professionally binding.
Some legally binding legislation has been passed, however, to safeguard vulnerable
populations. One such legislation, the Genetic Information and Nondiscrimination Act
(GINA), was passed in 2008, making it illegal for health insurers or employers to discriminate
against individuals based on their genetic information (Becze, 2011). GINA applies to all

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chapter 6 Patient, Subordinate, and Professional Advocacy 123
employers regardless of the number of employees, unlike the Affordable Care Act which is
only for employers with more than 15 employees. However, it does not protect an individual
from discrimination based on genetic information when qualifying for life, disability, and
long-term care insurance (Becze).
Other countries have passed legally binding legislation as well. The Deprivation of
Liberty Safeguards and Mental Capacity Act was legislated in the United Kingdom in 2005,
providing some protection for residents in care homes who are at risk for being deprived of
their liberties through a whole host of interventions, including the use of physical restraints
and even locked doors (Goodall, 2012). The act requires that deprivation of liberty safeguards
be in place through the use of standard or urgent authorization processes so that when the
deprivation of liberty must occur, it is in the best interest of the resident.
Similarly, mental health patients who are involuntarily admitted to hospitals in Alberta,
Canada, are afforded some legal protections, including the Mental Health Act of Alberta
(Orr, 2013). This act provides the authority, protocols, and timelines for admitting, detaining,
and treating persons with serious mental disorders.
In accordance with section 70707 of the California Administrative Code, the hospital and medical
staff have adopted the following list of patient rights to:
1. Exercise these rights without regard to sex; cultural, economic, educational, or religious back-
ground; or the source of payment for care.
2. Considerate and respectful care.
3. Knowledge of the name of the physician who has primary responsibility for coordinating care and
the names and professional relationships of other physicians who will see the patient.
4. Receive information from the physician about illness, course of treatment, and prospects for
recovery in terms the patient can understand.
5. Receive as much information about any proposed treatment or procedure as the patient may
need to give informed consent or to refuse this course of treatment. Except in emergencies,
this information shall include a description of the procedure or treatment, the medically signifi-
cant risks involved in this treatment, alternate course of treatment or nontreatment and the risks
involved in each, and the name of the person who will carry out the procedure or treatment.
6. Participate actively in decisions regarding medical care. To the extent permitted by law, this
includes the right to refuse treatment.
7. Full consideration of privacy concerning medical care program. Case discussion, consultation,
examination, and treatment are confidential and should be conducted discreetly. The patient has
the right to be advised of the reason for the presence of any individual.
8. Confidential treatment of all communications and records pertaining to the patient’s care and
stay in the hospital. Written permission shall be obtained before medical records are made avail-
able to anyone not directly concerned with the patient’s care.
9. Reasonable responses to any reasonable requests for service.
10. Ability to leave the hospital even against the advice of the physician.
11. Reasonable continuity of care and to know in advance the time and location of appointment and
the physician providing care.
12. Be advised if hospital/personal physician proposes to engage in or perform human experimentation
affecting care or treatment. The patient has the right to refuse to participate in such research projects.
13. Be informed by the physician or a delegate of the physician of continuing health-care require-
ments following discharge from the hospital.
14. Examine and receive an explanation of the bill, regardless of source of payment.
15. Know which hospital rules and policies apply to the patient’s conduct.
16. Have all patient’s rights apply to the person who may have legal responsibility to make decisions
regarding medical care on behalf of the patient.
Source: Prepared by Consumer Watchdog (n.d.) and available at http://www.calpatientguide.org/index.html
DISpLAy 6.4 List of patient rights in california
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124 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
The bottom line is that patients are increasingly aware that they have rights, and as a result,
they are more assertive and involved in their health care. They want to know and understand
their treatment options and to be participants in decisions about their health care. This right
to information and participation in medical care decisions has led to some conflicts in the
areas of informed consent and access to medical records. Leader-managers, however, have a
responsibility to see that all patient rights are met, including the right to privacy and personal
liberty, which are guaranteed by the constitution.
SUBORDINATE AND WORKpLACE ADVOCACy
Subordinate advocacy is a neglected concept in management theory but is an essential part of
the leadership role. Standard 16 of the ANA Scope and Standards for Nursing Administration
(2009) suggests that nurse administrators should advocate for other health-care providers
(including subordinates) as well as patients, especially when this is related to health and safety.
For example, workplace advocacy is a critical role managers assume to promote
subordinate advocacy. In this type of advocacy, the manager works to see that the work
environment is both safe and conducive to professional and personal growth for subordinates.
Unfortunately, workplace violence is an ever increasing problem in contemporary society.
The Occupational Safety and Health Administration (OSHA) reports that over 2 million
American workers are victims of workplace violence each year and the second leading cause
of death from women while at work is workplace homicides from assaults and other violent
acts (Papa & Venella, 2013).
Survey results from a descriptive study of experiences of 3,465 registered nurse members
of the Emergency Nurses Association noted that approximately 25% of the respondents
had experienced physical violence greater than 20 times in the previous 3 years and nearly
20% reported encountering verbal abuse more than 200 times in that same time frame.
Respondents suggested these incidents were often not reported due to fear of retaliation and
fear of a lack of support from their employer. The researchers concluded that one factor
important to mitigating this type of workplace violence then is a commitment by upper
management to ensuring a safer workplace by hospital administrators, emergency department
managers, and hospital security.
In addition, occupational health and safety must be assured by interventions such as
reducing worker exposure to workplace violence, needle sticks, or blood and body fluids.
Subordinates should also be able to have the expectation that their work hours and schedules
will be reasonable, that staffing ratios will be adequate to support safe patient care, that wages
will be fair and equitable, and that nurses will be allowed participation in organizational
decision making. When these working conditions do not exist, managers must advocate to
higher levels of the administrative hierarchy to correct the problems.
In addition, when the health-care industry has faced the crisis of inadequate human
resources and nursing shortages, many organizations have made quick, poorly thought-out
decisions to find short-term solutions to a long-term and severe problem. New workers have
been recruited at a phenomenally high cost, yet the problems that caused high worker attrition
were not solved. Upper-level managers must advocate for subordinates in solving problems
and making decisions about how best to use limited resources. These decisions must be made
carefully, following a thorough examination of the political, social, economic, and ethical costs.
Another way leaders advocate for subordinates is in creating a work environment
that promotes risk taking and leadership. For example, administrators should foster work
environments that promote subordinate empowerment so that workers have the courage to speak
up for patients, themselves, and their profession. In addition, managers must help members of
their health-care team resolve ethical problems and live with the solutions at the unit level.

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chapter 6 Patient, Subordinate, and Professional Advocacy 125
The following are suggestions for creating an environment that promotes subordinate
advocacy:
• Invite collaborative decision making.
• Listen to staff needs.
• Get to know staff personally.
• Take time to understand the challenges faced by the staff in delivering care.
• Face challenges and solve problems together.
• “Go to bat” for staff when needed.
• Promote shared governance.
• Empower staff.
• Promote nurse autonomy.
• Provide staff with workable systems.
Managers must recognize what subordinates are striving for and the goals and values that
subordinates consider appropriate. The leader-manager should be able to guide subordinates
toward actualization while defending their right to autonomy. To help nurses deal with ethical
dilemmas in their practice, nurse-managers should establish and utilize appropriate support
groups, ethics committees, and channels for dealing with ethical problems.
LEARNING EXERCISE 6.4
how can You Best advocate?
You are a unit supervisor in a skilled nursing facility. One of your aides, Martha Greenwald,
recently reported that she suffered a “back strain” several weeks ago when she was lifting an
elderly patient. She did not report the injury at the time because she did not think it was serious.
Indeed, she finished the remainder of her shift and has performed all of her normal work duties
since that time.
Today, Martha reports that she has just left her physician’s office and that he has advised her to
take 4 to 6 weeks off from work to fully recover from her injury. He has also prescribed physical
therapy and electrical nerve stimulation for the chronic pain. Martha is a relatively new employee,
so she has not yet accrued enough sick leave to cover her absence. She asks you to complete
the paperwork for her absence and the cost of her treatments to be covered as a work-related
injury.
When you contact the workers’ compensation case manager for your facility, she states that
the claim will be investigated; however, with no written or verbal report of the injury at the time
it occurred, there is great likelihood that the claim will be rejected.
assignment: How best can you advocate for this subordinate?
WHISTLEBLOWING AS ADVOCACy
The public has become much more aware of ethical malfeasance within its institutions and
corporate organizations as a result of various scandals that have occurred in the last 50 years.
From Watergate to Morgan Stanley to Bernard Madoff’s ponzi scheme, the American public
has been fed a diet of wrongdoing that has led to an increase in moral awareness.
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126 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
Wrongdoing does not stop at large corporations or political activity, it also occurs within
health-care organizations. Huston (2014a) states, “In an era of managed care, declining
reimbursements and the ongoing pressure to remain fiscally solvent, the risk of fraud,
misrepresentation, and ethical malfeasance in healthcare organizations has never been higher.
As a result, the need for whistle-blowing has also likely never been greater” (p. 251).
Huston (2014a) states that there are basically two types of whistleblowing. Internal
whistleblowing occurs within an organization, reporting up the chain of command. External
whistleblowing involves reporting outside the organization such as the media and an elected
official. An example of whistleblowing by a nurse might be to report abuse to a patient by
one another care provider.
It is interesting to note that while much of the public wants wrongdoing or corruption to
be reported, such behavior is often looked upon with distrust, and whistleblowers may be
considered disloyal or experience repercussions for their actions, even if the whistleblowing
was done with the best of intentions. The whistleblower cannot even trust that other health-
care professionals, with similar belief systems about advocacy, will value their efforts,
because the public’s feelings about whistleblowers are so mixed (Huston, 2014a). Leader-
managers then must be willing to advocate for whistleblowers so that they feel assured, that
if they are acting within the scope of their expertise, and that remedy can be sought through
appropriate channels without fear of retaliation.
Speaking out as a whistleblower is often honored more in theory than in fact.
Huston (2014a) suggests that nurses as health-care professionals have a responsibility to
uncover, openly discuss, and condemn shortcuts which threaten the clients they serve.
Yet clearly, there has been a collective silence in many such cases. The reality is that
whistleblowing offers no guarantee that the situation will change or the problem will
improve, and the literature is replete with horror stories regarding negative consequences
endured by whistleblowers (see Examining the Evidence 6.1). For all these reasons, it takes
tremendous courage to come forward as a whistleblower. It also takes a tremendous sense of
what is right and what is wrong as well as a commitment to follow a problem through until
an acceptable level of resolution is reached (Huston).
Source: Thomas, M., & Willmann, J. (2012). Why nurses need whistleblower protection. Journal of Nursing
Regulation, 3(3), 19–23.
Thomas and Willmann shared the case of two Winkler County, Texas, nurses who voiced concerns
about a physician’s dangerous practices including unprofessional conduct, via what they thought
was a confidential report to the State Board for Medicine. One nurse was the compliance officer
for the hospital and the other was the performance improvement officer. Instead of the physician
being investigated, the nurses found themselves indicted for unprofessional conduct charges
(misuse of official information, a third-degree felony) brought by the local Sheriff and County
Attorney, who were friends and business associates of the reported physician. In the end, the
nurses who had a combined 47 years of experience at the hospital were fired. The charges for
the two nurses were eventually dropped and the Sherriff, County Attorney, and hospital admini-
strator were indicted (violation of the nurses’ civil rights under Federal Law as well as violation of
the Texas Public Employee Whistleblower Law) for retaliating against the whistleblowers. All four
of the indictments resulted in convictions. In addition, the nurses sued the county and settled for
a shared $750,000.
examining the evidence 6.1

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chapter 6 Patient, Subordinate, and Professional Advocacy 127
Leader-managers must be willing to advocate for whistleblowers, who speak out about
organizational practices that they believe may be harmful or inappropriate.
Although whistleblower protection has been advocated at the federal level and has passed in
some states, many employees are reluctant to report unsafe conditions for fear of retaliation.
Nurses should check with their state association to assess the status of whistleblower
protection in their state. At present, there is no universal legal protection for whistleblowers
in the United States.
pROFESSIONAL ADVOCACy
Managers also must be advocates for the nursing profession. This type of advocacy has a long
history in nursing. It was nurses who pushed for accountability through state Nurse Practice
Acts and state licensing, although this was not accomplished until 1903. Beyers (as cited in
Huston, 2014b) suggests that nurse leaders collaborated on defining the profession, achieving
legal recognition of the profession, and establishing a culture for professional nursing which
has continued to the present time. Advocating for professional nursing is a leadership role.
Joining a profession requires making a personal decision to involve oneself in a system of
socially defined roles. Thus, entry into a profession involves a personal and public promise
to serve others with the special expertise that a profession can provide and that society
legitimately expects it to provide.
Professional issues are always ethical issues. When nurses find a discrepancy between
their perceived role and society’s expectations, they have a responsibility to advocate for the
profession. At times, individual nurses believe that the problems of the profession are too big
for them to make a difference; however, their commitment to their profession obligates them
to ask questions and think about problems that affect the profession. They cannot afford to
become powerless or helpless or claim that one person cannot make a difference. Often, one
voice is all it takes to raise the consciousness of colleagues within a profession.
A professional commitment means that people cannot shrink from their duty to question and
contemplate problems that face the profession.
If nursing is to advance as a profession, practitioners and managers must broaden their
sociopolitical knowledge base to better understand the bureaucracies in which they live. This
includes speaking out on consumer issues, continuing and expanding attempts to influence
legislation, and increasing membership on governmental health policy-making boards and
councils. Only then will nurses be able to influence the tremendous problems facing society today
in terms of the homeless, teenage pregnancy, drug and alcohol abuse, inadequate health care for
the poor and elderly, and medical errors. These are essential advocacy roles for the profession.
LEARNING EXERCISE 6.5
Write it down. What Would You change?
List five things that you would like to change about nursing or the health-care system. Prioritize
the changes that you have identified. Write a one-page essay about the change that you believe
is most needed. Identify the strategies that you could use individually and collectively as a
profession to make the change happen. Be sure that you are realistic about the time, energy,
and fiscal resources you have to implement your plan.
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128 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
Nursing’s advocacy role in Legislation and public policy
A distinctive feature of American society is the manner in which citizens can participate in the
political process. People have the right to express their opinions about issues and candidates
by voting. People also have relatively easy access to lawmakers and policy makers and
can make their individual needs and wants known. Theoretically, then, any one person can
influence those in policy-making positions. In reality, this rarely happens; policy decisions
are generally focused on group needs or wants.
Much attention has recently been paid to nurses and the importance of the nursing
profession and how nurses impact health-care delivery. This has been especially true in the
areas of patient safety and staff shortages.
In addition to active participation in national nursing organizations, nurses can influence
legislation and health policy in many other ways. Nurses who want to be directly involved
can lobby legislators either in person or by letter. This process may seem intimidating to the
new nurse; however, there are many books and workshops available that deal with the subject
and a common format is used. In addition to nurse-leaders and individual nurses, there is
a need for collective influence to impact health-care policy. The need for organized group
efforts by nurses to influence legislative policy has long been recognized in this country. In
fact, the first state associations were organized expressly for unifying nurses to influence the
passage of state licensure laws.
Nurses must exert their collective influence and make their concerns known to policy makers
before they can have a major impact on political and legislative outcomes.
Political action committees (PACs) of the Congress of Industrial Organizations attempt to
persuade legislators to vote in a particular way. Lobbyists of the PAC may be members of
a group interested in a particular law or paid agents of the group that wants a specific bill
passed or defeated. Nursing must become more actively involved with PACs to influence
health-care legislation, and PACs provide one opportunity for small donors to feel like they
are making a difference.
In addition, professional organizations generally espouse standards of care that are
higher than those required by law. Voluntary controls often are forerunners of legal controls.
What nursing is and should be depends on nurses taking an active part in their professional
organizations. Currently, nursing lobbyists in our nation’s capital are influencing legislation
on quality of care, access to care issues, patient and health worker safety, health-care
restructuring, direct reimbursement for advanced practice nurses, and funding for nursing
education. Representatives of the ANA regularly attend and provide testimony for meetings
of the U.S. Department of Health and Human Services, the Department of Health, the
National Institutes of Health, the OSHA, and the White House to be sure that the “nursing
perspective” is heard in health policy issues (Huston, 2014c).
As a whole, the nursing profession has not yet recognized the full potential of collective
political activity. Nurses must exert their collective influence and make their concerns known
to policy makers before they can have a major impact on political and legislative outcomes.
Because they have been reluctant to become politically involved, nurses have failed to have
a strong legislative voice in the past. Legislators and policy makers are more willing to deal
with nurses as a group rather than as individuals; thus, joining and supporting professional
organizations allow nurses to become active in lobbying for a stronger nurse practice act or
for the creation or expansion of advanced nursing roles.
Personal letters are more influential than form letters, and the tone should be formal but
polite. The letter should also be concise (not more than one page). Be sure to address the

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chapter 6 Patient, Subordinate, and Professional Advocacy 129
legislator properly by title. Establish your credibility early in the letter as both a constituent
and a health-care expert. State your reason for writing the letter in the first paragraph, and
refer to the specific bill that you are writing about. Then, state your position on the issue
and give personal examples as necessary to support your position. Offer your assistance as a
resource person for additional information. Sign the letter, including your name and contact
information. Remember to be persistent, and write legislators repeatedly who are undecided
on an issue. Display 6.5 displays a format common to letters written to legislators.
March 15, 2014
The Honorable John Doe
Member of the Senate
State Capitol, Room ____
City, State, Zip Code
Dear Senator Doe,
I am a registered nurse and member of the American Nurses Association (ANA). I am also a
constituent in your district. I am writing in support of SB XXX, which requires the establishment of
minimum RN staffing ratios in acute care facilities. As a staff nurse on an oncology unit in our local
hospital, I see firsthand the problems that occur when staffing is inadequate to meet the complex
needs of acutely ill patients: medical errors, patient and nurse dissatisfaction, workplace injuries, and
perhaps most importantly, the inability to spend adequate time with and comfort patients who are
dying.
I have enclosed a copy of a recent study conducted by John Smith and will be published in the
January 2014 edition of Nurses Today. This article details the positive impact of legislative staffing
ratio implementation on patient outcomes as measured by medication errors, patient falls, and
nosocomial infection rates.
I strongly encourage you to vote for SB XXX when it is heard by the Senate Business and
Professions Committee next week. Thank you for your ongoing concern with nursing and health-care
issues and for your past support of legislation to improve health-care staffing. Please feel free to
contact me if you have any questions or would like additional information.
Respectfully,
Nancy Thompson, RN, BSN
Street
City, State, Zip Code
Phone number including area code
E-mail address
DISpLAy 6.5 sample: a Letter to a Legislator
Other nurses may choose to monitor the progress of legislation, count congressional votes,
and track a specific legislator’s voting intents as well as past voting records. Still other nurses
may choose to join network groups, where colleagues meet to discuss professional issues and
pending legislation.
For nurses interested in a more indirect approach to professional advocacy, their role may
be to influence and educate the public about nursing and the nursing agenda to reform health
care. This may be done by speaking with professional and community groups about health-
care and nursing issues and by interacting directly with the media. Never underestimate the
influence that a single nurse may have even in writing letters to the editor of local newspapers
or by talking about nursing and health-care issues with friends, family, neighbors, teachers,
clergy, and civic leaders.
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130 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
Nursing and the Media
“Although registered nurses are among the most knowledgeable, educated, frontline healthcare
providers in the country, their voices are rarely ever heard or consulted by mainstream media
organizations” (Taking Media into Our Own Hands, 2011, p. 10). This is because too few
nurses are willing to interact with the media about vital nursing and health-care issues. Often,
this is because they believe that they lack the expertise to do so or because they lack self-
confidence. This is especially unfortunate because both the media and the public place a high
trust in nurses and want to hear about health-care issues from a nursing perspective.
The reality is that the responsibility for nursing’s image as perceived by the public lies
solely upon the shoulders of those who claim nursing as their profession. Until such time
as nurses are able to agree upon the desired collective image and are willing to do what is
necessary to both tell and show the public what that image is, little will change (Huston,
2014d). Nurses should take every opportunity to appear in the media—in newspapers, radio,
and television. Nurses should also complete special training programs to increase their self-
confidence in working with journalists and other media representatives. Regardless, the
first few media interactions will likely be stressful, just like any new task or learning. The
following tips may be helpful to nurses learning to navigate media waters (Display 6.6):
• Remember that reporters often have short deadlines. A delay in responding to a reporter’s
request for an interview usually results in the reporter looking elsewhere for a source.
• Do not be unduly paranoid that the reporter “is out to get you” by inaccurately
representing what you have to say. The reporter has a job to do and most reporters do
their best to be fair and accurate in their reporting.
• Come to the interview prepared with any statistics, important dates and times, anecdotes,
or other information you want to share.
• Limit your key points to two or three and frame them as bullet points to reduce the
likelihood that you will be misheard or misinterpreted. Brief, but concise sound bites are
much more quotable than rambling arguments.
• Avoid technical or academic jargon.
• Speak with credibility and confidence, but do not be afraid to say that you do not know if
asked a question beyond your expertise or which would be better answered by someone
else. If you choose not to answer a question, give a brief reason for not wanting to do
so, rather than simply saying “no comment.”
• Avoid being pulled into inflammatory arguments or blame setting. If you feel that you
have been baited or that you are being pulled off on tangents, simply repeat the key
points you intended to make and refocus the conversation if possible. Remember that
you cannot control the questions you are asked, but you can control your responses.
• Provide contact information so that the reporter can contact you if additional information
or clarifications are needed. Be aware, however, that most reporters will not allow you
to preview their story prior to publication.
LEARNING EXERCISE 6.6
realistic advocacy for the Nursing profession
Do you belong to your state nursing organization or student nursing organization? Why or why
not? Make a list of six other things that you could do to advocate for the profession. Be specific.
Is your list realistic in terms of your energy and commitment to nursing?

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chapter 6 Patient, Subordinate, and Professional Advocacy 131
INTEGRATING LEADERSHIp ROLES AND MANAGEMENT FUNCTIONS
IN ADVOCACy
Nursing leaders and managers recognize that they have an obligation not only to advocate
for the needs of their patients, subordinates, and themselves at a particular time but also to be
active in furthering the goals of the profession. To accomplish all of these types of advocacy,
nurses must value autonomy and empowerment.
However, the leadership roles and management functions to achieve advocacy with
patients and subordinates and for the profession differ greatly. Advocating for patients
requires that the manager create a work environment that recognizes patient’s needs and
goals as paramount. This means creating a work culture where patients are respected, well
1. Respect and meet the reporter’s deadlines.
2. Assume, until proven otherwise, that the reporter will be fair and accurate in his/her reporting.
3. Have key facts and figures ready for the interview.
4. Limit your key points to two or three and frame them as bullet points.
5. Avoid technical or academic jargon.
6. Speak confidently but do not be afraid to say when you do not have the expertise to answer a
question or when a question is better directed to someone else.
7. Avoid being pulled into inflammatory arguments or blame setting and repeat key points if you are
pulled off into tangents.
8. Provide the reporter with contact information for follow-up and needed clarifications.
DISpLAy 6.6 tips for interacting with the Media
LEARNING EXERCISE 6.7
preparing for a Media interview
You are the staffing coordinator for a medium-sized community hospital in California. Minimum
staffing ratios were implemented in January 2004. While this has represented an even greater
challenge in terms of meeting your organization’s daily staffing needs, you believe that the
impetus behind the legislative mandate was sound. You also are a member of the state nursing
association that sponsored this legislation and wrote letters of support for its passage. The
hospital that employs you and the state hospital association fought unsuccessfully against the
passage of minimum staffing ratios.
The local newspaper contacted you this morning and wants to interview you about staffing
ratios in general as well as how these ratios are impacting the local hospital. You approach your
Chief Nursing Officer, and she tells you to go ahead and do the interview if you want but to
remember that you are a representative of the hospital.
assignment: Assume that you have agreed to participate in the interview.
1. How might you go about preparing for the interview?
2. Identify three factual points that you can state during the interview as your sound bites.
What would be your primary points of emphasis?
3. Is there a way to reconcile the conflict between your personal feelings about staffing ratios
and those of your employer? How would you respond if asked directly by the reporter to
comment about whether staffing ratios are a good idea?
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132 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
informed, and empowered. The leadership role required to advocate for patients is often
one of risk taking, particularly when advocating for a client may be in direct conflict with
a provider or institutional goal. Leaders must also be willing to accept and support patient
choices that may be different from their own.
Advocating for subordinates requires that the manager create a safe and equitable work
environment where employees feel valued and appreciated. When working conditions are
less than favorable, the manager is responsible for relaying these concerns to higher levels of
management and advocating for needed changes. The same risk taking that is required in patient
advocacy is a leadership role in subordinate advocacy, since subordinate needs and wants may
be in conflict with the organization. There is always a risk that the organization will view the
advocate as a troublemaker, but this does not provide an excuse for managers to be complacent
in this role. Managers also must advocate for subordinates in creating an environment where
ethical concerns, needs, and dilemmas can be openly discussed and resolved.
Advocating for the profession requires that the nurse-manager be informed and involved
in all legislation affecting the unit, organization, and the profession. The manager also must
be an astute handler of public relations and demonstrate skill in working with the media. It is
the leader, however, who proactively steps forth to be a role model and active participant in
educating the public and improving health care through the political process.
KeY cONcepts
l Advocacy is helping others to grow and self-actualize and is a leadership role.
l Managers, by virtue of their many roles, must be advocates for patients, subordinates, and the
profession.
l It is important for the patient advocate to be able to differentiate between controlling patient choices
(domination and dependence) and in assisting patient choices (allowing freedom).
l Since the 1960s, some advocacy groups, professional associations, and states have passed Bills
of Rights for patients. Although these are not legally binding, they can be used to guide professional
practice.
l In workplace advocacy, the manager works to see that the work environment is both safe and conducive
to professional and personal growth for subordinates.
l While much of the public wants wrongdoing or corruption to be reported, such behavior is often
looked upon with distrust, and whistleblowers are often considered disloyal and experience negative
repercussions for their actions.
l Leader-managers must be willing to advocate for whistleblowers, who speak out about organizational
practices that they believe may be harmful or inappropriate.
l Professional issues are ethical issues. When nurses find a discrepancy between their perceived role and
society’s expectations, they have a responsibility to advocate for the profession.
l If nursing is to advance as a profession, practitioners and managers must broaden their sociopolitical
knowledge base to better understand the bureaucracies in which they live.
l Because legislators and policy makers are more willing to deal with nurses as a group rather than as
individuals, joining and actively supporting professional organizations allow nurses to have a greater
voice in health-care and professional issues.
l Nurses need to exert their collective influence and make their concerns known to policy makers before
they can have a major impact on political and legislative outcomes.
l Nurses have great potential to educate the public and influence policy through the media as a result of
the public’s high trust in nurses and because the public wants to hear about health-care issues from a
nursing perspective.

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chapter 6 Patient, Subordinate, and Professional Advocacy 133
ADDITIONAL LEARNING EXERCISES AND AppLICATIONS
LEARNING EXERCISE 6.8
ethics and advocacy
You are a new graduate staff nurse in a home health agency. One of your clients is a 23-year-
old man with acute schizophrenia who was just released from the local county, acute care,
behavioral health-care facility, following a 72-hour hold. He has no insurance. His family no
longer has contact with him, and he is unable to hold a permanent job. He is noncompliant
in taking his prescription drugs for schizophrenia. He is homeless and has been sleeping and
eating intermittently at the local homeless shelter; however, he was recently asked not to return
because he is increasingly agitated and, at times, violent. He calls you today and asks you “to
help him with the voices in his head.”
You approach the senior RN case manager in the facility for help in identifying options for this
individual to get the behavioral health-care services that he needs. She suggests that you tell
the patient to go to Maxwell’s Mini Mart, a local convenience store, at 3 pm today and wait by
the counter. Then, she tells you that you should contact the police at 2:55 pm and tell them that
Maxwell’s Mini Mart is being robbed by your patient so that he will be arrested. She states, “I do
this with all of my uninsured mental health patients, since the state Medicaid program offers only
limited mental health services and the state penal system provides full mental health services for
the incarcerated.” She goes on to say that the store owner and the police are aware of what she
is doing and support the idea, since it is the only way “patients really have a chance of getting
better.” She ends the conversation by saying, “I know you are a new nurse and don’t understand
how the real world works, but the reality is that this is the only way I can advocate for patients
like this, and you need to do the same for your patients.”
assignment:
1. Will you follow the advice of the senior RN case manager?
2. If not, how else can you advocate for this patient?
LEARNING EXERCISE 6.10
determining Nursing’s entry Level
Grandfathering is the term used to grant certain people working within the profession for a given
period of time or prior to a deadline date the privilege of applying for a license without having
to take the licensing examination. Grandfathering clauses have been used to allow licensure for
wartime nurses−those with on-the-job training and expertise−even though they did not graduate
from an approved school of nursing.
LEARNING EXERCISE 6.9
Letter Writing in advocacy
Identify three legislative bills affecting nursing that are currently being considered in committee,
the House of Representatives, or the Senate. Select one and draft a letter to your state
assembly person, representative, or senator regarding your position on the bill.
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134 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
Some professional nursing organizations are once again proposing that the BSN become the
entry-level requirement for professional nursing. Some have suggested that as a concession to
current Associate Degree (ADN) and diploma-prepared nurses, all nurses who have passed the
registered nursing licensure examination before the new legislation, regardless of educational
preparation or experience, would retain the title of professional nurse. Non-baccalaureate nurses
after that time would be unable to use the title of professional nurse.
assignment: Do you believe that the “BSN as entry level” proposal advocates the advancement
of the nursing profession? Is grandfathering conducive to meeting this goal? Would you
personally support both of these proposals? Does the long-standing internal dissension
about making the BSN the entry level into professional nursing reduce nursing’s status as a
profession? Do lawmakers or the public understand this dilemma or care about it?
LEARNING EXERCISE 6.12
conflict of Values
You are a case manager in a disease management program, assigned to coordinate the care
needs of Sam, a 72-year-old man with multiple chronic health problems. His medical history
includes myocardial infarctions, implantation of a pacemaker, open-heart surgery, an inoperable
abdominal aneurysm, and repeated episodes of congestive heart failure. Because of his poor
health, he cannot operate the small business he owns or work for any length of time at his
gardening or other hobbies.
Although Joe has told you that death would be a relief to his nearly constant discomfort and
depression, his wife dismisses such talk as “nonsense” and tells Sam that “she still needs him and
will always do everything in her power to keep him here with her.” In deference to his wife’s wishes,
Joe has not completed any of the legal paperwork necessary to create a durable power of attorney
LEARNING EXERCISE 6.11
how Would You proceed?
You are an RN case manager for a large insurance company. Sheila Johannsen is a 34-year-old
mother of two small children. She was diagnosed with advanced, metastatic breast cancer 6
months ago. Traditional chemotherapy and radiation seem to have slowed the spread of the
cancer, but the prognosis is not good.
Sheila contacted you this morning to report that she has been in contact with a physician at
one of the most innovative medical centers in the country. He told her that she might benefit
from an experimental gene therapy treatment; however, she is ineligible for participation in the
free clinical trials since her cancer is so advanced. The cost for the treatment is approximately
$250,000. Sheila states that she does not have the financial resources to pay for the treatment
and begs you “to do whatever you can to get the insurance company to pay. Otherwise, she
will die.”
You know that the cost of experimental treatments is almost always disallowed by your insurance
company. You also know that even with the experimental treatment, Sheila’s probability of a cure
is very small.
assignment: Decide how you will proceed. How can you best advocate for this patient?

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chapter 6 Patient, Subordinate, and Professional Advocacy 135
LEARNING EXERCISE 6.13
peer advocacy
You are a nursing student. Like many of the students in your nursing program, sometimes you
feel you study too much and therefore miss out on partying with friends; something many of
your college friends do on a regular basis. Today, after a particularly grueling exam, three of
your nursing school peers approach you and ask you to go out with them to a party tonight,
off campus, which is being co-hosted by Matt, another nursing student. Alcohol will be readily
available although not everyone at the party is of legal drinking age, including you and one of
your nursing peers (Jenny). Because you really do not want to drink anyway, you agree to be
the designated driver.
Almost immediately after you arrive at the party, all three of your nursing peers begin drinking.
At first it seems pretty harmless, but after several hours, you decide the tenor of the party is
changing and becoming less controlled, and that it is time to take your friends home. Two of
your peers agree, but you cannot find Jenny. As you begin searching for her, several partygoers
tell you that she has been drinking “kamikazes” all night and that she “looked pretty wasted” the
last time they saw her. They suggest that you check the bathroom since Jenny said she wasn’t
feeling very well.
When you enter the bathroom, you see Jenny slumped in the corner by the toilet. She has
vomited all over the floor as well as her clothing and she reeks of alcohol. When you attempt
to rouse her, her eyelids flutter but she is unable to wake up or answer any questions. Her
breathing seems regular and unlabored, but she is continuing to vomit in her “blacked-out” state.
Her skin feels somewhat clammy to the touch and she cannot stand or walk on her own. You are
not sure how much Jenny actually had to drink or how long it has been since she “passed out.”
You are worried that Jenny is experiencing acute alcohol poisoning but are not very experienced
with this sort of thing. The other two nursing students you brought to the party feel you are
overreacting, although they agree that Jenny has had too much to drink and needs to be
watched. One of your peers suggests calling the new young, clinical instructor in the nursing
program, who offered just the other day to provide rides to students who have been drinking.
You think she might be able to provide some guidance. Another one tells you that she feels
Jenny just needs to “sleep it off” and that she will stay with Jenny tonight to make sure she is
OK, although she has had a fair amount to drink herself.
You think Jenny should be seen in the local emergency department (ED) for treatment and are
contemplating calling for an ambulance. One partygoer agrees with you that Jenny should be
seen at the hospital but suggests you drop Jenny off anonymously at the front door of the ED
so “you won’t get in any trouble.” Matt encourages you not to take her to the ED at all, because
he is afraid the incident will be reported to the local police since Jenny is a minor and that he
could be in “real trouble” for furnishing alcohol to a minor. He argues that this could threaten
or a living will should he become unable to make his own health-care decisions. Today, Sam takes
you aside and suggests that “he wants to fill out this paperwork so that no extraordinary means of
life support are used,” and he “wants you to witness it so that his wife will not know.”
assignment: Decide what you will do. What is your obligation to Sam? To his wife? To yourself?
Whose needs are paramount? How do the ethical principles of autonomy, duty, and veracity
intersect or compete in this case?
(Continued )
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136 UNit ii FOUNDATION FOR EFFECTIVE LEADERSHIP
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jurisprudence in action. Alberta RN, 68(4), 14–15.
Papa, A., & Venella, J. (2013, January 31). Workplace
violence in healthcare: Strategies for advocacy.
Online Journal of Issues in Nursing, 18(1), 1.
Taking Media Into Our Own Hands. (2011). National Nurse,
107(1), 10–13. Retrieved Sept. 29, 2013, from http://
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The Free Dictionary. (2013). Definition of advocacy.
Accessed April 18, 2013, from http://www.
thefreedictionary.com/advocacy
Thomas, M., & Willmann, J. (2012). Why nurses need
whistleblower protection. Journal of Nursing
Regulation, 3(3), 19–23.
both his progression and Jenny’s in the nursing program. He says that she can just stay at the
house tonight and that he will check in on her on a regular basis.
To complicate things, you, Jenny, and the other two students you brought to the party live in
the college dormitories and they lock down for the evening in another 30 minutes. It will take
you at least 20 minutes to gather the manpower you need to get Jenny down to your car and
up to her dormitory room by lockdown, if that is what you decide to do. If you are not inside the
dormitories by lockdown, you will need to find another place to spend the evening. In addition,
there will likely be someone at the door to the dormitory assigned to turn away students who
are clearly intoxicated.
assignment: Decide what you will do. How do you best advocate for a peer when they are
unable to advocate for themselves? Does it matter if the risk is self-inducted? How do you
weigh the benefits of advocating for one person when it can result in potential harm or risk to
another person?

http://www.cancer.org/treatment/findingandpayingfortreatment/understandingfinancialandlegalmatters/patients-bill-of-rights

http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1525&ChapterID=35

http://www.nlm.nih.gov/medlineplus/patientrights.html

http://nurses.3cdn.net/37eb9af628395bf916_0im6b0snw

http://www.thefreedictionary.com/advocacy

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Roles and Functions
in Planning
UNIT III
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138
Strategic and Operational Planning
… in the absence of clearly defined goals, we are forced to concentrate on activity and ultimately
become enslaved by it.
—Chuck Conradt
… he who fails to plan, plans to fail.
—Anonymous
CROSSWALK this ChApter Addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential III: scholarship for evidence-based practice
BSN Essential V: health-care policy, finance, and regulatory environments
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential IV: translating and integrating scholarship into practice
MSN Essential VI: health policy and advocacy
AONE Nurse Executive Competency II: A knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency V: Business skills
QSEN Competency: teamwork and collaboration
QSEN Competency: evidence-based practice
LEARNING OBJECTIVES The learner will:
l identify contemporary paradigm shifts and trends impacting health-care organizations
l analyze social, political, and cultural forces that may affect the ability of 21st-century health-
care organizations to forecast accurately in strategic planning
l describe the steps necessary for successful strategic planning
l identify barriers to planning as well as actions the leader-manager can take to reduce or
eliminate these barriers
l include evaluation checkpoints in strategic planning to allow for midcourse corrections as needed
l discuss the relationship between an organizational mission statement, philosophy, goals,
objectives, policies, procedures, and rules
l write an appropriate mission statement, organization philosophy, nursing service philosophy,
goals, and objectives for a known or fictitious organization
l compare the societal values regarding access to and payment of health care in the United
states and at least one other country
l discuss appropriate actions that may be taken when personal values are found to be in
conflict with those of an employing organization
l recognize the need for periodic value clarification to promote self-awareness
l describe personal planning style
7

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Chapter 7 Strategic and Operational Planning 139
Planning is critically important to and precedes all other management functions. Without
adequate planning, the management process fails and organizational needs and objectives
cannot be met. Planning may be defined as deciding in advance what to do; who is to do it;
and how, when, and where it is to be done. Therefore, all planning involves choosing among
alternatives.
All planning involves choice: A necessity to choose from among alternatives.
This implies that planning is a proactive and deliberate process that reduces risk and
uncertainty. It also encourages unity of goals and continuity of energy expenditure (human
and fiscal resources) and directs attention to the objectives of the organization. Adequate
planning also provides the manager with some means of control and encourages the most
appropriate use of resources.
In effective planning, the manager must identify short- and long-term goals and changes
needed to ensure that the unit will continue to meet its goals. Identifying such short- and
long-term goals requires leadership skills such as vision and creativity, since it is impossible
to plan what cannot be dreamed or envisioned.
Likewise, planning requires flexibility and energy—two other leadership characteristics.
Yet, planning also requires management skills such as data gathering, forecasting, and
transforming ideas into action.
Unit III focuses on several aspects of planning, including strategic and operational
planning, planned change, time management, fiscal planning, and career planning. This
chapter deals with skills needed by the leader-manager to implement strategic and operational
planning. In addition, the leadership roles and management functions involved in developing,
implementing, and evaluating the planning hierarchy are discussed (Display 7.1).
DISpLAy 7.1 Leadership Roles and Management Functions Associated with Operational
and Strategic Planning
LEADERSHIP ROLES
1. translates knowledge regarding contemporary paradigm shifts and trends impacting health
care into vision and insights which foster goal attainment.
2. Assesses the organization’s internal and external environment in forecasting and identifying
driving forces and barriers to strategic planning.
3. demonstrates visionary, innovative, and creative thinking in organizational and unit planning,
thus inspiring proactive rather than reactive planning.
4. influences and inspires group members to be actively involved in both short- and long-term
planning.
5. periodically completes value clarification to increase self-awareness.
6. encourages subordinates toward value clarification by actively listening and providing feedback.
7. Communicates and clarifies organizational goals and values to subordinates.
8. encourages subordinates to be involved in policy formation, including developing, implement-
ing, and reviewing unit philosophy, goals, objectives, policies, procedures, and rules.
9. is receptive to new and varied ideas.
10. role models proactive planning methods to followers.
MANAGEMENT FUNCTIONS
1. is knowledgeable regarding legal, political, economic, and social factors affecting health-care
planning.
2. demonstrates knowledge of and uses appropriate techniques in both personal and organiza-
tional planning.
(Continued)
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140 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
LOOKING TO THE FUTURE
Because of health-care reform, rapidly changing technology, increasing government
involvement in regulating health care, and scientific advances, health-care organizations are
finding it increasingly difficult to identify long-term needs appropriately and plan accordingly.
In fact, most long-term planners find it difficult to plan more than a few years ahead.
Unlike the 20-year strategic plans of the 1960s and 1970s, most long-term planners today find it
difficult to look even 5 years in the future.
The health-care system is in chaos, as is much of the business world. Traditional management
solutions no longer apply, and a lack of strong leadership in the health-care system has limited
the innovation needed to create solutions to the new and complex problems that the future
will bring. Because change is occurring so rapidly, managers can easily become focused on
short-range plans and miss changes that can drastically alter specific long-term plans.
Health-care facilities are particularly vulnerable to external social, economic, and political
forces; long-range planning, then, must address these changing dynamics. It is imperative,
therefore, that long-range plans be flexible, permitting change as external forces assert their
impact on health-care facilities. In as far as it is possible, a picture of the future should be
used to formulate long-range planning. One reason for envisioning the future is to study
developments that may have an impact on the organization. This process of learning about the
future allows us to determine what we want to happen. Identifying what may or could happen
allows us to avert, encourage, or direct the course of events.
There are many factors emerging in the rapidly changing health-care system that must be
incorporated in planning for a health-care organization’s future. Some emerging paradigms
include the following:
• The tension between “value” and “volume” has reached a tipping point. With
growing linkages between expected quality outcomes and reimbursement, health-care
organizations must increasingly determine whether value drives volume or whether
volume is necessary to achieve value. The end result in both cases is continued
escalation of health-care costs.
• The transformation from revenue management to cost management will continue
as declining reimbursement forces providers to focus on how to maximize limited
resources and provide care at less cost.
• Physician integration (an interdependence between physicians and health-care
organizations (typically hospitals) that may involve employment, as well as
shared decision making and mutual goal setting, is changing practice patterns and
3. provides opportunities for subordinates, peers, competitors, regulatory agencies, and the
general public to participate in planning.
4. Coordinates unit-level planning to be congruent with organizational goals.
5. periodically assesses unit constraints and assets to determine available resources for planning.
6. develops and articulates a unit philosophy that is congruent with the organization’s philosophy.
7. develops and articulates unit goals and objectives that reflect unit philosophy.
8. develops and articulates unit policies, procedures, and rules that put unit objectives into operation.
9. periodically reviews unit philosophy, goals, policies, procedures, and rules and revises them to
meet the unit’s changing needs.
10. Actively participates in organizational strategic planning, defining and operationalizing such
strategic plans at the unit level.

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Chapter 7 Strategic and Operational Planning 141
reimbursement patterns as hospitals increasingly assume more of the financial and
liability risks for what was historically private physician practice.
• There is a need to build different work relationships because the way we manage
systems is changing. For example, health-care continues to move toward managing
populations rather than individuals.
• The health-care industry continues to move away from illness care to wellness care to
reduce the demand for expensive, acute care services.
• The use of complementary and alternative medicine is increasing as public acceptance
and demand for these services increases.
• A movement is underway for interdependence of professionals and interprofessional
collaboration rather than professional autonomy. With the movement toward managed
care, autonomy has decreased for all health-care professionals, including managers.
• There continues to be a shift in framework to the patient as a consumer of cost and
quality information. Historically, many providers assumed that consumers, both
payers and patients, had minimal interest in or knowledge about the services that they
received. Currently, a change in the balance of power among payers, patients, and
providers has occurred, and providers are increasingly being held accountable for the
quality of outcomes that their patients experience.
• A transition from continuity of provider to continuity of information is occurring.
Historically, continuity of care was maintained by continuity of provider. In the future,
however, the meaning and operationalizing of continuity will become predicated on
having complete, accurate, and timely information that moves with the patient. For
example, electronic health records (EHRs) provide such real-time, point-of-care
information as well as a longitudinal medical record with full information about each
patient.
• Technology, which facilitates mobility and portability of relationships, interactions, and
operational processes, will increasingly be a part of high functioning organizations. EHRs
and clinical decision support are examples of such technology, since both impact not only
what health-care data is collected, but how it is used, communicated, and stored.
• Commercially purchased expert networks (communities of top thinkers, managers,
and scientists) will increasingly be used to address “wicked problems” (problems
with innumerable causes that are tough to describe, and for which there is no right
answer) and improve the quality of their decision making (Saint-Amand, 2008;
Camillus, 2008). Such network panels are typically made up of researchers, health-
care professionals, attorneys, and industry executives.
• The health-care team will be characterized by highly educated, multidisciplinary
experts. While this would appear to ease the leadership challenges of managing such
a team, it is far easier to build teams of experts than to build expert teams.
In addition, Huston (2014) suggests the following factors will further influence the future
of health care:
• Robotic technology and the use of prototype nurse robots called nursebots will serve
as an adjunct to scarce human resources in the provision of health care.
• Biomechatronics, which creates machines that replicate or mimic how the body works,
will increase in prominence in the future. This interdisciplinary field encompasses
biology, neurosciences, mechanics, electronics, and robotics to create devices that
interact with human muscle, skeleton, and nervous systems to establish or restore
human motor or nervous system function.
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142 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
• Biometrics, the science of identifying people through physical characteristics such as
fingerprints, handprints, retinal scans, voice recognition, and facial structure, will be
used to assure targeted and appropriate access to client records.
• Health-care organizations will integrate biometrics with “smart cards” (credit card–
sized devices with a chip, stored memory, and an operating system) to ensure that an
individual presenting a secure ID credential really has the right to use that credential.
• Point-of-care testing will improve bedside care and promote more positive outcomes,
as a result of more timely decision making and treatment.
• Given declining reimbursement, the current nursing shortage, and an increasing
shift in care to outpatient settings, home care agencies will increasingly explore
technology-aided options such as telehealth that allow them to avoid the traditional
1:1 nurse–patient ratio with face-to-face contact.
• The Internet will continue to improve Americans’ health by enhancing communications
and improving access to information for care providers, patients, health plan
administrators, public health officials, biomedical researchers, and other health
professionals. It will also change how providers interact with patients with consumers
increasingly adopting the role of expert patient.
• A growing elderly population, medical advances that increase the need for well-
educated nurses, consumerism, the increased acuity of hospitalized patients, and a
ballooning health-care system will continue to increase the demand for RNs.
• An aging workforce, improving economy, inadequate enrollment in nursing schools to
meet projected demand, increased employment of nurses in outpatient or ambulatory
care settings, and inadequate long-term pay incentives will lead to a nursing shortage
in acute care hospitals.
Such paradigm shifts and trends change almost constantly. Successful leader-managers
stay abreast of the dynamic environments in which health care are provided so that this can
be reflected in their planning. The end result is proactive or visionary planning that allows
health-care agencies to function successfully in the 21st century.
pROACTIVE pLANNING
Planning has a specific purpose and is one approach to developing strategy. In addition,
planning represents specific activities that help achieve objectives; therefore, planning should
be purposeful and proactive. Although there is always some crossover between types of
planning within organizations, there is generally an orientation toward one of four planning
modes: reactive planning, inactivism, preactivism, or proactive planning.
LEARNING EXERCISE 7.1
Forces Affecting Health Care
in small groups, identify six additional forces, beyond those identified in this chapter, affecting
today’s health-care system. You may include legal, political, economic, social, or ethical forces.
try to prioritize these forces in terms of how they will affect you as a manager or rN. For at least
one of the six forces you have identified, brainstorm how that force would affect your strategic
planning as a unit manager or director of a health-care agency.

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Chapter 7 Strategic and Operational Planning 143
Reactive planning occurs after a problem exists. Because there is dissatisfaction with the
current situation, planning efforts are directed at returning the organization to a previous,
more comfortable state. Frequently, in reactive planning, problems are dealt with separately
without integration with the whole organization. In addition, because it is done in response to
a crisis, this type of planning can lead to hasty decisions and mistakes.
Inactivism is another type of conventional planning. Inactivists seek the status quo, and
they spend their energy preventing change and maintaining conformity. When changes do
occur, they occur slowly and incrementally.
A third planning mode is preactivism. Preactive planners utilize technology to accelerate
change and are future oriented. Unsatisfied with the past or present, preactivists do not value
experience and believe that the future is always preferable to the present.
The last planning mode is interactive or proactive planning. Planners who fall into
this category consider the past, present, and future and attempt to plan the future of their
organization rather than react to it. Because the organizational setting changes often,
adaptability is a key requirement for proactive planning. Proactive planning occurs,
then, in anticipation of changing needs or to promote growth within an organization and
is required of all leader-managers so that personal as well as organizational needs and
objectives are met.
Proactive planning is dynamic, and adaptation is considered to be a key requirement since the
environment changes so frequently.
LEARNING EXERCISE 7.2
What Is Your Planning Style?
individually write a plan for the current year. how would you describe your planning? Which type
of planner are you? Write a brief essay that describes your planning style. Use specific examples
and then share your insights in a group.
Forecasting
A mistake common to novice managers is a failure to complete adequate proactive planning.
Instead, many managers operate in a crisis mode and fail to use available historical patterns
to assist them in planning. Nor do they examine present clues and projected statistics to
determine future needs. In other words, they fail to forecast. Forecasting involves trying
to estimate how a condition will be in the future. Forecasting takes advantage of input
from others, gives sequence in activity, and protects an organization against undesirable
changes.
With changes in technology, payment structures, and resource availability, the manager
who is unwilling or unable to forecast accurately impedes the organization’s efficiency and
the unit’s effectiveness. Increased competition, changes in government reimbursement,
and decreased hospital revenues have reduced intuitive managerial decision making. To
avoid disastrous outcomes when making future professional and financial plans, managers
need to stay well informed about the legal, political, and socioeconomic factors affecting
health care.
Managers who are uninformed about the legal, political, economic, and social factors affecting
health care make planning errors that may have disastrous implications for their professional
development and the financial viability of the organization.
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144 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
STRATEGIC pLANNING
Planning also has many dimensions. Two of these dimensions are time span and complexity
or comprehensiveness. Generally, complex organizational plans that involve a long period
(usually 3 to 10 years) are referred to as long-range or strategic plans. However, strategic
planning may be done once or twice a year in an organization that changes rapidly. At the
unit level, any planning that is at least 6 months in the future may be considered long-range
planning.
Strategic planning forecasts the future success of an organization by matching and aligning
an organization’s capabilities with its external opportunities. For instance, an organization
could develop a strategic plan for dealing with a nursing shortage, preparing succession
managers in the organization, developing a marketing plan, redesigning workload, developing
partnerships, or simply planning for organizational success.
Strategic planning typically examines an organization’s purpose, mission, philosophy, and goals
in the context of its external environment.
Some experts suggest, however, that value-based payment, an increased need for cost
cutting, quality mandates, and the need for increased operational efficiencies will require
a reconfiguration of how strategic planning is done in most health-care organizations
(Operational Assessment in Strategic Planning, 2012). Instead of focusing on the external
environment and the marketplace, health-care organizations will need to look closely at their
competencies and weaknesses, examine their readiness for change, and identify those factors
critical to achieving future goals and objectives.
This operational assessment should begin with gathering data related to financial
performance, human resources, strategy, and service offerings as well as outcomes and
results. Feedback from senior leadership, the medical staff, and the Board is then needed
so that consensus can be obtained from stakeholders regarding the organization’s strengths
and weaknesses. Then an action plan can be created that strengthens the organization’s
infrastructure. The operational assessment concludes with an evaluation of how well
the organization is achieving its goals and objectives and the process begins once again
(Operational Assessment in Strategic Planning, 2012).
SWOT Analysis
There are many effective tools that assist in strategic planning. One of the most commonly
used in health-care organizations is SWOT analysis (identification of strengths, weaknesses,
opportunities, and threats) (see Display 7.2). SWOT analysis, also known as TOWS analysis,
was developed by Albert Humphrey at Stanford University in the 1960s and 1970s.
The first step in SWOT analysis is to define the desired end state or objective. After the
desired objective is defined, the SWOTs are discovered and listed. Decision makers must then
decide if the objective can be achieved in view of the SWOTs. If the decision is no, a different
objective is selected and the process repeats.
Strengths are those internal attributes that help an organization to achieve its objectives.
Weaknesses are those internal attributes that challenge an organization in achieving its objectives.
Opportunities are external conditions that promote achievement of organizational objectives.
Threats are external conditions that challenge or threaten the achievement of organizational objectives.
DISpLAy 7.2 SWOT Definitions

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Chapter 7 Strategic and Operational Planning 145
Performed correctly, SWOT allows strategic planners to identify those issues most
likely to impact a particular organization or situation in the future and then to develop an
appropriate plan for action. Marketing Teacher Ltd. (2000–2013), however, warns that several
simple rules must be followed for SWOT analysis to be successful and these are shown in
Display 7.3. In essence, they suggest that honesty, specificity, simplicity, and self-awareness
are integral to successful SWOT analysis.
● Be realistic about the strengths and weaknesses of your organization.
● Be clear about how the present organization differs from what might be possible in the future.
● Be specific about what you want to accomplish.
● Always apply sWOt in relation to your competitors.
● Keep sWOt short and simple.
● remember that sWOt is subjective.
Source: Adapted from Marketing Teacher Ltd. (2000–2013). SWOT analysis: Lesson. Retrieved April 22, 2013, from
http://www.marketingteacher.com/wordpress/swot-analysis/
DISpLAy 7.3 Simple Rules for SWOT Analysis
Balanced Scorecard
Balanced Scorecard, developed by Robert Kaplan and David Norton in the early 1990s, is
another tool that is highly assistive in strategic planning. Indeed, JaxWorks (2012, para 2)
notes that the Harvard Business Review calls Balanced Scorecard “one of the most significant
ideas of the last 75 years.”
Strategic planners using a Balanced Scorecard develop metrics (performance measurement
indicators), collect data, and analyze that data from four organizational perspectives: financial,
customers, internal business processes (or simply processes), and learning and growth. These
measures “align individual, departmental, and organizational goals and identify entirely
new processes for meeting customer and shareholder objectives” (JaxWorks, para 7). Since
all of the measures are considered to be related, and since all of the measures are assumed
to eventually lead to outcomes, an overemphasis on financial measures is avoided. The
scorecard then is “balanced” in that outcomes are in balance.
Balanced Scorecards also allow organizations to align their strategic activities with
the strategic plan. The best Balanced Scorecards are not a static set of measurements, but
instead reflect the dynamic nature of the organizational environment. Because the Balanced
Scorecard is able to translate strategy into action, it is an effective tool for translating an
organization’s strategic vision into clear and realistic objectives.
Strategic Planning as a Management Process
Although SWOT and Balanced Scorecard are different, they are also similar in that they
can help organizations assess what they do well and what they need to do to continue to be
effective and financially sound. Many other strategic planning tools exist as well, although
they are not discussed in this text. Regardless of the tool(s) used, strategic planning as a
management process generally includes the following steps:
1. Clearly define the purpose of the organization.
2. Establish realistic goals and objectives consistent with the mission of the organization.
3. Identify the organization’s external constituencies or stakeholders and then determine
their assessment of the organization’s purposes and operations.
4. Clearly communicate the goals and objectives to the organization’s constituents.
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146 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
5. Develop a sense of ownership of the plan.
6. Develop strategies to achieve the goals.
7. Ensure that the most effective use is made of the organization’s resources.
8. Provide a base from which progress can be measured.
9. Provide a mechanism for informed change as needed.
10. Build a consensus about where the organization is going.
It should be noted, though, that some critics argue that strategic planning is rarely this
linear. Nor is it static. Strategic planning instead involves various actions and reactions that
are partially planned and partially unplanned.
Who Should Be Involved in Strategic Planning?
Long-range planning for health-care organizations historically has been accomplished by top-
level managers and the board of directors, with limited input from middle-level managers.
To give the strategic plan meaning and to implement it successfully, input from subordinates
from all organizational levels may be solicited. There is increasing recognition, however, of
the importance of subordinate input from all levels of the organization to give the strategic
plan meaning and to increase the likelihood of its successful implementation.
The first-level manager is generally more involved in long-range planning at the unit level.
However, because the organization’s strategic plans affect unit planning, managers at all
levels must be informed of organizational long-range plans so that all planning is coordinated.
All organizations should establish annual strategic planning conferences, involving all
departments and levels of the hierarchy; this action should promote increased effectiveness
of nursing staff, better communication between all levels of personnel, a cooperative spirit
relative to solving problems, and a pervasive feeling that the departments are unified, goal
directed, and doing their part to help the organization accomplish its mission.
LEARNING EXERCISE 7.3
Making a Long-Term Plan
the human resource manager in the facility where you are a supervisor has just completed
a survey of the potential retirement plans of the nursing staff and found that within 5 years,
45% of the staff will probably be retiring. You know that past and present available statistics
show that you normally replace 10% to 15% of your staff each year with new hires. You are
concerned, as you do not know how you will be able to handle this new increase in your need
for staff.
Assignment: Make a 5-year, long-term plan that will increase the likelihood of you being able
to meet this new demand. remember that other units within your facility and other health-care
organizations in your region may also be facing the same problem.
ORGANIZATIONAL pLANNING: THE pLANNING HIERARCHy
There are many types of planning; in most organizations, these plans form a hierarchy,
with the plans at the top influencing all the plans that follow. As depicted in the pyramid in
Figure 7.1, the hierarchy broadens at lower levels, representing an increase in the number of
planning components. In addition, planning components at the top of the hierarchy are more
general, and lower components are more specific.

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Chapter 7 Strategic and Operational Planning 147
VISION AND MISSION STATEMENTS
Vision statements are used to describe future goals or aims of an organization. It is a description
in words that conjures up a picture for all group members of what they want to accomplish
together. It is critical, then, that organization leaders recognize that the organization will
never be greater than the vision that guides it. An appropriate vision statement for a hospital
is shown in Display 7.4.
Philosophy
Goals
Objectives
Policies
Procedures
Rules
Mission
FIGURE 7.1 • the planning hierarchy.
DISpLAy 7.4 Sample Vision Statement
County hospital will be the leading center for trauma care in the region.
An organization will never be greater than the vision that guides it.
The purpose or mission statement is a brief statement (typically no more than three or four
sentences) identifying the reason that an organization exists. The mission statement identifies
the organization’s constituency and addresses its position regarding ethics, principles, and
standards of practice.
A well-written mission statement will identify what is unique about the organization. For
example, Brozovich and Totten (2012) suggest that all hospitals want to have high-quality,
cost-effective care, but mission statements that include only this verbiage do not differentiate
between organizations. In addition, the mission statement should have the capacity to
drive action that reflects the mission over time. In other words, mission statements can
become powerful decision-making tools when they become a template of purpose for the
organization’s activities (Brozovich and Totten).
Voges (2012) notes, however, that many contemporary health-care administrators find the
challenges of meeting their stated mission in an era of cost cutting to be a challenge; hence the
often stated adage, “no margin, no mission.” Voges concludes that balance between margin
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148 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
and mission is key but warns that sustaining a health-care organization’s mission in the face
of increasing economic challenges will be difficult.
An example of a mission statement for County Hospital, a teaching hospital, is shown in
Display 7.5.
County hospital is a tertiary care facility that provides comprehensive, holistic care to all state
residents who seek treatment. the purpose of County hospital is to combine high-quality, holistic
health care with the provision of learning opportunities for students in medicine, nursing, and allied
health sciences. research is encouraged to identify new treatment regimens and to promote high-
quality health care for generations to come.
DISpLAy 7.5 Sample Mission Statement
The mission statement is of highest priority in the planning hierarchy because it influences
the development of an organization’s philosophy, goals, objectives, policies, procedures, and
rules. Managers employed by County Hospital would have two primary goals to guide their
planning: (a) to provide high-quality, holistic care and (b) to provide learning opportunities
for students in medicine, nursing, and other allied health sciences. To meet these goals,
adequate fiscal and human resources would have to be allocated for preceptorships and
clinical research. In addition, an employee’s performance appraisal would examine the
worker’s performance in terms of organizational and unit goals.
Mission statements then have value, only if they provide more than lip service. Indeed,
actions taken at all levels of the organization should be congruent with the stated organization
mission. This is why involving individuals from all levels of the organization in crafting
mission statements is so important.
Curran and Totten (2010) suggest that in seeking employment, nurses should review the
mission statement of a potential employer and ask themselves what it tells them about the
organization’s stakeholders, what beliefs and values are espoused, and how the organization
intends to meet the needs of its stakeholders. Only then can the potential employee determine
whether this is an organization they want to work for.
An organization must truly believe and act upon its mission statement; otherwise, the statement
has no value.
THE ORGANIZATION’S pHILOSOpHy STATEMENT
The philosophy flows from the purpose or mission statement and delineates the set of values
and beliefs that guide all actions of the organization. It is the basic foundation that directs
all further planning toward that mission. A statement of philosophy can usually be found
in policy manuals at the institution or is available on request. A philosophy that might be
generated from County Hospital’s mission statement is shown in Display 7.6.
The organizational philosophy provides the basis for developing nursing philosophies
at the unit level and for nursing service as a whole. Written in conjunction with the
organizational philosophy, the nursing service philosophy should address fundamental
beliefs about nursing and nursing care; the quality, quantity, and scope of nursing services;
and how nursing specifically will meet organizational goals. Frequently, the nursing service
philosophy draws on the concepts of holistic care, education, and research. The nursing
service philosophy in Display 7.7 builds on County Hospital’s mission statement and
organizational philosophy.

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Chapter 7 Strategic and Operational Planning 149
the board of directors, medical and nursing staff, and administrators of County hospital believe that
human beings are unique, due to different genetic endowments, personal experiences in social and
physical environments, and the ability to adapt to biophysical, psychosocial, and spiritual stressors.
thus, each patient is considered a unique individual with unique needs. identifying outcomes and
goals, setting priorities, prescribing strategy options, and selecting an optimal strategy will be
negotiated by the patient, physician, and health-care team.
As unique individuals, patients provide medical, nursing, and allied health students invaluable
diverse learning opportunities. Because the Board of directors, medical and nursing staff, and
administrators believe that the quality of health care provided directly reflects the quality of the
education of its future health-care providers, students are welcomed and encouraged to seek out
as many learning opportunities as possible. Because high-quality health care is defined by and
depends on technological advances and scientific discovery, County hospital encourages research
as a means of scientific inquiry.
DISpLAy 7.6 Sample Philosophy Statement
the philosophy of nursing at County hospital is based on respect for the individual’s dignity and
worth. We believe that all patients have the right to receive effective nursing care. this care is a
personal service that is based on patients’ needs and their clinical disease or condition.
recognizing the obligation of nursing to help restore patients to the best possible state of
physical, mental, and emotional health and to maintain patients’ sense of spiritual and social well-
being, we pledge intelligent cooperation in coordinating nursing service with the medical and allied
professional practitioners. Understanding the importance of research and teaching for improving
patient care, the nursing department will support, promote, and participate in these activities. Using
knowledge of human behavior, we shall strive for mutual trust and understanding between nursing
service and nursing employees to provide an atmosphere for developing the fullest possible potential
of each member of the nursing team. We believe that nursing personnel are individually accountable
to patients and their families for the quality and compassion of the patient care rendered and for
upholding the standards of care as delineated by the nursing staff.
DISpLAy 7.7 Sample Nursing Service Philosophy
The unit philosophy, adapted from the nursing service philosophy, specifies how nursing
care provided on the unit will correspond with nursing service and organizational goals. This
congruence in philosophy, goals, and objectives among the organization, nursing service, and
unit is shown in Figure 7.2.
Although unit-level managers have limited opportunity to help develop the organizational
philosophy, they are active in determining, implementing, and evaluating the unit philosophy.
In formulating this philosophy, the unit manager incorporates knowledge of the unit’s internal
and external environments and an understanding of the unit’s role in meeting organizational
goals. The manager must understand the planning hierarchy and be able to articulate ideas
both verbally and in writing. Leader-managers also must be visionary, innovative, and
creative in identifying unit purposes or goals so that the philosophy not only reflects current
practice but also incorporates a view of the future.
Like the mission statement, statements of philosophy in general can be helpful only if they
truly direct the work of the organization toward a specific purpose. A department’s decisions,
priorities, and accomplishments reflect its working philosophy.
A working philosophy is evident in a department’s decisions, in its priorities, and in its
accomplishments.
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A person should be able to identify exactly how the organization is implementing its stated
philosophy by observing members of the staff, reviewing the budgetary priorities, and talking
to consumers of health care. The decisions made in an organization make the philosophy
visible to all—no matter what is espoused on paper. A philosophy that is not or cannot be
implemented is useless.
Goals, philosophy,
and objectives of the
__________ Department
Nursing
Unit B
goals
Unit B
philosophy
Unit B
objectives
Unit C
objectives
Unit C
philosophy
Unit A
objectives
Nursing
Unit A
goals
Unit A
philosophy
Nursing
Unit C
goals
Goals, philosophy,
and objectives of the
Nursing Department
Goals, philosophy,
and objectives of the
health-care agency
Goals, philosophy,
and objectives of the
__________ Department
FIGURE 7.2 • philosophical congruence in the planning hierarchy.
LEARNING EXERCISE 7.4
Developing a Philosophy Statement
recover inc., a fictitious for-profit home health agency, provides complete nursing and supportive
services for in-home care. services include skilled nursing, bathing, shopping, physical therapy,
occupational therapy, meal preparation, housekeeping, speech therapy, and social work. the
agency provides round-the-clock care, 7 days a week, to a primarily underserved rural area in
northern California. the brochure the company publishes says that it is committed to satisfying
the needs of the rural community and that it is dedicated to excellence.
Assignment: Based on this limited information, develop a brief philosophy statement that
might be appropriate for recover inc. Be creative and embellish information if appropriate.

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Chapter 7 Strategic and Operational Planning 151
SOCIETAL pHILOSOpHIES AND VALUES
Societies and organizations have philosophies or sets of beliefs that guide their behavior.
These beliefs that guide behavior are called values. Values have an intrinsic worth for a
society or an individual. Some strongly held American values are individualism, capitalism,
and competition. These values have profoundly affected health-care policy formation and
implementation. The result is a health-care system that has historically promoted structured
inequalities. Despite spending trillions of dollars on health care annually, tens of millions of
American citizens have no health insurance and millions of others are underinsured.
Although values seem to be of central importance for health-care policy development and
analysis, public discussion of this crucial variable is often neglected. Instead, health-care
policy makers tend to focus on technology, cost–benefit analysis, and cost-effectiveness.
Although this type of evaluation is important, it does not address the underlying values in this
country that have led to unequal access to health care.
LEARNING EXERCISE 7.5
Health Care at What Cost?
Both Canada and Germany have been held up as models in health-care reform because they
provide health care for all citizens. Although the United states spends more per capita than either
Germany or Canada, many citizens do not have access to comprehensive, quality health care.
Canadians receive hospitalization, doctor visits, and most dental care free of charge. Germany
spends even less and provides a level of service similar to Canada but with a very small copayment
for hospitalization. Unlike the emphasis on specialized care in the United states with limited choice
of physicians, health-care systems in Canada and Germany emphasize primary care, unlimited
choice of physicians, free physician visits, and an emphasis on health promotion. With little
financial incentive for physician specialization and a nationwide focus on health promotion, there
are many more general practitioners per capita in Germany and Canada than in the United states.
At what cost is this health care offered? Canadians and Germans experience longer waits for
some high-tech procedures, and the governments of those countries have limitations on the
proliferation of technology. however, the United states continues to have a higher incidence
of infant mortality and low birth weight than either country and the lowest life expectancy at
birth. despite the highest spending as a percentage of gross domestic product, American
consumers had the least number of physician visits and the shortest average hospital stay.
Assignment: in small groups, discuss the following: do you agree or disagree that the Us
health-care system represents societal values of individualism, capitalism, and competition?
do you believe that the American people are willing to pay the costs required to pursue
collectivism, cooperation, and equality in health care? Would you be willing to have fewer
choices about your health care if access could be guaranteed to all? do you believe that
the cost of universal coverage should be picked up by the consumer or by the employer?
recognize that both societal and individual values will affect your feelings.
INDIVIDUAL pHILOSOpHIES AND VALUES
As discussed in Chapter 1, values have a tremendous impact on the decisions that people
make. For the individual, personal beliefs and values are shaped by that person’s experiences.
All people should carefully examine their value system and recognize the role that it plays in
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152 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
how they make decisions and resolve conflicts and even how they perceive things. Therefore,
the nurse-leader must be self-aware and provide subordinates with learning opportunities or
experiences that foster increased self-awareness.
At times, it is difficult to assess whether something is a true value. McNally’s (1980)
classic work identified the following four characteristics that determine a true value:
1. It must be freely chosen from among alternatives only after due reflection.
2. It must be prized and cherished.
3. It is consciously and consistently repeated (part of a pattern).
4. It is positively affirmed and enacted.
If a value does not meet all four criteria, it is a value indicator. Most people have many value
indicators but few true values. For example, many nurses assert that they value their national
nursing organization, yet they do not pay dues or participate in the organization. True values
require that the person take action, whereas value indicators do not. Thus, the value ascribed
to the national nursing organization is a value indicator for these nurses and not a true value.
In addition, because our values change with time, periodic clarification is necessary to
determine how our values may have changed. Values clarification includes examining values,
assigning priorities to those values, and determining how they influence behavior so that
one’s lifestyle is consistent with prioritized values. Sometimes, values change as a result of
life experiences or newly acquired knowledge. Most of the values we have as children reflect
our parents’ values. Later, our values are modified by peers and role models. Although they
are learned, values cannot be forced on a person because they must be internalized. However,
restricted exposure to other viewpoints also limits the number of value choices a person is
able to generate. Therefore, becoming more worldly increases our awareness of alternatives
from which we select our values.
LEARNING EXERCISE 7.6
Reflecting on Your Values
Using what you have learned about values, value indicators, and value clarifications, answer the
following questions. take time to reflect on your values before answering. this may be used
as a writing exercise.
1. List three or four of your basic beliefs about nursing.
2. Knowing what you know now, ask yourself, “do i value nursing? Was it freely chosen from
among alternatives after appropriate reflection? do i prize and cherish nursing? if i had a
choice to do it over, would i still choose nursing as a career?”
3. Are your personal and professional values congruent? Are there any values espoused by
the nursing profession that are inconsistent with your personal values? how will you resolve
resultant conflicts?
Occasionally, individual values are in conflict with those of the organization. Because the
philosophy of an organization determines its priorities in goal selection and distribution of
resources, nurses need to understand the organization’s philosophy. For example, assume that
a nurse is employed by County Hospital, which clearly states in its philosophy that teaching is
a primary purpose for the hospital’s existence. Consequently, medical students are allowed to
practice endotracheal intubation on all people who die in the hospital, allowing the students to
gain needed experience in emergency medicine. This practice disturbs the nurse a great deal;
it is not consistent with his or her own set of values and thus creates great personal conflict.

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Chapter 7 Strategic and Operational Planning 153
Nurses who frequently make decisions that conflict with their personal values may
experience confusion and anxiety. This intrapersonal struggle ultimately will lead to job
stress and dissatisfaction, especially for the novice nurse who comes to the organization with
inadequate values clarification. The choices that nurses make about client care are not merely
strategic options; they are moral choices. Internal conflict and burnout may result when
personal and organizational values do not mesh.
When a nurse experiences cognitive dissonance between personal and organizational values,
the result may be intrapersonal conflict and burnout.
As part of the leadership role, the manager should encourage all potential employees
to read and think about the organization’s mission statement or philosophy before
accepting the job. The manager should give a copy of the philosophy to the prospective
applicant before the hiring interview. The applicant also should be encouraged to speak to
employees in various positions within the organization regarding how the philosophy is
implemented at their job level. For example, a potential employee may want to determine
how the organization feels about cultural diversity and what policies they have in place to
ensure that patients from diverse cultures and languages have a mechanism for translation
as needed. Finally, new employees should be encouraged to speak to community
members about the institution’s reputation for care. New employees who understand the
organizational philosophy will not only have clearer expectations about the institution’s
purposes and goals but will also have a better understanding of how they fit into the
organization.
Although all nurses should have a philosophy comparable with that of their employer, it
is especially important for the new manager to have a value system consistent with that of
the organization. Institutional changes that closely align with the value system of the nurse-
manager will receive more effort and higher priority than those that are not true values or
that conflict with the nurse-manager’s value system. Managers who take a position with the
idea that they can change the organization’s philosophy to more closely agree with their own
philosophy are likely to be disappointed.
It is unrealistic for managers to accept a position under the assumption that they can change the
organization’s philosophy to more closely match their personal philosophy.
Such a change will require extraordinary energy and precipitate inevitable conflict because
the organization’s philosophy reflects the institution’s historical development and the
beliefs of those people who were vital in the institution’s development. Nursing managers
must recognize that closely held values may be challenged by current social and economic
constraints and that philosophy statements must be continually reviewed and revised to
ensure ongoing accuracy of beliefs.
GOALS AND OBJECTIVES
Goals and objectives are the ends toward which the organization is working. All philosophies
must be translated into specific goals and objectives if they are to result in action. Thus, goals
and objectives “operationalize” the philosophy.
A goal may be defined as the desired result toward which effort is directed; it is the aim
of the philosophy. Although institutional goals are usually determined by the organization’s
highest administrative levels, there is increasing emphasis on including workers in setting
organizational goals. Goals, much like philosophies and values, change with time and require
periodic reevaluation and prioritization.
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154 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
Goals, although somewhat global in nature, should be measurable and ambitious but
realistic. Goals also should clearly delineate the desired end product. When goals are not
clear, simple misunderstandings may compound, and communication may break down.
Organizations usually set long- and short-term goals for services rendered; economics; use
of resources, including people, funds, and facilities; innovations; and social responsibilities.
Display 7.8 lists sample goal statements.
● All nursing staff will recognize the patient’s need for independence and right to privacy and will
assess the patient’s level of readiness to learn in relation to his or her illness.
● the nursing staff will provide effective patient care relative to patient needs insofar as the
hospital and community facilities permit through the use of care plans, individual patient care, and
discharge planning, including follow-up contact.
● An ongoing effort will be made to create an atmosphere that is conducive to favorable patient and
employee morale and that fosters personal growth.
● the performance of all employees in the nursing department will be evaluated in a manner that
produces growth in the employee and upgrades nursing standards.
● All nursing units within County hospital will work cooperatively with other departments within the
hospital to further the mission, philosophy, and goals of the institution.
DISpLAy 7.8 Sample Goal Statements
Although goals may direct and maintain the behavior of an organization, there are
several dangers in using goal evaluation as the primary means of assessing organizational
effectiveness. The first danger is that goals may be in conflict with each other, creating
confusion for employees and consumers. For example, the need for profit maximization
in health-care facilities today may conflict with some stated patient goals or quality goals.
The second danger with the goal approach is that publicly stated goals may not truly reflect
organizational goals. In addition, some organizational goals may be developed simply as a
conduit for individual or personal goals. The final danger is that because goals are global, it
is often difficult to determine whether they have been obtained.
Although goals may direct and maintain the behavior of an organization, there are several
dangers in using goal evaluation as the primary means of assessing organizational
effectiveness.
Objectives are similar to goals in that they motivate people to a specific end and are explicit,
measurable, observable or retrievable, and obtainable. Objectives, however, are more specific
and measurable than goals because they identify how and when the goal is to be accomplished.
Goals usually have multiple objectives that are each accompanied by a targeted completion
date. The more specific the objectives for a goal can be, the easier for all involved in goal
attainment to understand and carry out specific role behaviors. This is especially important
for the nurse-manager to remember when writing job descriptions; if there is little ambiguity
in the job description, there will be little role confusion or distortion. Clearly written goals
and objectives must be communicated to all those in the organization responsible for their
attainment. This is a critical leadership role for the nurse-manager.
Objectives can focus on either the desired process or the desired result. Process objectives
are written in terms of the method to be used, whereas result-focused objectives specify the
desired outcome. An example of a process objective might be “100% of staff nurses will
orient new patients to the call-light system, within 30 minutes of their admission, by first
demonstrating its appropriate use and then asking the patient to repeat said demonstration.”
An example of a result-focused objective might be “All postoperative patients will perceive

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Chapter 7 Strategic and Operational Planning 155
a decrease in their pain levels following the administration of parenteral pain medication.”
Writing good objectives requires time and practice.
For the objectives to be measurable, they should have certain criteria. There should be a
specific time frame in which the objectives are to be completed, and the objectives should
be stated in behavioral terms, be objectively evaluated, and identify positive outcomes rather
than negative outcomes.
As a sample objective, one of the goals at Mercy Hospital is that “all RNs will be
proficient in the administration of intravenous fluids.” Objectives for Mercy Hospital might
include the following:
• All RNs will complete Mercy Hospital’s course “IV Therapy Certification” within
1 month of beginning employment. The hospital will bear the cost of this program.
• RNs who score less than 90% on a comprehensive examination in “IV Therapy
Certification” must attend the remedial 4-hour course “Review of Basic IV Principles”
not more than 2 weeks after the completion of “IV Therapy Certification.”
• RNs who achieve a score of 90% or better on the comprehensive examination for
“IV Therapy Certification” after completing “Review of Basic IV Principles” will
be allowed to perform IV therapy on patients. The unit manager will establish
individualized plans of remediation for employees who fail to achieve this score on
the examination.
The leader-manager clearly must be skilled in determining and documenting goals
and objectives. Prudent managers assess the unit’s constraints and assets and determine
available resources before developing goals and objectives. The leader must then be creative
and futuristic in identifying how goals might best be translated into objectives and thus
implemented. The willingness to be receptive to new and varied ideas is a critical leadership
skill. In addition, well-developed interpersonal skills allow the leader to involve and inspire
subordinates in goal setting. The final step in the process involves clearly writing the
identified goals and objectives, communicating changes to subordinates, and periodically
evaluating and revising goals and objectives as needed.
pOLICIES AND pROCEDURES
Policies are plans reduced to statements or instructions that direct organizations in
their decision making. These comprehensive statements, derived from the organization’s
philosophy, goals, and objectives, explain how goals will be met and guide the general course
and scope of organizational activities. Thus, policies direct individual behavior toward the
organization’s mission and define broad limits and desired outcomes of commonly recurring
situations while leaving some discretion and initiative to those who must carry out that policy.
Although some policies are required by accrediting agencies, many policies are specific to the
individual institution, thus providing management with a means of internal control.
LEARNING EXERCISE 7.7
Writing Goals and Objectives
practice writing goals and objectives for County hospital based on the mission and philosophy
statements in this chapter. identify three goals and three objectives to operationalize each of
these goals.
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156 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
Policies also can be implied or expressed. Implied policies, neither written nor expressed
verbally, have usually developed over time and follow a precedent. For example, a hospital
may have an implied policy that employees should be encouraged and supported in their
activity in community, regional, and national health-care organizations. Another example
might be that nurses who limit their maternity leave to 3 months can return to their former
jobs and shifts with no status change.
Expressed policies are delineated verbally or in writing. Most organizations have many
written policies that are readily available to all people and promote consistency of action.
Expressed policies may include a formal dress code, policy for sick leave or vacation time,
and disciplinary procedures.
All organizations need to develop facility-wide policies and procedures to guide workers
in their actions. These policies and procedures are ideally developed with input from all levels
of the organization. Unfortunately, in many health-care organizations, this function falls to
isolated policy and procedure committees. Involving more individuals in the process, as in a
shared governance approach, should increase the quality of the end product and the likelihood
that procedures will be implemented as desired.
Although top-level management is more involved in setting organizational policies
(usually by policy committees), unit managers must determine how those policies will be
implemented on their units. Input from subordinates in forming, implementing, and reviewing
policy allows the leader-manager to develop guidelines that all employees will support
and follow. Even if unit-level employees are not directly involved in policy setting, their
feedback is crucial to its successful implementation. Having uniform policies and procedures
developed through collaboration is critical.
In addition, policies and procedures should be evidence based. The addition of evidence
to policies and procedures, however, requires the development of a process that ensures
consistency, rigor, and safe nursing practice. Unfortunately, many policies continue to be
driven by tradition or regulatory requirements and inadequate evidence exists to guide best
practices in policy development (Examining the Evidence 7.1).
After policy has been formulated, the leadership role of managers includes the responsibility
for communicating that policy to all who may be affected by it. This information should be
transmitted in writing and verbally. A policy’s perceived value often depends on how it is
communicated.
Source: Coursey, J., Rodriguez, R., Dieckmann, L., & Austin, P. (2013). Successful implementation of policies
addressing lateral violence. AOrN Journal, 97(1), 101–109.
The authors completed an online literature search (1990 to present), an ancestry approach, and
informal networking to locate and appraise evidence about effectively implementing lateral vio-
lence policies. They found that most evidence was from low-level sources and that no consistent,
effective means was presented to implement lateral violence policies. In addition, the evidence
suggested that lateral violence policies exist in most facilities only to comply with the standards
of accrediting agencies and their existence does not indicate effective implementation of those
policies. The appraised evidence did, however, suggest the importance of collaboratively prepared
(administrative and staff) implementation strategies.
The authors concluded that minimal evidence-based information exists that addresses effec-
tive implementation strategies for lateral violence policies and they noted that this void in the
research leaves managers at a loss for best practice techniques to manage lateral violence
behavior and prevent the proliferation of toxic work environments.
Examining the Evidence 7.1

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Chapter 7 Strategic and Operational Planning 157
Procedures are plans that establish customary or acceptable ways of accomplishing a
specific task and delineate a sequence of steps of required action. Established procedures
save staff time, facilitate delegation, reduce cost, increase productivity, and provide a means
of control. Procedures identify the process or steps needed to implement a policy and are
generally found in manuals at the unit level of the organization.
The manager also has a responsibility to review and revise policies and procedure
statements to ensure currency and applicability. Given the current explosion of evidence-
based research as well as new regulations, technology, and drugs, keeping policies and
procedures current and relevant is a tremendous management challenge. In addition, because
most units are in constant flux, the needs of the unit and the most appropriate means of
meeting those needs constantly change. For example, the unit manager is responsible for
seeing that a clearly written policy regarding holiday and vacation time exists and that it is
communicated to all those it affects. The unit manager must also provide a clearly written
procedural statement regarding how to request vacation or holiday time on that specific unit.
The unit manager would assess any long-term change in patient census or availability of
human resources and revise the policy and procedural statements accordingly.
Because procedural instructions involve elements of organizing, some textbooks place the
development of procedures in the organizing phase of the management process. Regardless
of where procedural development is formulated, there must be a close relationship with
planning—the foundation for all procedures.
RULES
Rules and regulations are plans that define specific action or nonaction. Generally included as
part of policy and procedure statements, rules describe situations that allow only one choice
of action. Rules are fairly inflexible, so the fewer rules, the better. Existing rules, however,
should be enforced to keep morale from breaking down and to allow organizational structure.
Chapter 25, on discipline, includes a more detailed discussion of rules and regulations.
OVERCOMING BARRIERS TO pLANNING
Benefits of effective planning include timely accomplishment of higher quality work and the
best possible use of capital and human resources. Because planning is essential, managers
must be able to overcome barriers that impede planning. For successful organizational
planning, the manager must remember several points:
• The organization can be more effective if movement within it is directed at specified
goals and objectives. Unfortunately, the novice manager frequently omits establishing
a goal or objective. Setting a goal for a plan keeps managers focused on the bigger
picture and saves them from getting lost in the minute details of planning. Just as
the nursing care plan establishes patient care goals before delineating problems and
interventions, managers must establish goals for their planning strategies that are
congruent with goals established at higher levels.
• Because a plan is a guide to reach a goal, it must be flexible and allow for readjustment
as unexpected events occur. This flexibility is a necessary attribute for the manager in
all planning phases and the management process.
• The manager should include in the planning process all people and units that could
be affected by a plan. Although time-consuming, employee involvement is how
things are done and by whom increases commitment to goal achievement. Although
not everyone will want to contribute to unit or organizational planning, all should
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158 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
be invited. The manager also needs to communicate clearly the goals and specific
individual responsibilities to all those responsible for carrying out the plans so that
work is coordinated.
• Plans should be specific, simple, and realistic. A vague plan is impossible to
implement. A plan that is too global or unrealistic discourages rather than motivates
employees. If a plan is unclear, the nurse-leader must restate the plan in another
manner or use group process to clarify common goals.
• Know when to plan and when not to plan. It is possible to overplan and underplan.
For example, one who overplans may devote excessive time to arranging details that
might be better left to those who will carry out the plan. Underplanning occurs when
the manager erroneously assumes that people and events will naturally fall into some
desired and efficient method of production.
• Good plans have built-in evaluation checkpoints so that there can be a midcourse
correction if unexpected events occur. A final evaluation should always occur at the
end of the plan. If goals were not met, the plan should be examined to determine why
it failed. This evaluation process assists the manager in future planning.
INTEGRATING LEADERSHIp ROLES AND MANAGEMENT FUNCTIONS
IN pLANNING
Planning requires managerial expertise in health-care economics, human resource management,
political and legislative issues affecting health care, and planning theory. Planning also
requires the leadership skills of being sensitive to the environment, being able to appraise
accurately the social and political climate, and being willing to take risks.
Clearly, the leader-manager must be skilled in determining, implementing, documenting,
and evaluating all types of planning in the hierarchy because an organization’s leaders
are integral to realizing the mission of the organization. Managers then must draw on
the philosophy and goals established at the organizational and nursing service levels in
implementing planning at the unit level. Initially, managers must assess the unit’s constraints
and assets and determine its resources available for planning. The manager then draws on his
or her leadership skills in creativity, innovation, and futuristic thinking to problem solve how
philosophies can be translated into goals, goals into objectives, and so on down the planning
hierarchy. The wise manager will develop the interpersonal leadership skills needed to inspire
and involve subordinates in this planning hierarchy. The manager also must demonstrate the
leadership skill of being receptive to new and varied ideas.
The final step in the process involves articulating identified goals and objectives clearly;
this learned management skill is critical to the success of the planning. If the unit manager
lacks management or leadership skills, the planning hierarchy fails.
KEY CONCEPTS
● the planning phase of the management process is critical and precedes all other functions.
● planning is a proactive function required of all nurses.
● A plan is a guide for action in reaching a goal and must be flexible.
● plans should be specific, simple, and realistic.
● All planning must include an evaluation step and requires periodic reevaluation and prioritization.

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Chapter 7 Strategic and Operational Planning 159
● All people and organizational units affected by a plan should be included in the planning.
● plans have a time for evaluation built into them so that there can be a midcourse correction if necessary.
● New paradigms and trends emerge continuously, requiring leader-managers to be observant and
proactive in organizational strategic planning.
● Because of the rapidly changing technology, increasing government regulatory involvement in health
care, changing population demographics, and reduced provider autonomy, health-care organizations are
finding it increasingly difficult to appropriately identify long-term needs and plan accordingly.
● Organizations and planners tend to use one of the four planning modes: reactive, inactivism, preactivism,
or proactive. A proactive planning style is always the goal.
● strategic planning tools such as sWOt and Balanced scorecard help planners to identify those
issues most likely to impact a particular organization or situation in the future and then to develop an
appropriate plan for action.
● All planning in the organizational hierarchy must flow from and be congruent with planning done at
higher levels in the hierarchy.
● planning in the organizational hierarchy typically includes the development of organizational vision and
mission statements, philosophies, goals, objectives, policies, procedures, and rules.
● An organizational philosophy that is not or cannot be implemented is useless.
● to avoid ongoing intrapersonal values conflicts, employees should have a philosophy compatible with
that of their employer.
● policies and procedures should be evidence based.
● rules are fairly inflexible, so the fewer rules, the better. existing rules, however, should be enforced to
keep morale from breaking down and to allow organizational structure.
ADDITIONAL LEARNING ExERCISES AND AppLICATIONS
LEARNING EXERCISE 7.8
Exploring the Impact of Philosophy on Management Action
susan is the supervisor of the 22-bed oncology unit at Memorial hospital, a 150-bed hospital.
Unit morale and job satisfaction are high, despite a unit occupancy rate of less than 50% in
the last 6 months. patient satisfaction on this unit is as high as or higher than that of any other
unit in the hospital.
susan’s personal philosophy is that oncology patients have physical, social, and spiritual needs
that are different from other patients. Both the unit and nursing service philosophy reflect this
belief. thus, nurses working in the oncology unit receive additional education, orientation, and
socialization regarding their unique roles and responsibilities in working with oncology patients.
At this morning’s regularly scheduled department head meeting, the Chief Nursing Officer
suggests that because of extreme budget shortfalls and continuing low census, the oncology
unit should be closed and its patients merged with the general medical–surgical patient
population. the oncology nursing staff would be reassigned to the medical–surgical unit, with
susan as the unit’s cosupervisor.
(Continued)
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160 UNIT III ROleS aNd FUNcTIONS IN PlaNNINg
REFERENCES
the idea receives immediate support from the medical–surgical supervisor because of the
current staffing shortage on her unit. susan, startled by the proposal, immediately voices her
disapproval and asks for 2 weeks to prepare her argument. her request is granted.
Assignment: What values or beliefs are guiding susan, the Chief Nursing Officer, and the
medical–surgical unit supervisor? determine an appropriate plan of action for susan. What
impact does a unit or nursing service philosophy have on the actions of management and
employees?
Brozovich, J., & Totten, M. (2012). Mission-based decision-
making for boards. Trustee, 65(4), 15–18.
Camillus, J. C. (2008, May). Strategy as a wicked problem.
Harvard Business Review, 99–106.
Coursey, J., Rodriguez, R., Dieckmann, L., & Austin, P.
(2013). Successful implementation of policies
addressing lateral violence. AORN Journal,
97(1), 101–109.
LEARNING EXERCISE 7.9
Incremental Goal Setting
Assume that your career goal is to become a nurse-lawyer. You are currently an rN in an
acute care facility in a large, metropolitan city. You have your BsN degree but will need to take
at least 12 units of prerequisite classes for acceptance into law school. A law school within
commuting distance of your home offers evening classes that would allow you to continue
your current day job at least part-time. Quitting your job entirely would be financially unfeasible.
Assignment: identify at least four objectives that you need to set to achieve your career
goal. Be sure that these objectives are explicit, measurable, observable or retrievable, and
obtainable. then identify at least three actions for each objective that delineate how you will
achieve them.
LEARNING EXERCISE 7.10
Current Events and Planning
You are a manager in a public health agency. in reading the morning paper before going to
work today, you peruse an article about the influx of hispanic families in your county. there has
been an increase of 10% in this population in the last year, and it is expected to continue to
rise. You ponder how this will affect your client population and your agency.
You decide to gather your staff together and develop a strategic plan for dealing with the
problems and opportunities that this change in client demographics presents.
Assignment: in examining the 10 steps listed in development of strategic plans, what are the
things that you can personally influence, and what other individuals in the organization should
be involved with the strategic plan? Make a list of 10 to 12 strategies that will assist you in
planning for this new client population. What other statistics will you need to help you plan?
What are some other future developments in your county that could have a positive or negative
influence on your plan?

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Chapter 7 Strategic and Operational Planning 161
Curran, C., & Totten, M. (2010). Mission, strategy, and
stakeholders. Nursing Economics, 28(2), 116–118.
Huston, C. (2014). Technology in the health care workplace:
Benefits, limitations, and challenges. In C. J. Huston
(Ed.), Professional issues in nursing (3rd ed.).
Philadelphia, PA: Lippincott Williams & Wilkins
214–227.
JaxWorks. (2012). The balanced scorecard concept.
Retrieved April 22, 2013, from http://www.jaxworks
.com/thebalancedscorecardconcept.htm
Marketing Teacher. (2000–2013). SWOT analysis: Lesson.
Retrieved April 22, 2013, from http://www
.marketingteacher.com/wordpress/swot-analysis/
McNally, M. (1980). Values. As individual experience
broadens, realistic value systems must be flexible
enough to grow… part 1. Supervisor Nurse, 11,
27–30.
Operational Assessment in Strategic Planning. (2012).
H&HN: Hospitals & Health Networks, 86(11), 39–41.
Saint-Amand, A. (2008, February 6). Building an expert
exchange. Networks in decision-making. O’Reilly
Media, Inc. Retrieved April 22, 2013, from http://
en.oreilly.com/money2008/public/schedule/
detail/2187
Voges, N. (2012). The ethics of mission and margin.
Healthcare Executive, 27(5), 30–32, 34, 36.
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162
8
Planned Change
… managing and innovation did not always fit comfortably together. That’s not surprising. Managers
are people who like order. They like forecasts to come out as planned. In fact, managers are often
judged on how much order they produce. Innovation, on the other hand, is often a disorderly
process. Many times, perhaps most times, innovation does not turn out as planned. As a result, there
is tension between managers and innovation.
—Lewis Lehro (about the first years at Minnesota Mining and Manufacturing)
… I can’t understand why people are frightened of new ideas. I’m frightened of old ones.
—John Cage
CROSSWALK this Chapter addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential III: scholarship for evidence-based practice
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
MSN Essential II: Organizational and systems leadership
MSN Essential IV: translating and integrating scholarship into practice
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
MSN Essential IX: advanced generalist nursing practice
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency V: Business skills
QSEN Competency: teamwork and collaboration
LEARNING OBJECTIVES The learner will:
l differentiate between planned change and change by drift
l identify the responsibilities of a change agent
l develop strategies for unfreezing, movement, and refreezing a specific planned change
l assess driving and restraining forces for change in given situations
l apply rational–empirical, normative–reeducative, and power–coercive strategies for effecting change
l describe resistance as a natural and expected response to change
l identify and implement strategies to manage resistance to change
l involve all those who may be affected by a change in planning for that change whenever possible
l identify characteristics of aged organizations as well as strategies to keep them ever-renewing
l identify critical features of complex adaptive systems change theory
l describe the impact of chaos and the butterfly effect on both short- and long-term planning
l plan at least one desired personal change

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Chapter 8 Planned Change 163
Many forces are driving change in contemporary health care, including rising health-care
costs, declining reimbursement, workforce shortages, increasing technology, the dynamic
nature of knowledge, and a growing elderly population. Contemporary health-care agencies
then must continually institute change to upgrade their structure, promote greater quality,
and keep their workers. In fact, most health-care organizations find themselves undergoing
continual change directed at organizational restructuring, quality improvement, and employee
retention.
In most cases, these changes are planned. Planned change, in contrast to accidental change
or change by drift, results from a well thought-out and deliberate effort to make something
happen. Planned change is the deliberate application of knowledge and skills by a leader to
bring about a change. Successful leader-managers must be well grounded in change theories
and be able to apply such theories appropriately.
Today, most health-care organizations find themselves undergoing continual change directed at
organizational restructuring, quality improvement, and employee retention.
Many change attempts fail because the individual undertaking the change uses an unstructured
approach to implementation (Mitchell, 2013). Indeed, what often differentiates a successful
change effort from an unsuccessful one is the ability of the change agent—a person skilled in
the theory and implementation of planned change—to deal appropriately with conflicted human
emotions and to connect and balance all aspects of the organization that will be affected by that
change. In organizational planned change, the manager is often the change agent.
In some large organizations today, however, multidisciplinary teams of individuals,
representing all key stakeholders in the organization, are assigned the responsibility for
managing the change process. In such organizations, this team manages the communication
between the people leading the change effort and those who are expected to implement the
new strategies. In addition, this team manages the organizational context in which change
occurs and the emotional connections essential for any transformation.
But having a skilled change agent alone is not enough. Change is never easy, and
regardless of the type of change, all major change brings feelings of achievement and pride
as well as loss and stress. The leader then must use developmental, political, and relational
expertise to ensure that needed change is not sabotaged.
In addition, many good ideas are never realized because of poor timing or a lack of power
on the part of the change agent. For example, both organizations and individuals tend to reject
outsiders as change agents because they are perceived as having inadequate knowledge or
expertise about the current status, and their motives often are not trusted. Therefore, there
is more widespread resistance if the change agent is an outsider. The outside change agent,
however, tends to be more objective in his or her assessment, whereas the inside change agent
is often influenced by a personal bias regarding how the organization functions.
Likewise, some greatly needed changes are never implemented because the change agent
lacks sensitivity to timing. If the organization or the people within that organization have
recently undergone a great deal of change or stress, any other change should wait until group
resistance decreases.
It becomes clear that initiating and coordinating change requires well-developed leadership
and management skills. It also requires vision and expert planning skills because a vision is not
the same as a plan. The failure to reassess goals proactively and to initiate these changes results
in misdirected and poorly used fiscal and human resources. Leader-managers must be visionary
in identifying where change is needed in the organization and they must be flexible in adapting
to change they directly initiated as well as change that has indirectly affected them. Display 8.1
delineates selected leadership roles and management functions necessary for leader-managers
acting either in the change agent role or as a coordinator of the planned change team.
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164 UNIT III ROLES AND FUNCTIONS IN PLANNING
THE DEVELOPMENT OF CHANGE THEORY: KURT LEWIN
Most of the current research on change builds on the classic change theories developed by
Kurt Lewin in the mid-20th century. Lewin (1951) identified three phases through which the
change agent must proceed before a planned change becomes part of the system: unfreezing,
movement, and refreezing.
Unfreezing occurs when the change agent convinces members of the group to change or
when guilt, anxiety, or concern can be elicited. Thus, people become discontented and aware
of a need to change. For effective change to occur, the change agent needs to have made a
thorough and accurate assessment of the extent of and interest in change, the nature and depth
of motivation, and the environment in which the change will occur.
Because human beings have little control over many changes in their lives, the change agent
must remember that people need a balance between stability and change in the workplace.
Change for change’s sake subjects employees to unnecessary stress and manipulation.
Change should be implemented only for good reasons.
The second phase of planned change is movement. In movement, the change agent
identifies, plans, and implements appropriate strategies, ensuring that driving forces exceed
LEADERSHIP ROLES
1. is visionary in identifying areas of needed change in the organization and the health-care system.
2. demonstrates risk taking in assuming the role of change agent.
3. demonstrates flexibility in goal setting in a rapidly changing health-care system.
4. anticipates, recognizes, and creatively problem solves resistance to change.
5. serves as a role model to followers during planned change by viewing change as a challenge and
opportunity for growth.
6. role models high-level interpersonal communication skills in providing support for followers
undergoing rapid or difficult change.
7. demonstrates creativity in identifying alternatives to problems.
8. demonstrates sensitivity to timing in proposing planned change.
9. takes steps to prevent aging in the organization and to keep current with the new realities of
nursing practice.
10. supports and reinforces the individual adaptive efforts of those affected by change.
MANAGEMENT FUNCTIONS
1. Forecasts unit needs with an understanding of the organization’s and unit’s legal, political,
economic, social, and legislative climate.
2. recognizes the need for planned change and identifies the options and resources available to
implement that change.
3. appropriately assesses and responds to the driving and restraining forces when planning for
change.
4. identifies and implements appropriate strategies to minimize or overcome resistance to change.
5. seeks subordinates’ input in planned change and provides them with adequate information
during the change process to give them some feeling of control.
6. supports and reinforces the individual efforts of subordinates during the change process.
7. identifies and uses appropriate change strategies to modify the behavior of subordinates as
needed.
8. periodically assesses the unit/department for signs of organizational aging and plans renewal
strategies.
9. Continues to be actively involved in the refreezing process until the change becomes part of the
new status quo.
DISPLAY 8.1 Leadership Roles and Management Functions in Planned Change

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Chapter 8 Planned Change 165
restraining forces. Because change is such a complex process, it requires a great deal of
planning and intricate timing. Recognizing, addressing, and overcoming resistance may
be a lengthy process, and whenever possible, change should be implemented gradually.
Any change of human behavior, or the perceptions, attitudes, and values underlying that
behavior, takes time.
LEARNING EXERCISE 8.1
Unnecessary Change
try to remember a situation in your own life that involved unnecessary change. Why do you think
that the change was unnecessary? What types of turmoil did it cause? Were there things a
change agent could have done that would have increased unfreezing in this situation?
The last phase is refreezing. During the refreezing phase, the change agent assists in
stabilizing the system change so that it becomes integrated into the status quo. If refreezing is
incomplete, the change will be ineffective and the prechange behaviors will be resumed. For
refreezing to occur, the change agent must be supportive and reinforce the individual adaptive
efforts of those affected by the change. Because change needs at least 3 to 6 months before
it will be accepted as part of the system, the change agent must be sure that he or she will
remain involved until the change is completed.
Change agents must be patient and open to new opportunities during refreezing, as complex
change takes time and several different attempts may be needed before desired outcomes are
achieved.
It is important to remember though that refreezing does not eliminate the possibility of further
improvements to the change. Indeed, measuring the impact of change should always be a part
of refreezing. Display 8.2 illustrates the change agent’s responsibilities during the various
stages of planned change.
STAGE 1—UNFREEZING
1. Gather data.
2. accurately diagnose the problem.
3. decide if change is needed.
4. Make others aware of the need for change; often involves deliberate tactics to raise the group’s
discontent level; do not proceed to stage 2 until the status quo has been disrupted and the need
for change is perceived by the others.
STAGE 2—MOVEMENT
1. develop a plan.
2. set goals and objectives.
3. identify areas of support and resistance.
4. include everyone who will be affected by the change in its planning.
5. set target dates.
6. develop appropriate strategies.
7. implement the change.
DISPLAY 8.2 Stages of Change and Responsibilities of the Change Agent
(Continued)
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166 UNIT III ROLES AND FUNCTIONS IN PLANNING
LEWIN’S DRIVING AND RESTRAINING FORCES
Lewin also theorized that people maintain a state of status quo or equilibrium by the
simultaneous occurrence of both driving forces (facilitators) and restraining forces (barriers)
operating within any field. Driving forces advance a system toward change; restraining forces
impede change.
The forces that push the system toward change are driving forces, whereas the forces that pull
the system away from change are called restraining forces.
Examples of driving forces might include a desire to please one’s boss, to eliminate a
problem that is undermining productivity, to get a pay raise, or to receive recognition.
Restraining forces include conformity to norms, an unwillingness to take risks, and a fear of
the unknown.
Lewin’s model suggested that people like feeling safe, comfortable, and in control of their
environment. For change to occur then, the balance of driving and restraining forces must be
altered. The driving forces must be increased or the restraining forces decreased.
In Figure 8.1, the person wishing to return to school must reduce the restraining forces or
increase the driving forces to alter the present state of equilibrium. There will be no change
or action until this occurs. Therefore, creating an imbalance within the system by increasing
the driving forces or decreasing the restraining forces is one of the tasks required of a change
agent.
8. Be available to support others and offer encouragement through the change.
9. Use strategies for overcoming resistance to change.
10. evaluate the change.
11. Modify the change, if necessary.
STAGE 3—REFREEZING
support others so that the change continues.
FIGURE 8.1 • driving and restraining forces.

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Chapter 8 Planned Change 167
A CONTEMPORARY ADAPTATION OF LEWIN’S MODEL
Burrowes and Needs (2009) shared a more contemporary adaptation of Lewin’s model in
their discussion of a five-step Stages of Change Model (SCM). In this model, the first stage
is precontemplation. During this stage, the individual “has no intention to change his or her
behavior in the foreseeable future” (p. 41). Next comes the contemplation stage, at which
point the individual considers making a change, but has not yet made a commitment to take
action. This would be the phase in which unfreezing would occur, according to Lewin.
A transition from unfreezing to movement begins in the preparation stage, as the individual
intends to take action in the short-term future. The action stage then occurs (movement) in
which the individual actively modifies his or her behavior. Finally, the process ends with
the maintenance stage at which point the individual works to maintain changes made during
the action stage and prevent relapse. This stage would be synonymous with refreezing.
Display 8.3 illustrates the steps of the SCM.
Stage 1: Precontemplation No current intention to change.
Stage 2: Contemplation individual considers making a change.
Stage 3: Preparation there is intent to make a change in the near future.
Stage 4: Action individual modifies his or her behavior.
Stage 5: Maintenance Change is maintained and relapse is avoided.
DISPLAY 8.3 Stages of Change Model (Burrowes & Needs, 2009)
Burrowes and Needs (2009) suggest that breaking the process of change down into steps
makes it easier to assess an individual’s readiness to change. For example, change agents
might need to consider using motivation enhancement strategies if individuals are in the
contemplation stage, whereas more action-based interventions would be appropriate for
individuals who have already made a commitment to change. The actions taken by change
agents in the action stage would be the same as those identified by Lewin for movement and
in maintenance for refreezing.
CLASSIC CHANGE STRATEGIES
In addition to being aware of the stages of change, the change agent must be highly skilled
in the use of behavioral strategies to prompt change in others. Three such classic strategies
for effecting change were described by Bennis, Benne, and Chinn (1969), with the most
appropriate strategy for any situation depending on the power of the change agent and the
amount of resistance expected from the subordinates.
LEARNING EXERCISE 8.2
Making Change Possible
identify a change that you would like to make in your personal life (such as losing weight,
exercising daily, and stopping smoking). List the restraining forces keeping you from making this
change. List the driving forces that make you want to change. determine how you might be able
to change the status quo and make the change possible.
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168 UNIT III ROLES AND FUNCTIONS IN PLANNING
One of these strategies is to give current research as evidence to support the change. This
group of strategies is often referred to as rational–empirical strategies. The change agent
using this set of strategies assumes that resistance to change comes from a lack of knowledge
and that humans are rational beings who will change when given factual information
documenting the need for change. This type of strategy is used when there is little anticipated
resistance to the change or when the change is perceived as reasonable.
Because peer pressure is often used to effect change, another group of strategies exists,
which use group process and these are called normative–reeducative strategies. These
strategies use group norms and peer pressure to socialize and influence people so that change
will occur. The change agent assumes that humans are social creatures, more easily influenced
by others than by facts. This strategy does not require the change agent to have a legitimate
power base. Instead, the change agent gains power by skill in interpersonal relationships.
He or she focuses on noncognitive determinants of behavior, such as people’s roles and
relationships, perceptual orientations, attitudes, and feelings, to increase acceptance of change.
The third group of strategies, power–coercive strategies, features the application of power by
legitimate authority, economic sanctions, or political clout of the change agent. These strategies
include influencing the enactment of new laws and using group power for strikes or sit-ins. Using
authority inherent in an individual position to effect change is another example of a power–
coercive strategy. These strategies assume that people often are set in their ways and will change
only when rewarded for the change or when they are forced by some other power–coercive
method. Resistance is handled by authority measures; the individual must accept it or leave.
Often, the change agent uses strategies from each of these three groups. An example may
be reflected in the change agent who wants someone to stop smoking. The change agent might
present the person with the latest research on cancer and smoking (the rational–empirical
approach); at the same time, the change agent might have friends and family encourage the
person socially (normative–reeducative approach). The change agent also might refuse to ride
in the smoker’s car if the person smokes while driving (power–coercive approach). By selecting
from each set of strategies, the change agent increases the chance of successful change.
LEARNING EXERCISE 8.3
Using Change Strategies to Increase Sam’s Compliance
You are a staff nurse in a home health agency. One of your patients, sam Little, is a 38-year-
old man with type 1 diabetes. he has developed some loss of vision and had to have two toes
amputated as consequences of his disease process. sam’s compliance with four-times-daily
blood glucose monitoring and sliding-scale insulin administration has never been particularly
good, but he has been worse than usual lately. sam refuses to use an insulin pump; however, he
has been willing to follow a prescribed diabetic diet and has kept his weight to a desired level.
sam’s wife called you at the agency yesterday and asked you to work with her in developing a
plan to increase sam’s compliance with his blood glucose monitoring and insulin administration.
she said that sam, while believing it “probably won’t help,” has agreed to meet with you to
discuss such a plan. he does not want, however, “to feel pressured into doing something he
doesn’t want to do.”
Assignment: What change strategy or combination thereof (rational–empirical, normative–
reeducative, and power–coercive) do you believe has the greatest likelihood of increasing
sam’s compliance? how could you use this strategy? Who would be involved in this change
effort? What efforts might you undertake to increase the unfreezing so that sam is more willing
to actively participate in such a planned change effort?

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Chapter 8 Planned Change 169
RESISTANCE: THE EXPECTED RESPONSE TO CHANGE
Even though change is inevitable, it creates instability in our lives and some conflict should
always be expected between those supporting the status quo and those advocating for change
(Amos, Johns, Hines, Skov, & Kloosterman, 2012). Indeed, conflict and resistance almost
always accompany change because change alters the balance of a group.
The level of resistance, however, generally depends on the type of change proposed.
Technological changes encounter less resistance than changes that are perceived as social or
that are contrary to established customs or norms. For example, nursing staff are more willing
to accept a change in the type of IV pump to be used than a change regarding who is able to
administer certain types of IV therapy. Nursing leaders also must recognize that subordinates’
values, educational levels, cultural and social backgrounds, and experiences with change
(positive or negative) will have a tremendous impact on the degree of resistance. It is also
much easier to change a person’s behavior than it is to change an entire group’s behavior.
Likewise, it is easier to change knowledge levels than attitudes.
Similarly, Amos et al. (2012) suggest that straightforward change, learning to do something
a different way, and responding to something that obviously needs to be changed are often
relatively easy to accomplish. However, changing something that involves a challenge to the
beliefs that underpin our lives threatens the security of the individuals involved and these
types of changes are much more apt to result in resistance.
In an effort to eliminate resistance to change in the workplace, managers historically used
an autocratic leadership style with specific guidelines for work, an excessive number of rules,
and a coercive approach to discipline. The resistance, which occurred anyway, was both
covert (such as delaying tactics and passive–aggressive behavior) and overt (openly refusing
to follow a direct command). The result was wasted managerial energy and time and a high
level of frustration.
Because change disrupts the homeostasis or balance of the group, resistance should always be
expected.
Today, resistance is recognized as a natural and expected response to change and leader-
managers must resist the impulse to focus on blaming others when resistance to planned
change occurs. Instead, they should immerse themselves in identifying and implementing
strategies to minimize or manage this resistance to change. One such strategy is to encourage
subordinates to speak openly so that options can be identified to overcome objections.
In addition, it is the role of the leader to see the vision of what the future state will be
like after the change has taken place and to share that vision with their followers. If people
cannot see the benefit to themselves, their working practices or to patient care, then they will
continue to be resistant (Stonehouse, 2012).
Likewise, workers should be encouraged to talk about their perceptions of the forces driving
the planned change so that the leader can accurately assess change support and resources. It
takes a strong leader to step up and engage when a change effort meets with pushback.
Still, there are individual variations in terms of risk taking and willingness to accept
change. Some individuals, even at very early ages, demonstrate more risk taking than others.
Certainly temperament and personality play at least some role in this. Change agents then
should be aware of life history variables as well as risk-taking propensity when assessing the
likelihood of an individual or group being willing to change.
Early in a planned change then, leader-managers should assess which workers will
promote or resist a specific change, by both observation and direct communication. Then,
the manager can collaborate with change promoters on how best to convert those individuals
more resistant to change.
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170 UNIT III ROLES AND FUNCTIONS IN PLANNING
Perhaps the greatest factor contributing to the resistance encountered with change is a
lack of trust between the employee and the manager or the employee and the organization.
Workers want security and predictability. That is why trust erodes when the ground rules
change, as the assumed “contract” between the worker and the organization is altered.
Subordinates’ confidence in the change agent’s ability to manage change depends on whether
they believe that they have sufficient resources to cope with it. In addition, the leader-
manager must remember that subordinates in an organization will generally focus more on
how a specific change will affect their personal lives and status than on how it will affect
the organization.
Perhaps that is why research by Spetz, Burgess, and Phibbs (2012) suggested that
organizational stability, team leadership skills, and flexibility in implementation were
key factors influencing successful implementation of a computerized patient record
system (CPRS) and Bar Code Medication Administration (BCMA) in the VA health-care
system over the past decade. Staff and managers faced numerous challenges since these
information technology (IT) systems changed how care was organized, documented,
and communicated. Most staff reported being frightened or nervous about the change
and found it difficult to see the opportunities the change would bring in the future.
Having an experienced change agent or project champion to help staff work through this
resistance as well as to oversee implementation of training, support, workflow changes,
and communication was critical to the system-wide change effort’s success (Examining
the Evidence 8.1).
LEARNING EXERCISE 8.4
What Is Your Attitude Toward Change?
how do you typically respond to change? do you embrace it? seek it out? accept it reluctantly?
avoid it at all cost? is this behavioral pattern similar to your friends and that of your family? has
your behavior always fit this pattern, or has the pattern changed throughout your life? if so, what
life events have altered how you view and respond to change?
Source: Spetz, J., Burgess, J. F., & Phibbs, C. S. (2012). What determines successful implementation of inpatient
information technology systems? american Journal of Managed Care, 18(3), 157–162.
The US Department of Veterans Affairs (VA), the nation’s largest integrated health-care system,
has made one of the largest investments in hospital-based information technology (HIT) in the
United States, implementing a fully integrated system nationwide. Their CPRS was phased in
over a decade in the early 1990s and BCMA was implemented over a much shorter time period,
with implementation required 1 year after the software became available.
This qualitative study (118 interviews at 7 VA hospitals over a 15-month time) examined the
factors and strategies associated with successful implementation of these HIT interventions in
VA inpatient settings. Five broad themes were identified as factors affecting the process and
success of implementation: (1) organizational stability and implementation team leadership,
(2) implementation timelines, (3) equipment availability and reliability, (4) staff training, and (5)
changes in workflow.
Examining the Evidence 8.1

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Chapter 8 Planned Change 171
PLANNED CHANGE AS A COLLABORATIVE PROCESS
Often, the change process begins with a few people who meet to discuss their dissatisfaction
with the status quo, and an inadequate effort is made to talk with anyone else in the
organization. This approach virtually guarantees that the change effort will fail. People abhor
“information vacuums,” and when there is no ongoing conversation about the change process,
gossip usually fills the void. These rumors are generally much more negative than anything
that is actually happening.
As a rule, anyone who will be affected by a change should be included in planning it.
When information and decision making are shared, subordinates feel that they have played
a valuable role in the change. Change agents and the elements of the system—the people
or groups within it—must openly develop goals and strategies together. All must have the
opportunity to define their interest in the change, their expectation of its outcome, and their
ideas on strategies for achieving change.
It is not always easy, however, to attain grassroots involvement in planning efforts. Even when
managers communicate that change is needed and subordinate feedback is wanted, the message
often goes unheeded. Some people in the organization may need to hear a message repeatedly
before they listen, understand, and believe the message. If the message is one that they do not
want to hear, it may take even longer for them to come to terms with the anticipated change.
Whenever possible, all those who may be affected by a change should be involved in planning
for that change.
When change agents fail to communicate with the rest of the organization, they prevent
people from understanding the principles that guided the change, what has been learned from
prior experience, and why compromises have been made. Likewise, subordinates affected by
the change should thoroughly understand the change and the impacts that will likely result.
Good, open communication throughout the process can reduce resistance. Leaders must
ensure that group members share perceptions about what change is to be undertaken, who is
to be involved and in what role, and how the change will directly and indirectly affect each
person in the organization.
THE LEADER-MANAGER AS A ROLE MODEL DURING PLANNED CHANGE
Leader-managers must act as role models to subordinates during the change process.
The leader-manager must attempt to view change positively and to impart this view to
subordinates. Rather than viewing change as a threat, managers should embrace it as a
challenge and the chance or opportunity to do something new and innovative. Indeed,
the leader has two responsibilities in facilitating change in nursing practice. First, leader-
managers must be actively engaged in change in their own work and model this behavior
to staff. Second, leaders must be able to assist staff members in making the needed change
requirements in their work.
Overall IT implementation success depended on (1) whether there was support for change from
both leaders and staff; (2) development of a gradual and flexible implementation approach;
(3) allocation of adequate resources for equipment and infrastructure, hands-on support, and
deployment of additional staff; and (4) how the implementation team planned for setbacks,
and continued the process to achieve success. Problems that developed in the early stages of
implementation tended to become persistent, and poor implementation was noted to be related
to an increased risk of patient harm.
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172 UNIT III ROLES AND FUNCTIONS IN PLANNING
It is critical that managers not view change as a threat.
Managers must also believe that they can make a difference. This feeling of control is
probably the most important trait for thriving in a changing environment. Unfortunately,
many leader-managers lack confidence in their ability to serve as an effective change agent
as noted in research conducted by Salmela, Eriksson, and Fagerström (2013) (Examining
the Evidence 8.2). The end result, when this occurs, is a lack of engagement in the change
process and a role modeling to followers that the change may not be worth the time and
energy necessary to bring it to fruition.
Source: Salmela, S., Eriksson, K., & Fagerström, L. (2013). Nurse leaders’ perceptions of an approaching organiza-
tional change. Qualitative health research, 23(5), 689–699.
The aim of this study was to better understand nurse-leaders’ perceptions of approaching orga-
nizational change. Using a three-dimensional hermeneutical method of interpretation to analyze
text from 17 interviews, the researchers found that nurse-leaders’ were positive toward and
actively engaged in continual change on their units, but perceived themselves as mere specta-
tors of the change process. While they believed that change might yield positive benefits, their
adaptation lacked deeper engagement. This occurred in part because many felt uneasiness and
anxiety with regard to their leadership role, the future of nursing care, and their mandate to be a
patient advocate. The researchers concluded that while nurse-leaders’ are in a critical position to
influence the success of organizational change, the organizations covered in this study did not
incorporate their knowledge and experience in approaching change.
Examining the Evidence 8.2
“As healthcare organizations continue to change and develop to meet new political agendas,
meeting the needs of patients and associated improvements to service will be shaped by those
who are willing to take ideas forward” (Norman, 2012, p. 162).
ORGANIZATIONAL CHANGE ASSOCIATED WITH NONLINEAR DYNAMICS
Most 21st-century organizations experience fairly brief periods of stability followed by
intense transformation. In fact, some later organizational theorists feel that Lewin’s refreezing
to establish equilibrium should not be the focus of contemporary organizational change since
change is unforeseeable and ever present. This is particularly true in health-care organizations,
where long-term outcomes are almost always unpredictable.
In the past, organizations looked at change and organizational dynamics as linear,
occurring both in steps and sequentially. More contemporary theorists maintain that the world
is so unpredictable that such dynamics are truly nonlinear. As a result, nonlinear change
theories such as complex adaptive systems (CAS) theory and chaos theory now influence the
thinking of many organizational leaders.
Complexity and Complex Adaptive Systems Change Theory
Complexity science has emerged from the exploration of the subatomic world and quantum
physics and suggests that the world is complex as are the individuals who operate within it.
Thus, control and order are emergent rather than predetermined, and mechanistic formulas
do not provide the flexibility needed to predict what actions will result in what outcomes.

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Chapter 8 Planned Change 173
CAS theory, an outgrowth of complexity theory, suggests that the relationship between
elements and agents within any system is nonlinear and that these elements are the key
players in changing settings or outcomes.
CAS theory suggests that the relationship between elements and agents within any system is
nonlinear and that these elements are constantly in play to change the environment or outcome.
For example, while an individual may have behaved one way in the past, CAS theory suggests
that future behavior may not always be the same (not always predictable). This is because
that individual’s prior experience and past learning may change her or his future choices. In
addition, the rules or parameters of each situation are different, even if these differences are
subtle; even small variations can dramatically alter choice of action. CAS theory also suggests
that the actions of any agent within the system affect all other agents in the system; that is,
that context and action are interconnected. Finally, CAS theory suggests that there are always
hidden or unanticipated elements in systems that make linear thinking almost impossible.
In their classic work on CAS, Olson and Eoyang (2001) suggest that the self-organizing
nature of human interactions in a complex organization leads to surprising effects. Rather
than focusing on the macro-level of the organization system, complexity theory suggests that
most powerful change processes occur at the micro-level, where relationships, interactions,
and simple rules shape emerging patterns. The main features of the CAS approach are shown
in Display 8.4.
In applying CAS theory to planned change, it becomes clear that the multidimensionality
of health-care organizations, and the individuals who work within them, results in significant
challenges for the change agent. Change agents then must carefully examine and focus on the
relationships between the elements and be careful not to look at any one element in isolation
from the others. It also suggests that time and attention must be given to trying to understand
these relationships and interactions even before unfreezing is attempted and that continual
monitoring and adaptation will likely be needed for movement and refreezing to be successful.
Chaos Theory
The roots of chaos theory, considered by some to be a subset of complexity science, likely
emerged from the early work of meteorologist Edward Lorenz in the 1960s to improve
weather forecasting techniques (Massachusetts Institute of Technology [MIT] News, 2008).
Lorenz discovered that even tiny changes in variables often dramatically affected outcomes.
● Change should be achieved through connections among change agents instead of from the top-
down.
● there should be adaptation to uncertainty during the change instead of trying to predict stages of
development.
● Goals, plans, and structures should be allowed to emerge instead of depending on clear, detailed
plans and goals.
● Value differences should be amplified and explored instead of focusing on consensus in change
efforts.
● patterns in one part of the organization are often repeated in another part. thus, change does
not need to begin at the top of an organization to be successful. the goal instead is self-similarity
rather than differences in how change is implemented in different parts of the organization.
● successful change fits with the current organizational environment instead of with an ideal. this is
what makes it sustainable.
DISPLAY 8.4 Main Features of Olson and Eoyang’s (2001) Complex Adaptive Systems
Approach to Change
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174 UNIT III ROLES AND FUNCTIONS IN PLANNING
Lorenz also discovered that even though these chaotic changes appeared to be random, they
were not. Instead, he found that there were deterministic sequences and physical laws, which
prevail in nature, even if this does not appear to be the case. This is why Rae (n.d.) argues that
chaos theory is really about finding order in what appears to be random data.
Chaos theory is really about finding the underlying order in apparently random data.
Determining this underlying order, however, is challenging, and the order itself is constantly
changing. This chaos makes it difficult to predict the future. In addition, chaos theory suggests
that even small changes in conditions can drastically alter a system’s long-term behavior
(commonly known as the butterfly effect). Thus, changes in outcomes are not proportional to
the degree of change in the initial condition. As a result of this sensitivity, the behavior of a
system exhibiting chaos appears to be random, even though the system is deterministic in the
sense that it is well defined and contains no random parameters.
Chaos and complexity theories have great application within the health-care arena. For
example, despite putting a great time of energy and time into planning, many plans with
sharply delivered strategies and targets are often not effective. This is because hidden
variables are not explored and general goals and boundaries are not developed. For example,
a single individual or unit can undermine a planned organizational change, particularly if the
actions of that individual or unit to undermine the change are covert. The change agent might
inadvertently focus on the aftermath of the subversive action without ever realizing the root
cause of the problem.
It is imperative that change agents have an understanding of complexity theory and chaos
theory since the use of nonlinear theories to explain organizational functioning and change
are expected to increase in the 21st century. Rae (n.d.) agrees, arguing that
Chaos has already had a lasting effect on science, yet there is much … to be discovered. Many
scientists believe that twentieth century science will be known for only three theories: relativity,
quantum mechanics, and chaos. Aspects of chaos show up everywhere around the world, from
the currents of the ocean and the flow of blood through fractal blood vessels to the branches
of trees and the effects of turbulence. Chaos has inescapably become part of modern science.
As chaos changed from a little-known theory to a full science of its own, it has received
widespread publicity. Chaos theory has changed the direction of science: in the eyes of the
general public, physics is no longer simply the study of subatomic particles in a billion-dollar
particle accelerator, but the study of chaotic systems and how they work (para 33).
ORGANIZATIONAL AGING: CHANGE AS A MEANS OF RENEWAL
Organizations progress through developmental stages, just as people do—birth, youth,
maturity, and aging. As organizations age, structure increases to provide greater control
and coordination. The young organization is characterized by high energy, movement,
and virtually constant change and adaptation. Aged organizations have established “turf
boundaries,” function in an orderly and predictable fashion, and are focused on rules and
regulations. Change is limited.
It is clear that organizations must find a balance between stagnation and chaos, between
birth and death. In the process of maturing, workers within the organization can become
prisoners of procedures, forget their original purposes, and allow means to become the ends.
Without change, the organization may stagnate and die. Organizations need to keep foremost
what they are going to do, not what they have done.
For example, Bayan (2012), Gordon (2012), and Owarish (2013) shared insights regarding
Kodak, founded in 1880 by George Eastman, and one of America’s most notable companies,
helping establish the market for camera film and then dominating the field. But it suffered

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Chapter 8 Planned Change 175
from a variety of problems over the last four decades—almost all related to being an aged
organization. Kodak’s top management never fully grasped how the world around them was
changing and they hung on to obsolete assumptions (such as digital prints will never replace
film prints) long after they were no longer the case.
In addition, Kodak followed a pattern seen by a number of aged organizations who face
technological change. First, they tried to ignore a new technology hoping it would go away by
itself. Then they openly put it down by using various justifications such as it is too expensive,
too slow, and too complicated. Then they tried to prolong the life of the existing technology
by attempting to create synergies between the new technology and the old (like photo CD).
This further delayed any serious commitment to the new order of things.
In the end, Kodak failed to realize its limitations, ignored the data, and spent an additional
15 years in avoidance mode until it became virtually irrelevant in the market. With only one
full year of profit after 2004, Kodak ended up filing for bankruptcy in 2012, after 131 years
of being the pioneer in the film industry.
Philpot (2013) provides another example in her accounting of Blackberry’s market plunge
from having 40% of the smartphone market in North America in 2010 to only 2% by the end of
2012. Philpot suggests this death spiral occurred as the result of accelerated obsolescence and
notes that the “shelf life” of any business model is shorter now than ever before. She concludes
that leaders today have to know how to “keep one foot in today and the other in tomorrow. In
other words, their responsibility is to successfully execute their current business model while
also re-inventing their company to compete in a market that they have not yet seen” (para 4).
LEARNING EXERCISE 8.5
Young or Old Organization?
reflect on the organization in which you work or the nursing school you attend. do you believe
that this organization has more characteristics of a young or aged organization? diagram on a
continuum from birth to death where you feel that this organization would fall. What efforts has
this organization taken to be dynamic and innovative? What further efforts could be made? do
you agree or disagree that most organizations change unpredictably? Can you support your
conclusions with examples?
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
IN PLANNED CHANGE
It should be clear that leadership and management skills are necessary for successful planned
change to occur. The manager must understand the planning process and planning standards
and be able to apply both to the work situation. The manager is also cognizant of the specific
driving and restraining forces within a particular environment for change and is able to
provide the tools or resources necessary to implement that change. The manager, then, is the
mechanic who implements the planned change.
The leader, however, is the inventor or creator. Leaders today are forced to plan in a chaotic
health-care system that is changing at a frenetic pace. Out of this chaos, leaders must identify
trends and changes that may affect their organizations and units and proactively prepare for
these changes. Thus, the leader must retain a big-picture focus while dealing with each part
of the system. In the inventor or creator role, the leader displays such traits as flexibility,
confidence, tenacity, and the ability to articulate vision through insights and versatile
thinking. The leader also must constantly look for and attempt to adapt to the changing
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176 UNIT III ROLES AND FUNCTIONS IN PLANNING
and unpredictable interactions between agents and environmental factors as outlined by the
complexity science theorists.
Both leadership and management skills are necessary in planned change. The change
agent fulfills a management function when identifying situations where change is necessary
and appropriate and when assessing the driving and restraining forces affecting the plan for
change. The leader is the role model in planned change. He or she is open and receptive
to change and views change as a challenge and an opportunity for growth. Other critical
elements in successful planned change are the change agent’s leadership skills—interpersonal
communication, group management, and problem-solving abilities.
Perhaps, there is no greater need for the leader than to be the catalyst for professional
change as well as organizational change. Many people attracted to nursing now find that their
values and traditional expectations no longer fit as they once did. It is the leader’s role to help
their followers turn around and confront the opportunities and challenges of the realities of
emerging nursing practice; to create enthusiasm and passion for renewing the profession; to
embrace the change of locus of control, which now belongs to the health-care consumer; and
to engage a new social context for nursing practice.
KEY CONCEPTS
● Change should not be viewed as a threat but as a challenge and a chance to do something new and
innovative.
● Change should be implemented only for good reason.
● Because change disrupts the homeostasis or balance of the group, resistance should be expected as a
natural part of the change process.
● the level of resistance to change generally depends on the type of change proposed. technological
changes encounter less resistance than changes that are perceived as social or that are contrary to
established customs or norms.
● perhaps the greatest factor contributing to the resistance encountered with change is a lack of trust
between the employee and the manager or the employee and the organization.
● it is much easier to change a person’s behavior than it is to change an entire group’s behavior. it is also
easier to change knowledge levels than attitudes.
● Change should be planned and thus implemented gradually, not sporadically or suddenly.
● those who may be affected by a change should be involved in planning for it. Likewise, workers should
thoroughly understand the change and its effect on them.
● the feeling of control is critical to thriving in a changing environment.
● Friends, family, and colleagues should be used as a network of support during change.
● the successful change agent has the leadership skills of problem solving and decision making and has
good interpersonal skills.
● in contrast to planned change, change by drift is unplanned or accidental.
● historically, many of the changes that have occurred in nursing or have affected the profession are the
results of change by drift.
● people maintain status quo or equilibrium when both driving and restraining forces operating within any field
simultaneously occur. For change to happen, this balance of driving and restraining forces must be altered.
● emerging theories such as complexity science suggest that change is unpredictable, occurs at random,
and is dependent upon rapidly changing relationships between agents and factors in the system and
that even small changes can affect an entire organization.
● Organizations are preserved by change and constant renewal. Without change, the organization may
stagnate and die.

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Chapter 8 Planned Change 177
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
LEARNING EXERCISE 8.7
Retain the Status Quo or Implement Change?
assume that morale and productivity are low on the unit where you are the new manager. in an
effort to identify the root of the problem, you have been meeting informally with staff to discuss
their perceptions of unit functioning and to identify sources of unrest on the unit. You believe that
one of the greatest factors leading to unrest is the limited advancement opportunity for your staff
nurses. You have a fixed charge nurse on each shift. this is how the unit has been managed for
as long as everyone can remember. You would like to rotate the charge nurse position but are
unsure of your staff’s feelings about the change.
Assignment: Using the phases of change identified by Lewin (1951), identify the actions
you could take in unfreezing, movement, and refreezing. What are the greatest barriers to this
change? What are the strongest driving forces?
LEARNING EXERCISE 8.8
How Would You Handle This Response to Change?
You are the unit manager of a cardiovascular surgical unit. the workstation on the unit is small,
dated, and disorganized. the unit clerks have complained for some time that the chart racks on
the counter above their desk are difficult to reach, that staff frequently impinge on the clerks’ work
(Continued)
LEARNING EXERCISE 8.6
Implementing Planned Change in a Family Planning Clinic
You are a hispanic rN who has recently received a 2-year grant to establish a family planning
clinic in an impoverished, primarily hispanic area of a large city. the project will be evaluated at
the end of the grant to determine whether continued funding is warranted. as project director,
you have the funds to choose and hire three health-care workers. You will essentially be able to
manage the clinic as you see fit.
the average age of your patients will be 14 years, and many come from single-parent homes. in
addition, the population with which you will be working has high unemployment, high crime and
truancy levels, and great suspicion and mistrust of authority figures. You are aware that many
restraining forces exist that will challenge you, but you feel strongly committed to the cause. You
believe that the high teenage pregnancy rate and maternal and infant morbidity can be reduced.
Assignment:
1. identify the restraining and driving forces in this situation.
2. identify realistic short- and long-term goals for implementing such a change. What can
realistically be accomplished in 2 years?
3. how might the project director use hiring authority to increase the driving forces in this
situation?
4. is refreezing of the planned change possible so that changes will continue if the grant is
not funded again in 2 years?
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178 UNIT III ROLES AND FUNCTIONS IN PLANNING
LEARNING EXERCISE 8.9
The Nursing Profession and Change
Assignment: if professions were classified in a manner similar to organizations, do you believe
that the nursing profession would be classified as (a) an aging organization, (b) in constant
motion and ever renewing, or (c) a closed system that does not respond well to change?
space to discuss patients or to chart, that the call-light system is antiquated, and that supplies
and forms need to be relocated. You ask all eight of your shift unit clerks to make a “wish list” of
how they would like the workstation to be redesigned for optimum efficiency and effectiveness.
Construction is completed several months later. You are pleased that the new workstation
incorporates what each unit clerk included in his or her top three priorities for change. there
is a new revolving chart rack in the center of the workstation, with enhanced accessibility to
both staff and unit clerks. a new state-of-the-art, call-light system has been installed. a small,
quiet room has been created for nurses to chart and conference, and new cubbyholes and filing
drawers now put forms within arm’s reach of the charge nurse and unit clerk.
almost immediately, you begin to be barraged with complaints about the changes. several of
the unit clerks find the new call-light system’s computerized response system overwhelming
and complain that patient lights are now going unanswered. Others complain that with the
chart rack out of their immediate work area, charts can no longer be monitored and are being
removed from the unit by physicians or left in the charting room by nurses. One unit clerk has
filed a complaint that she was injured by a staff member who carelessly and rapidly turned the
chart rack. she refuses to work again until the old chart racks are returned. the regular day-shift
unit clerk complains that all the forms are filed backward for left-handed people and that after
20 years, she should have the right to put them the way that she likes it. several of the nurses
are complaining that the workstation is “now the domain of the unit clerk” and that access to
the telephones and desk supplies is limited by the unit clerks. there have been some rumblings
that several staff members believe that you favored the requests of some employees over others.
today, when you make rounds at change of shift, you find the day-shift unit clerk and charge
nurse involved in a heated conversation with the evening-shift unit clerk and charge nurse. each
evening, the charge nurse and unit clerk reorganize the workstation in the manner that they
believe is most effective, and each morning, the charge nurse and unit clerk put things back the
way they had been the prior day. Both believe that the other shift is undermining their efforts to
“fix” the workstation organization and that their method of organization is the best. Both groups
of workers turn to you and demand that you “make the other shift stop sabotaging our efforts
to change things for the better.”
Assignment: despite your intent to include subordinate input into this planned change,
resistance is high and worker morale is decreasing. is the level of resistance a normal and
anticipated response to planned change? if so, would you intervene in this conflict? how? Was
it possible to have reduced the likelihood of such a high degree of resistance?
LEARNING EXERCISE 8.10
Overcoming Resistance to a Needed Change
You are the charge nurse of a medical/surgical unit. recently, your hospital spent millions of
dollars to implement BCMa to reduce medication errors and to promote a culture of patient
safety. in this system, the nurse, using a handheld device, scans the drug he or she is planning

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Chapter 8 Planned Change 179
REFERENCES
to give against the patient’s medication record to make sure that the right drug, at the right dose,
is being given at the right time to the right patient. the nurse then scans the patient’s name
band/arm band to assure the right patient is receiving the drug and finally scans his or her own
name badge to document who is administering the drug to the patient. if any of the codes do
not match, a signal goes off, alerting the nurse of the discrepancy.
it has come to your attention, however, that some nurses are overriding the safety features built
into the bar-coding system. For example, some nurses are reluctant to wake sleeping patients
to scan their bar code before they administer an iV push medication, and instead simply scan
the chart label. some nurses have overridden the bar code warning, assuming it was some
kind of technological glitch. some nurses have administered drugs to patients despite having
name bands that have become smudged or torn and no longer scan well. still other nurses
are carrying multiple prescanned pills on one tray or charting that drugs have been given, even
though they were left at the bedside. Finally, you learned that one nurse even affixed extra copies
of her patient’s bar codes to her clipboard, so that they could be scanned more quickly.
Assignment: despite thorough orientation and training regarding bar coding, it is clear that
some staff have developed “work-arounds” to the bar-coding system, increasing the risk of
medication errors and patient harm. Your staff suggest that while they understand BCMa
reduces risks to patients, that the equipment does not always work, and that performing the
additional safety checks inherent in BCMa often takes them more time than how they did it
in the past, ultimately delaying medications to patients who need them. the staff states they
will try to be more careful in implementing the BCMa procedures, but you continue to sense
resistance on their part. What strategies could you employ now to foster refreezing of the new
BCMa system? Would rational–empirical, power–coercive, or normative–reeducative strategies
be more effective? provide a rationale for your choice.
Amos, A., Johns, C., Hines, N., Skov, T., & Kloosterman,
L. (2012). The handwriting on the wall: Program
transformations utilizing effective change
management strategies. CANNT Journal,
22(2), 31–35.
Bayan, R. (2012, January 20). Elegy for Kodak: An American
icon goes bankrupt. Retrieved May 15, 2013, from
http://www.forbes.com/sites/ericsavitz/2013/02/25/
lessons-from-blackberrys-accelerated-obsolesence/
Bennis, W., Benne, K., & Chinn, R. (1969). The planning of
change (2nd ed.). New York, NY: Holt, Rinehart, &
Winston.
Burrowes, N., & Needs, A. (2009, January/February). Time
to contemplate change? A framework for assessing
readiness to change with offenders. Aggression &
Violent Behavior, 14(1), 39–49.
Gordon, M. (2012). The fall of Kodak: 5 lessons for small
business. Biznik. Retrieved May 13, 2014, from
http://biznik.com/articles/the-fall-of-kodak-5-lessons
-for-small-business
Lewin, K. (1951). Field theory in social sciences.
New York, NY: Harper & Row.
Massachusetts Institute of Technology (MIT) News. (2008,
April 30). Edward Lorenz, father of chaos theory
and butterfly effect, dies at 90. Retrieved May 12,
2013, from http://web.mit.edu/newsoffice/2008/obit
-lorenz-0416.html
Mitchell, G. (2013). Selecting the best theory to implement
planned change. Nursing Management—UK,
20(1), 32–37.
Norman, K. (2012). Leading service improvement in
changing times. British Journal of Community
Nursing, 17(4), 162–167.
Olson, E. E., & Eoyang, G. H. (2001). Facilitating
organization change: Lessons from complexity
science. San Francisco, CA: Jossey-Boss/Pfeiffer.
Owarish, F. (2013). Strategic leadership of technology:
Lessons learned. E-Leader Singapore. Retrieved May
14, 2013, from http://www.g-casa.com/conferences/
singapore12/papers/Owarish-2
Philpot, S. (2013, February 25). Lessons from BlackBerry’s
accelerated obsolescence. Forbes. Retrieved May
14, 2014, from http://www.forbes.com/sites/
ericsavitz/2013/02/25/lessons-from-blackberrys
-accelerated-obsolesence/
Rae, G. (n.d.). Chaos theory: A brief introduction. Retrieved
September 13, 2006, from http://www.imho.com/
grae/chaos/chaos.html
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http://www.imho.com/grae/chaos/chaos.html

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180 UNIT III ROLES AND FUNCTIONS IN PLANNING
Salmela, S., Eriksson, K., & Fagerström, L. (2013). Nurse
leaders’ perceptions of an approaching organizational
change. Qualitative Health Research, 23(5), 689–699.
Spetz, J., Burgess, J. F., & Phibbs, C. S. (2012). What
determines successful implementation of inpatient
information technology systems? American Journal
of Managed Care, 18(3), 157–162.
Stonehouse, D. (2012). Resistance to change: The human
dimension. British Journal of Healthcare Assistants,
6(9), 456–457.

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181
9
Time Management
… nothing is particularly hard if you divide it into small jobs.
—Henry Ford
… things which matter most must never be at the mercy of things that matter least.
—Johann Wolfgang von Goethe
CROSSWALK tHis cHapter addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
MSN Essential II: Organizational and systems leadership
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
QSEN Competency: safety
QSEN Competency: teamwork and collaboration
LEARNING OBJECTIVES The learner will:
l analyze how time is managed both personally and at the unit level of the organization
l describe the importance of allowing adequate time for daily planning and priority setting
l describe how planning fallacies influence the perception of the time needed to complete a
task
l complete tasks according to the priority level they have been assigned whenever possible
l build evaluation steps into planning so that reprioritization can occur
l identify common internal and external time wasters as well as interventions that can be taken
to reduce their impact
l complete a time inventory to increase self-awareness regarding personal priority setting and
time management
l identify how technology applications such as e-mail, the internet, telecommunications, and
social networking can both facilitate and hinder personal time management
l involve subordinates and followers in maximizing time use, and guiding work to its successful
implementation and conclusion
Another part of the planning process is short-term planning. This operational planning
focuses on achieving specific tasks. Short-term plans involve a period of 1 hour to 3 years
and are usually less complex than strategic or long-range plans. Short-term planning may be
done annually, quarterly, monthly, weekly, daily, or even hourly.
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182 UNIT III ROLES AND FUNCTIONS IN PLANNING
Previous chapters examined the need for prudent planning of resources, such as money,
equipment, supplies, and labor. Time is an equally important resource. Being overwhelmed
by work and time constraints leads to increased errors, the omission of important tasks, and
general feelings of stress and ineffectiveness. If leaders are to empower others to achieve
personal and shared goals, they need to become experts in the planning and implementation
of goal attainment. If managers are to direct employees effectively and maximize other
resources, they must first be able to find the time to do so. In other words, both must become
experts at time management.
Time management can be defined as making optimal use of available time. Homisak
(2012) notes that many people with poor time management skills spend inordinate amounts of
time burning the candle at both ends, blaming others for their time inefficiencies, and getting
others to work harder. The reality is that each person is given 86,400 seconds every day to use
as they please and when they are wasted, they can never be retrieved. Homisak (p. 41) goes
on to suggest that “we invite all the activities in our lives and unless we choose differently,
nothing will change.”
Good time management skills allow an individual to spend time on things that matter.
The keys then to optimizing time management must include prioritizing duties, managing
and controlling crises, reducing stress, and balancing work and personal time (Homisak,
2012). All of these activities require some degree of both leadership skills and management
functions. Leadership roles and management functions needed for effective time management
are included in Display 9.1.
LEADERSHIP ROLES
1. is self-aware regarding personal blocks and barriers to efficient time management.
2. recognizes how one’s own value system influences his or her use of time and the expectations of
followers.
3. Functions as a role model, supporter, and resource person to others in setting priorities for goal
attainment.
4. assists followers in working cooperatively to maximize time use.
5. prevents and/or filters interruptions that prevent effective time management.
6. role models flexibility in working cooperatively with other people whose primary time management
style is different.
7. presents a calm and reassuring demeanor during periods of high unit activity.
8. prioritizes conflicting and overlapping requests for time.
9. appropriately determines the quality of work needed in tasks to be completed.
MANAGEMENT FUNCTIONS
1. appropriately prioritizes day-to-day planning to meet short-term and long-term unit goals.
2. Builds time for planning into the work schedule.
3. analyzes how time is managed on the unit level by using job analysis and time-and-motion
studies.
4. eliminates environmental barriers to effective time management for workers.
5. Handles paperwork promptly and efficiently and maintains a neat work area.
6. Breaks down large tasks into smaller ones that can more easily be accomplished by unit
members.
7. Utilizes appropriate technology to facilitate timely communication and documentation.
8. discriminates between inadequate staffing and inefficient use of time when time resources are
inadequate to complete assigned tasks.
DISPLAY 9.1 Leadership Roles and Management Functions in Time Management

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Chapter 9 Time Management 183
THREE BASIC STEPS TO TIME MANAGEMENT
There are three basic steps to time management (Fig. 9.1). The first step requires that time
be set aside for planning and establishing priorities. The second step entails completing the
highest priority task (as determined in step 1) whenever possible and finishing one task
before beginning another. In the final step, the person must reprioritize what tasks will be
accomplished based on new information received. Because this is a cyclic process, all three
steps must be accomplished sequentially.
Taking Time to Plan and Establishing Priorities
Planning is essential if an individual is to manage by efficiency rather than by crisis and the
old adage “fail to plan—plan to fail” is timeless. Managers who are new to time management
may underestimate the importance of regular planning and fail to allot enough time for it.
In addition, many individuals fail to allow enough time for their plans to be carried out.
Baiyun and Quanquan (2012) agree, noting that while many individuals make plans, often
that plan is not completed in the time predicted. And despite the fact that the time allowed
to carry out their plan is shown over and over again to be inadequate, most individuals
continue to be optimistic that their new forecasts, which are no different, will be realistic.
This phenomenon is known as planning fallacies. For example, the student who carries home
a full backpack every night with the expectation that every assignment or task contained
within the backpack will be completed is generally aware that they rarely get more than one
or two significant items done in that time span. Yet, they continue to be hopeful that this will
be different the next time and their behavior continues unchanged.
3. Reprioritize based on the remaining
tasks and on new information that
may have been received.
2. Complete the highest-priority task
whenever possible, and finish one
task before beginning another.
1. Allow time for planning, and
establish priorities.
FiGure 9.1 • the three basic steps in time management.
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184 UNIT III ROLES AND FUNCTIONS IN PLANNING
Researchers suggest this occurs because many individuals forget that in the past, they were
interrupted unexpectedly or because individuals may not consider all the subcomponents of
a task when planning (Baiyun & Quanquan, 2012). In addition, individuals may have been
overly narrow in their focus on the task or subconsciously disregarded memories of how long
similar tasks have taken in the past. Most people simply want to believe that tasks will always
go well and that no problems will arise. This unrealistic assumption leads to serious planning
errors and poor time management.
Planning occurs first in the management process because the ability to be organized
develops from good planning. During planning, there should be time to think about how plans
will be translated into action. The planner must pause and decide how people, activities, and
materials are going to be put together to carry out the objectives.
Many individuals believe that they are unproductive if they take time out early in their
day to design a plan for action, rather than immediately beginning work on tasks. Without
adequate planning, however, the individual finds it difficult to get started and begins to
manage by crisis. In addition, there can be no sense of achievement at day’s end if the goals
for the day are not clearly delineated.
unfortunately, two mistakes common in planning are underestimating the importance of a daily
plan and not allowing adequate time for planning.
Similarly, Pugsley (2009) suggests that many students fail to establish a plan for completing
their learning activities. Sometimes this is because they are unclear about what the finished
product must look like. Other times, they are unsure when assignments are due or how to
break large assignments down into workable subcomponents. In all of these cases, the end
result is that the student’s ability to achieve the desired outcome, within the required timeline,
is threatened. To counter this, Pugsley suggests students adopt a “SMART” approach to
planning that allows learners to make effective use of every study period, whether the
learning activities are formal or informal (Display 9.2).
Whether you are a student, a manager, or a staff nurse, planning takes time; it requires
the ability to think, analyze data, envision alternatives, and make decisions. Examples
1. set specific, clear goals to be accomplished.
2. record your progress as measurable progress maintains your interest.
3. identify the steps needed to accomplish your goals.
4. Be realistic about your time constraints and set goals that can be accomplished within these
constraints.
5. set a time frame and plan for this.
DISPLAY 9.2 The SMART Approach to Studying
Adapted from: Pugsley, L. (2009, May). How to … study effectively. education for primary care, 20(3), 195–197.
LeArNiNG eXerCiSe 9.1
Making Big Projects Manageable
think of the last major paper you wrote for a class. did you set short-term and intermediate
deadlines? did you break the task down into smaller tasks to eliminate a last-minute crisis?
What short-term and intermediate deadlines have you set to accomplish major projects that
have been assigned to you this quarter or semester? are you realistic about the time that will
be required to complete the task or are you likely to experience planning fallacies?

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Chapter 9 Time Management 185
of the types of plans a charge nurse might make in day-to-day planning include staffing
schedules, patient care assignments, coordination of lunch- and work-break schedules,
and interdisciplinary coordination of patient care. Examples of an acute care staff nurse’s
day-to-day planning might include determining how handoff reports will be given and
received; the timing and method used for initial patient assessments; the coordination of
medication administration, treatments, and procedures; and the organization of documentation
of the day’s activities.
The Time-Efficient Work Environment
Some staff nurses appear disorganized in their efforts to care for patients. This may be the
result of poor planning or it may be a symptom of a work environment that is not conducive
to efficient time management. The following suggestions, using industrial engineering
principles, may assist the staff nurse in planning work activities, especially when the
environment poses obstacles to time efficiency:
• Gather all the supplies and equipment that will be needed before starting an activity.
Breaking a job down mentally into parts before beginning the activity may help the staff
nurse identify what supplies and equipment will be needed to complete the activity.
• Group activities that are in the same location. If you have walked a long distance down a
hallway, attempt to do several things there before going back to the nurses station. If you
are a home health nurse, group patient visits geographically when possible to minimize
travel time and maximize time with patients.
• Use time estimates. For example, if you know an intermittent intravenous medication
(IV piggyback) will take 30 minutes to complete, then use that time estimate for
planning some other activity that can be completed in that 30-minute window of time.
• Document your nursing interventions as soon as possible after an activity is completed.
Waiting until the end of the workday to complete necessary documentation increases the
risk of inaccuracies and incomplete documentation.
• Always strive to end the workday on time. Although this is not always possible,
delegating appropriately to others and making sure that the workload goal for any given
day is reasonable are two strategies that will accomplish this goal.
Like staff nurses, unit managers need to coordinate how their duties will be carried out
and devise methods to make work simpler and more efficient. Often, this includes simple
tasks such as organizing how supplies are stored or determining the most efficient lunch and
break schedules for staff. In addition, it is the manager’s responsibility to see that units are
appropriately stocked with the equipment nurses need to do their work. This reduces the time
spent in trying to locate needed supplies.
This was certainly the case at Neepawa Health Center in Manitoba, which implemented
a nursing strategy in 2010 called Releasing Time to Care: The Productive Ward (RTC)
(Examining the Evidence 9.1). Ultimately, the goal in planning work and activities is to
facilitate greater productivity and satisfaction.
Source: Fortier, J. (2012). More time for care. canadian Nurse, 108(8), 22–27.
Fortier shared the story of the disorganization and disjointedness she discovered when she
joined the nursing staff of Neepawa Health Center in Manitoba in 2008. Fortier noted that staff
spent so much time searching for supplies that patient care was not getting done; that wards and
Examining the Evidence 9.1
(Continued )
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186 UNIT III ROLES AND FUNCTIONS IN PLANNING
Daily planning actions that may help the unit manager identify and utilize time as a
resource most efficiently might include the following:
• At the start of each workday, identify key priorities to be accomplished that day. Identify
what specific actions need to be taken to accomplish those priorities and in what order
they should be done. Also, identify specific actions that should be taken to meet ongoing,
long-term goals.
• Determine the level of achievement that you expect for each prioritized task. Is a
maximizing or “satisficing” approach more appropriate or more reasonable for each of
the goals you have identified?
• Assess the staff assigned to work with you. Assign work that must be delegated to staff
members who are both capable and willing to accomplish the priority task that you have
identified. Be sure that you have clearly expressed any expectations you may have about
how and when a delegated task must be completed. (Delegation is discussed further in
Chapter 20.)
• Review the short- and long-term plans of the unit regularly. Include colleagues and
subordinates in identifying unit problems or concerns so that they can be fully involved
in planning for needed change.
• Plan ahead for meetings. Prepare and distribute agendas in advance.
• Allow time at several points throughout the day and at the end of the day to assess
progress in meeting established daily goals and to determine if unanticipated events have
occurred or if new information has been received that may have altered your original
plan. Ongoing realities for the unit manager include work situations that are constantly
changing, and with them, setting new priorities and adjusting older ones.
Setting new priorities or adjusting priorities to reflect ever-changing work situations is an
ongoing reality for the unit manager.
• Take regularly scheduled breaks. Planning for periodic breaks from work during the
workday is an integral part of an individual’s time and task management. These work
breaks allow both managers and staff to refresh physically and mentally.
• Using an electronic calendar to organize your day can help make a day feel less chaotic.
It can also help you identify pockets of spare time that you could use for breaks.
supply areas were chaotic; that turnover report took upward of 40 minutes; and that communica-
tion between staff members and departments was poor.
To combat the problem, Neepawa Health Center implemented a nursing strategy in 2010
called Releasing Time to Care: The Productive Ward (RTC). One of the many goals of this
program was to increase the efficiency of care so that less time would be spent searching
for supplies so that more time could be spent at the patient bedside. In addition, experts
provided training as well as support materials for staff on time management and an analysis
was completed of work design so that environmental factors causing staff to waste time could
be identified and addressed. “Lean” manufacturing processes, like those used by Toyota to
eliminate all tasks workers do, that are not directly related to the building of vehicles, were
applied to the nursing workunits with the goal being to eliminate unnecessary paperwork and
searching for supplies. Work modules were also decluttered and reorganized.
Fortier noted that while the process took some time and hard work, the outcomes were clearly
worth the effort. The time available for direct care increased significantly and staff turnover
became almost nonexistent.

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Chapter 9 Time Management 187
Priority Setting and Procrastination
Because most individuals are inundated with requests for their time and energy, the next step
in time management is prioritizing, which may well be the key to good time management.
Unfortunately, some individuals lack self-awareness about what is important and therefore
how to spend their time.
Priority setting is perhaps the most critical skill in good time management, because all actions
we take have some type of relative importance.
One simple means of prioritizing what needs to be accomplished is to divide all requests
into three categories: “don’t do,” “do later,” and “do now” (Display 9.3). The “don’t do”
items probably reflect problems that will take care of themselves, are already outdated, or
are better accomplished by someone else. The individual either throws away the unnecessary
information or passes it on to the appropriate person in a timely fashion. In either case, the
individual removes unneeded clutter from his or her work area.
1. “don’t do”
2. “do later”
3. “do now”
DISPLAY 9.3 Three Categories of Prioritization
LeArNiNG eXerCiSe 9.2
Setting Daily Priorities
assume that you are the registered nurse (rN) leader of a team with one licensed vocational
nurse and one nursing assistant on the 7 am to 3 pm shift at an acute care hospital. the three of
you are responsible for providing total care to 10 patients. prioritize the following list of 10 things
that you need to accomplish this morning. Use a “1” for the first thing you will do and a “10” for
the last. Be prepared to provide rationale for your priorities.
___ check medication cards/sheets against the patient medication record.
___ Listen to night shift report 11:00 pm to 7:00 am.
___ take brief walking rounds to assess the night shift report and to introduce yourself to
patients.
___ Hang four 9:00 am iV medications.
___ set up the schedule for breaks and lunch among your team members.
___ Give 8:45 am preop on patient going to surgery at 9:00 am.
___ pass 8:30 am breakfast trays.
___ Meet with team members to plan the schedule for the day and to clarify roles.
___ read charts of patients who are new to you.
___ check 6:00 am blood glucose laboratory results for 7:30 am insulin administration.
Some “do later” items reflect trivial problems or those that do not have immediate
deadlines; thus, they may be procrastinated. To procrastinate means to put off something
until a future time, to postpone, or to delay needlessly. Although procrastination may be
appropriate in some cases, the reality is that more often than not, it is a barrier to effective
time management.
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188 UNIT III ROLES AND FUNCTIONS IN PLANNING
Procrastination is a difficult problem to solve because it rarely results from a single cause
and can involve a combination of dysfunctional attitudes, rationalizations, and resentment.
The key in procrastination is to use it appropriately and selectively. Procrastination is rarely
appropriate when it is done to avoid a task because it is overwhelming or unpleasant.
Before setting “do later” items aside, the leader-manager must be sure that large projects
have been broken down into smaller projects and that a specific timeline and plan for
implementation are in place. The plan should include short-term, intermediate, and final
deadlines. Likewise, one cannot ignore items without immediate time limits forever and must
make a definite time commitment in the near future to address these requests.
The “do now” requests most commonly reflect a unit’s day-to-day operational needs.
These requests may include daily staffing needs, dealing with equipment shortages, meeting
schedules, conducting hiring interviews, and giving performance appraisals. “Do now”
requests also may represent items that had been put off earlier.
Making Lists
In prioritizing all the “do now” items, the leader-manager may find preparing a written list
helpful. Remember, however, that a list is a plan, not a product, and that the creation of the
list is not the final goal. The list is a planning tool.
Although the individual may use monthly or weekly lists, a list also can assist in
coordinating daily operations. This daily list, however, should not be longer than what can be
realistically accomplished in 1 day; otherwise, it demotivates instead of assists.
In addition, although the leader-manager must be cognizant of and plan for routine tasks,
it is not always necessary to place them on the list because they may only distract attention
from other priority tasks. Lists should allow adequate time for each task and have blocks of
time built in for the unexpected. In addition, individuals who use lists to help them organize
their day must be careful not to confuse importance and urgency. Not all important things are
urgent, and not all urgent things are important. This is especially true when the urgency is
coming from an external source.
Not all important things are urgent, and not all urgent things are important.
In addition, the individual should periodically review lists from previous days to see what
was not accomplished or completed. If a task appears on a list for several successive days, the
manager must reexamine it and assess why it was not accomplished. Sometimes, tasks just
need to be removed from the list. This occurs when a task has low priority, or when it is better
LeArNiNG eXerCiSe 9.3
Targeting Personal Procrastination
spend a few moments reflecting on the last 2 weeks of your life. What are the things you put
off doing? do these things form a pattern? For instance, do you always put off writing a school
paper until the last minute? do you wait to do certain tasks at work until you cannot avoid the
task any longer? What things do you do when you really do not want to do something? do you
eat? play video games? Watch tV? read?
Assignment: Write a one-page essay on at least two things that you procrastinate and then
develop two strategies for breaking each of these habits.

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Chapter 9 Time Management 189
done by someone else. Other times, undone tasks on the list should be discarded because they
are no longer relevant or they represent a need that no longer exists.
Sometimes, however, items on the list remain unaccomplished because they are not
divided into steps or tasks that can be completed. Breaking a big job down into smaller parts
can make the task seem more manageable. For example, many well-meaning people begin
thinking about completing their tax returns in early January but feel overwhelmed by a project
that cannot be accomplished in 1 day. If preparing a tax return is not broken down into several
smaller tasks with intermediate deadlines, it may be almost perpetually procrastinated.
Some projects are not accomplished because they are not broken down into manageable tasks.
Reprioritizing
The last step in time management is reprioritizing. Often, one’s priorities or list will change
during a day, week, or longer because new information is received. If the individual does not
take time to reprioritize after each major task is accomplished, other priorities set earlier may
no longer be accurate. In addition, despite outstanding planning, an occasional crisis may
erupt.
No amount of planning can prevent an occasional crisis.
If a crisis does occur, the individual may need to set aside the original priorities for the day
and reorganize, communicate, and delegate a new plan reflecting the new priorities associated
with the unexpected event causing the crisis.
Dealing with Interruptions
All managers experience interruptions, but lower-level managers typically experience the
most. This occurs in part because first- and middle-level managers are more involved in
daily planning than higher-level managers and thus directly interact with a greater number
of subordinates. In addition, many lower-level managers do not have a quiet workspace or
clerical help to filter interruptions. Frequent work interruptions result in situational stress
and lowered job satisfaction. Managers need to develop skill in preventing interruptions that
threaten effective time management.
Lower-level managers experience more interruptions than higher-level managers.
Dealing with interruptions also requires leadership skills. Leaders role model flexibility and
the ability to regroup when new information or tasks emerge as priorities. Followers often
look to see how their leaders are coping with change and even crisis and their reactions
LeArNiNG eXerCiSe 9.4
Creating Planning Lists
do you make a daily plan to organize what needs to be done? Mentally or on paper, develop
a list of five items that must be accomplished today. prioritize that list. Now make a list of five
items that must be done this week. prioritize that list as well.
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190 UNIT III ROLES AND FUNCTIONS IN PLANNING
often mirror those of their leaders. That is often why a staff nurse who feels harried or out of
control typically finds these same feelings reflected in the individuals he or she is assigned
to work with.
Time Wasters
There are many time wasters, and the time wasters that are used most often vary by the
individual. Four time wasters warrant special attention here (see Display 9.4). The first of
these surprisingly is technology, which generally has been promoted as a time saver for
most people. Indeed, technology can and does save time. E-mail now makes instantaneous,
asynchronous communication to multiple parties possible simultaneously and the Internet
provides virtually unlimited access to emerging, state of the science knowledge globally. In
addition, social networks such as Facebook, MySpace, Pinterest, and Twitter have created
new opportunities for communicating in real time to vast networks of users.
1. technology (internet, gaming, e-mail, and social media sites)
2. socializing
3. paperwork overload
4. a poor filing system
5. interruptions
DISPLAY 9.4 Time Wasters
Yet, this same technology increasingly consumes more and more of our time. Many
individuals find themselves randomly searching the Internet or playing online games to
distract themselves from the tasks at hand. In addition, the need to check and respond to so
many different communication mediums (e-mail, blackberries, voice mail, pagers, and social
networking sites) is time consuming in and of itself.
Svehaug (2013, para 17) suggests that “many of us have fallen into the social media
black hole, and it can be tricky to find a balance with no parameters in place.” She
suggests using an egg timer or some other timing device to limit the time you spent on
social networking sites when you have important tasks that must be accomplished. Time
Management Ninja (2013, para 10) agrees, suggesting “You don’t need to check email 100
times a day. Email is not intended to be instant communication. Rather, check it morning,
noon, and close of day.”
You do not need to check e-mail 100 times a day.
Finally, all this technology can make it difficult to find an appropriate balance between
the need for virtual and face-to-face interaction and between work and personal life.
Time Management Ninja (2013) suggests that “not unplugging” is a huge risk to time
management since no one can be “on” all the time. Individuals who do not unplug from
their work and devices will burn out and the boundaries between work and personal life
will blur.
A second time waster is socializing. Socializing with colleagues during the workday can
waste significant amounts of time in a workday. Although socializing can help workers meet
relationship needs or build power, it can tremendously deter productivity. This is especially
true for managers with an open-door policy. Subordinates can be discouraged from taking up
a manager’s time with idle chatter in several ways:

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Chapter 9 Time Management 191
• Do not make yourself overly accessible. Make it easy for people to ignore you. Try not
to “work” at the nursing station, if this is possible. If charting is to be done, sit with your
back to others. If you have an office, close the door. Have people make appointments to
see you. All these behaviors will discourage casual socializers.
• Interrupt. When someone is rambling on without getting to the point, break in and
say gently, “Excuse me. Somehow I’ not getting your message. What exactly are you
saying?”
• Avoid promoting socialization. Having several comfortable chairs in your office, a full
candy dish, and posters on your walls that invite comments encourage socializing in
your office.
• Be brief. Watch your own long-winded comments, and stand up when you are finished.
This will signal an end to the conversation.
• Schedule long-winded pests. If someone has a pattern of lengthy chatter and manages
to corner you on rounds or at the nurse’ station, say, “I can’ speak with you now, but
I’m going to have some free time at 11 am. Why don’t you see me then?” Unless the
meeting is important, the person who just wishes to chat will not bother to make a formal
appointment. If you would like to chat and have the time to do so, use coffee breaks and
lunch hours for socializing.
Other external time wasters that a manager must conquer are paperwork overload
and a poor filing system. Managers are generally inundated with paper clutter, including
organizational memos, staffing requests, quality assurance reports, incident reports, and
patient evaluations. Because paperwork is often redundant or unnecessary, the manager needs
to become an expert at handling it. Whenever possible, incoming correspondence should be
handled the day it arrives; it should either be thrown away or filed according to the date to be
completed. Try to address each piece of correspondence only once.
An adequate filing system also is invaluable to handling paper overload. Keeping
correspondence organized in easily retrievable files rather than disorganized stacks saves time
when the manager needs to find specific information. The manager also may want to consider
increased use of computerization and e-mail to reduce the paper use and to increase response
time in time-sensitive communication.
Finally, interruptions can cause a great deal of time wasting as attention is continually
diverted from the task at hand. All managers need protected time to respond to time-
sensitive phone calls or e-mails and it is important not to be disturbed during these times
unless there is an urgent request for an answer or guidance on dealing with an emergency
situation. “Once staff recognize that the manager is serious about keeping protected time
and not accepting all types of interruptions, then it will become standard practice” (Ashurst,
2013, p. 51).
PERSONAL TIME MANAGEMENT
Personal time management refers in part to self-knowledge. Self-awareness is a leadership
skill. For people who are not certain of their own short- to long-term goals, time management,
in general, poses difficulties. Svehaug (2013) suggests that to most appropriately manage
time, each individual should step back and think about what they truly want to accomplish
and the time they are willing and able to dedicate to achieving that goal. Honesty should be
the key in performing this exercise because there is no right or wrong answer.
Managing time is difficult if a person is unsure of his or her priorities for time management,
including personal short-term, intermediate, and long-term goals.
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192 UNIT III ROLES AND FUNCTIONS IN PLANNING
These goals give structure to what should be accomplished today, tomorrow, and in the future.
However, goals alone are not enough; a concrete plan with timelines is needed. Plans outlined
in manageable steps are clearer, more realistic, and attainable. By being self-aware and setting
goals accordingly, people determine how their time will be spent. If goals are not set, others
often end up deciding how a person should spend his or her time.
Think for a moment about last week. Did you accomplish all that you wanted to
accomplish? How much time did you or others waste? In your clinical practice, did you
spend your time hunting for supplies and medicines instead of teaching your patient about
his or her diabetes? Too often, irrelevant decisions and insignificant activities take priority
over real purposes. Clearly, work redesign, clarification of job descriptions, or a change in
the type of care delivery system may alleviate some of these problems. However, the same
general principle holds: professional nurses who are self-aware and have clearly identified
personal goals and priorities have greater control over how they expend their energy and what
they accomplish.
When individuals lack this self-awareness, they may find it difficult to find a balance
between time spent on personal and professional priorities. Indeed, a study of more than
50,000 employees from a variety of manufacturing and service organizations found that two
out of every five employees were dissatisfied with the balance between their work and their
personal lives (Hansen, n.d.). Effective time management then is an essential part of finding
that balance between work life and personal life.
Brans (2013), building on thinking done by Benjamin Franklin more than 300 years
ago, suggests that there are 12 habits that should be nurtured for optimum personal
time management. These are shown in Display 9.5. All 12 habits are directed at being
DISPLAY 9.5 Bran’s 12 Habits to Master for Personal Time Management
Habit 1: Strive to be authentic. Be honest with yourself about what you want and why you do what
you do.
Habit 2: Favor trusting relationships. Build relationships with people you can trust and count on,
and make sure those same people can trust and count on you.
Habit 3: Maintain a lifestyle that will give you maximum energy. exercise, eat well, and get enough
sleep.
Habit 4: Listen to your biorhythms and organize your day accordingly. pay attention to regular
fluctuations in your physical and mental energy levels throughout the day and schedule tasks
accordingly.
Habit 5: Set very few priorities and stick to them. select a maximum of two things that are your
highest priority and work on them.
Habit 6: Turn down things that are inconsistent with your priorities. say no to other people when
their request is not a priority for you and you do not have the time to help.
Habit 7: Set aside time for focused effort. schedule time every day to work on just one thing.
Habit 8: Always look for ways of doing things better and faster. Watch for tasks you do over and
over again and look for ways of improving how you do them.
Habit 9: Build solid processes. set up processes that last and that run without your attention.
Habit 10: Spot trouble ahead and solve problems immediately. set aside time to think about what
lies ahead and face all problems as soon as you can.
Habit 11: Break your goals into small units of work, and think only about one unit at a time.
spend most of your time working on the task in front of you, and avoid dreaming too much about
the big goal.
Habit 12: Finish what is important and stop doing what is no longer worthwhile. do not stop
doing what you considered worth starting unless there is a good reason to give it up.
Source: Adapted from Brans, P. (2013, January 1). twelve time management habits to master in 2013. Forbes, Retrieved
May 20, 2014, from http://www.forbes.com/sites/patbrans/2013/01/01/twelve-time-management-habits-to-master-in-2013

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Chapter 9 Time Management 193
self-aware regarding what is important to accomplish in one’s life, staying focused on
the things that matter, taking care of oneself, and following through in a timely and
consistent manner.
In addition to being self-aware regarding the values that influence how people prioritize
the use of their time, people must be self-aware regarding their general tendency to
complete tasks in isolation or in combination. Some people prefer to do one thing at a time,
whereas others typically do two or more things simultaneously. Some individuals begin and
finish projects on time, have clean and organized desks because of handling each piece of
paperwork only once, and are highly structured. Others tend to change plans, borrow and
lend things frequently, emphasize relationships rather than tasks, and build longer-term
relationships. It is important to recognize one’s own preferred time management style and
to be self-aware about how this orientation may affect your interaction with others in the
workplace. A significant part of personal time management depends on self-awareness about
how and when a person is most productive. Everyone has ways to waste time or steer clear
of certain activities.
everyone avoids certain types of work or has methods of wasting time.
Likewise, each person works better at certain times of the day or for certain lengths of
time. Svehaug (2013) calls this finding your productivity sweet spot. Self-aware people
schedule complex or difficult tasks during the periods when they are most productive
and simpler or routine tasks during less productive times. Finally, each individual should
be cognizant of how he or she values the time of others. For example, being punctual
goes beyond common courtesy. Tardiness reflects some disregard for the value of other
people’s time.
A lack of punctuality suggests that you do not value other people’s time.
Using a Time Inventory
Because most people have an inaccurate perception of the time they spend on a particular task
or the total amount of time they are productive during the day, a time inventory may provide
insight. A time inventory is shown in Display 9.6. A time inventory allows you to compare
what you planned to do, as outlined by your appointments and “to do” entries, with what you
actually did.
Mattison (2013) notes that one of the biggest mistakes students make when they attempt
to get organized is to try and squeeze all responsibilities into their week without taking into
consideration that there are only 24 hours in a day. “Going without sleep, relationship time,
food or exercise is not a good option” (para 6).
When using a time inventory, Mattison suggests plotting in sleep first and then the time
that is immovable, including classes and clinicals. Once that is done, students should plug
in the things that are important to them, such as family time or church. Next, study time and
planned break times should be included in the time inventory.
Because the greatest benefit from a time inventory is being able to objectively identify
patterns of behavior, it may be necessary to maintain the time inventory for several days or
even several weeks. It may also be helpful to repeat the time inventory annually to see if
long-term behavior changes have been noted. Remember, there is no way to beg, borrow, or
steal more hours in the day. If time is habitually used ineffectively, managing time will be
very stressful.
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194 UNIT III ROLES AND FUNCTIONS IN PLANNING
LeArNiNG eXerCiSe 9.5
Writing a Personal Time Inventory
Use the time inventory shown in display 9.6 to identify your activities for a 24-hour period.
record your activities on the time inventory on a regular basis. Be specific. do not trust your
memory. star the periods of time when you were most productive. circle periods of time when
you were least productive. do not include sleep time. Was this a typical day for you? could you
have modified your activity during your least productive time periods? if so, how?
5:00 am __________________________________________________________________
6:00 am __________________________________________________________________
6:30 am __________________________________________________________________
7:00 am __________________________________________________________________
7:30 am __________________________________________________________________
8:00 am __________________________________________________________________
8:30 am __________________________________________________________________
9:00 am __________________________________________________________________
9:30 am __________________________________________________________________
10:00 am __________________________________________________________________
10:30 am __________________________________________________________________
11:00 am __________________________________________________________________
11:30 am __________________________________________________________________
12:00 pm __________________________________________________________________
12:30 pm __________________________________________________________________
1:00 pm __________________________________________________________________
1:30 pm __________________________________________________________________
2:00 pm __________________________________________________________________
2:30 pm __________________________________________________________________
3:00 pm __________________________________________________________________
3:30 pm __________________________________________________________________
4:00 pm __________________________________________________________________
4:30 pm __________________________________________________________________
5:00 pm __________________________________________________________________
5:30 pm __________________________________________________________________
6:00 pm __________________________________________________________________
6:30 pm __________________________________________________________________
7:00 pm __________________________________________________________________
7:30 pm __________________________________________________________________
8:00 pm __________________________________________________________________
8:30 pm __________________________________________________________________
9:00 pm __________________________________________________________________
9:30 pm __________________________________________________________________
10:00 pm __________________________________________________________________
11:00 pm __________________________________________________________________
12:00 pm __________________________________________________________________
1:00 am __________________________________________________________________
2:00 am __________________________________________________________________
3:00 am __________________________________________________________________
4:00 am __________________________________________________________________
DISPLAY 9.6 Time Inventory

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Chapter 9 Time Management 195
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
IN TIME MANAGEMENT
There is a close relationship between time management and stress. Managing time
appropriately reduces stress and increases productivity. The current status of health care,
the nursing shortage, and decreasing reimbursements have resulted in many health-care
organizations trying to do more with less. The effective use of time management tools,
therefore, becomes even more important to enable leader-managers to meet personal and
professional goals.
The leadership skills needed to manage time resources draw heavily on interpersonal
communication skills. The leader is a resource and role model to subordinates in how to
manage time. As has been stressed in other phases of the management process, the leadership
skill of self-awareness is also necessary in time management. Leaders must understand their
own value system, which influences how they use time and how they expect subordinates to
use time.
The management functions inherent in using time resources wisely are more related to
productivity. The manager must be able to prioritize activities of unit functioning to meet
short- and long-term unit needs. To do this, the leader-manager must initiate an analysis of
time management on the unit level, involve team members and gain their cooperation in
maximizing time use, and guide work to its conclusion and successful implementation.
Successful leader-managers are able to integrate leadership skills and management
functions; they accomplish unit goals in a timely and efficient manner in a concerted
effort with subordinates. They also recognize time as a valuable unit resource and share
responsibility for the use of that resource with subordinates. Perhaps most importantly, the
integrated leader-manager with well-developed, time management skills can maintain greater
control over time and energy constraints in his or her personal and professional life.
KEY CONCEPTS
l Because time is a finite and valuable resource, learning to use it wisely is essential for effective
management.
l time management can be reduced to three cyclic steps: (a) allow time for planning and establish
priorities; (b) complete the highest priority task, and whenever possible, finish one task before beginning
another; and (c) reprioritize based on remaining tasks and new information that may have been received.
l setting aside time at the beginning of each day to plan the day allows the manager to spend appropriate
time on high-priority tasks.
l Many individuals fall prey to planning fallacies, where they are overly optimistic about the time it will take
to complete a task.
l Making lists is an appropriate tool to manage daily tasks. this list should not be any longer than what
can realistically be accomplished in a day and must include adequate time to accomplish each item on
the list and time for the unexpected.
l a common cause of procrastination is failure to break large tasks down into smaller ones so that the
manager can set short-term, intermediate, and long-term goals.
l Lower-level managers have more interruptions in their work than do higher-level managers. this results
in situational stress and lowered job satisfaction.
l Managers must learn strategies to cope with interruptions from socializing.
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196 UNIT III ROLES AND FUNCTIONS IN PLANNING
l Because so much paperwork is redundant or unnecessary, the manager needs to develop expertise at
prioritizing it and eliminating unnecessary clutter at the work site.
l an efficient filing system is invaluable to handling paper overload.
l personal time management refers to “the knowing of self.” Managing time is difficult if a person is unsure
of his or her priorities, including personal short-term, intermediate, and long-term goals.
l Being punctual implies that you value other people’s time and creates an imperative for them to value
your time as well.
l effective time management is an essential part of finding that balance between work life and personal
life.
l Using a time inventory is one way to gain insight into how and when a person is most productive. it also
assists in identifying internal time wasters.
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
LeArNiNG eXerCiSe 9.6
A Busy Day at the Public Health Agency
You work in a public health agency. it is the agency’s policy that at least one public health nurse
is available in the office every day. today is your turn to remain in the office. From 1 pm to 5 pm,
you will be the public health nurse at the scheduled immunization clinic; you hope to be able to
spend some time finishing your end-of-month reports, which are due at 5 pm. the office stays
open during lunch; you have a luncheon meeting with a cancer society group from noon to 1 pm
today. the rN in the office is to serve as a resource to the receptionist and handle patient phone
calls and drop-ins. in addition to the receptionist, you may delegate appropriately to a clerical
worker. However, the clerical worker also serves the other clinic nurses and is usually fairly busy.
While you are in the office today trying to finish your reports, the following interruptions occur:
8:30 am: Your supervisor, anne, comes in and requests a count of the diabetic and hypertensive
patients seen in the last month.
9:00 am: an upset patient is waiting to see you about her daughter who just found out that she
is pregnant.
9:00 am: three drop-in patients are waiting to be interviewed for possible referral to the chest
clinic.
9:30 am: the public health physician calls you and needs someone to contact a family about a
child’s immunization.
9:30 am: the dental department drops off 20 referrals and needs you to pull charts of these
patients.
10:00 am: a confused patient calls to find out what to do about the bills that he has received.
10:45 am: six families have been waiting since 8:30 am to sign up for food vouchers.
11:45 am: a patient calls about her drug use; she does not know what to do. she has heard
about Narcotics anonymous and wants more information now.
Assignment: How would you handle each interruption? Justify your decisions. do not forget
lunch for yourself and the two office workers. Note: attempt your own solution before reading
the possible solution presented in the back of this book.

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Chapter 9 Time Management 197
LeArNiNG eXerCiSe 9.7
Realistic Prioritizing
You are an rN providing total patient care to four patients on an orthopedic unit during the 7 am
to 3 pm shift. Given the following patient information, prioritize your activities for the shift in eight
1-hour blocks of time. Be sure to include time for reports, planning your day’s activities, breaks,
and lunch. Be realistic about what you can accomplish. What activities will you delegate to the
next shift? What overall goals have guided your time management? What personal values or
priorities were factors in setting your goals?
room 101 a Ms. Jones 84 years old. Fractured left hip, secondary to fall at home.
disoriented since admission, especially at night. Fall precautions
ordered. Moans frequently. Being given iV pain medication
every 2 hours prn. Vital signs and checks for circulation, feeling,
and movement in toes ordered every 2 hours. scheduled for
surgery at 10:30 am. preoperative medications scheduled
for 9:30 am and 10:00 am. consent yet to be signed. Family
members will be here at 8:00 am and have expressed questions
about the surgery and recovery period. patient to return from
surgery at approximately 2:30 pm. Will require postoperative
vital signs every 15 minutes.
room 101 B Ms. Wilkins 26 years old. compound fracture of the femur with postoperative
fat emboli, now resolved. ten pound Buck’s traction. Has
been in the hospital 3 weeks. Very bored and frustrated with
prolonged hospitalization. Upset about roommate who calls
out all night and keeps her from sleeping. Wants to be moved
to new room. Has also requested to have hair washed during
bath today. Has iV medication running at 100 mL/h. iV antibiotic
piggybacks at 8:00 am and 12:00 pm. Oral medications at 8:00
am, 9:00 am, and 12:00 pm.
room 102 a Mr. Jenkins 47 years old. t-6 quadriplegic due to diving accident 14
years ago. two days postoperative above-knee amputation
due to osteomyelitis. cultures show methicillin-resistant
Staphylococcus aureus (Mrsa). strict wound isolation. Has
been hospitalized for 2 weeks. expressing great deal of anger
and frustration to anyone who enters room. iV site red and
puffy. iV needs to be restarted. dressing change of operative
site ordered daily. Heat lamp treatments ordered b.i.d. to small
pressure sores on coccyx. iV antibiotic piggybacks at 8:00 am,
10:00 am, 12:00 pm, and 2:00 pm. Main iV bag to run out at
10:00 am. 6:00 am laboratory results to be called to physician
this morning. Needs total assistance in performing activities of
daily living, such as bathing and feeding self.
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198 UNIT III ROLES AND FUNCTIONS IN PLANNING
LeArNiNG eXerCiSe 9.8
Creating a Shift Time Inventory
You are a 3 pm to 11 pm shift coordinator for a skilled nursing facility. You are the only rN on
your unit this shift. all the other personnel assigned to work with you this evening are unlicensed.
the unit census is 21. as the shift coordinator, your responsibility is to make shift assignments,
provide needed patient treatments, administer iV medications, and coordinate the work of
team members. this evening, you will need to administer treatments and/or medications to the
following patients:
room 101 a Gina adams 88 years old. senile dementia. resident for 6 years.
confused−strikes out at staff. soft wrist restraints
bilaterally. Has small grade 2 pressure ulcer on coccyx,
which requires evaluation and dressing change each shift.
room 102 B Gus taylor 64 years old. diabetes. New resident. Bilateral aK amputee.
right amputation 2 weeks ago. Left amputation performed
8 years ago. Needs stump dressing on right amputation
site this shift. Has developed Mrsa in wound site.
Wound isolation ordered. iV antibiotics due at 4:00 pm and
10:00 pm tonight. Blood glucose monitoring due at 4:30 pm
and 9:00 pm with sliding-scale coverage.
room 106 a Marvin Young 26 years old. closed head injury 5 years ago. resident since that
time. decerebrate posturing only. does not follow commands.
peG feeding tube site red and inflamed; Md has not yet been
notified. Needs feeding solution bag change this pm.
room 107 a sheila abood 93 years old. Functional decline. refusing to eat. physician
has written an order not to resuscitate in the event of
cardiac or respiratory failure but wants an iV line begun
this pm to minimize patient dehydration. Family will also be
here this pm and wants to talk about their mother’s status.
room 109 c tina crowden 89 years old. admit from local hospital, 2 weeks post-op
left hip replacement. anticipated length of stay−2 weeks.
arrives by ambulance at 3:30 pm. Needs to have admission
assessment and paperwork completed and care plan started.
room 103 a Mr. Novak 19 years old. severe tear of rotator cuff in left shoulder while
playing football. One-day postoperative rotator cuff repair. Very
quiet and withdrawn. refusing pain medication, which has
been ordered every 2 hours prn. says he can handle pain and
does not want to “mess up his body with drugs.” He wants
to be recruited into professional football after this semester.
Nonverbal signs of grimacing, moaning, and inability to sleep
suggest that moderate pain is present. physician states that
likelihood of Mr. Novak ever playing football again is very low
but has not yet told the patient. Girlfriend frequently in room at
patient’s bedside. iV infusing at 150 mL/h. iV antibiotics at 8:00
am and 2:00 pm. Has not had a bath since admission 2 days ago.

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Chapter 9 Time Management 199
Oral Medications Schedule
room 101 a—4 pm, 8 pm
room 101 B—4 pm, 8 pm
room 102 a—5 pm, 9 pm
room 103 B—4 pm, 10 pm
room 104 c—5 pm, 6 pm, 9 pm
room 106 B—6 pm, 9 pm
room 108 c—9 pm
room 109 c—5 pm, 6 pm, 8 pm, 9 pm
Assignment: create a time inventory from 3:00 pm to 11:30 pm by using 1-hour blocks of
time. plan what activities you will do during each 1-hour block. Be sure that you start with
the activities you have prioritized for the shift. also, remember that you will be in shift report
from 3:00 pm to 3:30 pm and from 11:00 pm to 11:30 pm and that you need to schedule a
dinner break for yourself. allow adequate time for planning and dealing with the unexpected.
compare the inventory that you created with other students in your class. did you identify the
same priorities? Were you more focused on professional, technical, or amenity care? Will your
plan require multitasking? Was the time inventory that you created realistic? is this a workload
that you believe you could handle?
LeArNiNG eXerCiSe 9.9
Plan Your Day
it is October of your second year as Nursing coordinator for the surgical department. a copy
of your appointment calendar for Monday, October 27, follows.
You will review your unfinished business from the preceding Friday and look at the new items
of business that have arrived on your desk this morning. (the new items follow the appointment
calendar.) the unit ward clerk is usually free in the afternoon to provide you with 1 hour of
clerical assistance, and you have a charge nurse on each shift to whom you may delegate.
1. assign a priority to each item, with 1 being the most important and 5 being the least
important.
2. decide when you will deal with each item, being careful not to use more time than you
have open on your calendar.
3. if the problem is to be handled immediately, explain how you will do this (e.g., delegated,
phone call).
4. explain the rationale for your decisions.
Monday, October 27
8:00 am arrive at work
8:15 am daily rounds with each head nurse in your area
8:30 am continuation of daily rounds with head nurses
9:00 am Open
9:30 am Open
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200 UNIT III ROLES AND FUNCTIONS IN PLANNING
10:00 am department Head meeting
10:30 am United Givers committee
11:00 am United Givers committee continued
11:30 am Open
Noon Lunch
12:30 pm Lunch
1:00 pm Weekly meeting with administrator−budget and annual report due
1:30 pm Open
2:00 pm infection control meeting
2:30 pm infection control meeting continued
3:00 pm Fire drill and critique of drill
3:30 pm Fire drill and critique of drill continued
4:00 pm Open
4:30 pm Open
5:00 pm Off duty
Correspondence
Item 1
From the desk of M. Jones, personnel manager
October 24
dear Joan:
i am sending you the names of two new graduate nurses who are interested in
working in your area. i have processed their applications; they seem well qualified. could you
manage to see them as early as possible in the week? i would hate to lose these prospective
employees, and they are anxious to obtain definite confirmation of employment.
Item 2
From the desk of John Brown, purchasing agent
October 23
Joan:
We really must get together this week and devise a method to control supplies. Your
area has used three times the amount of thermometer covers as any other area. are you taking
that many more temperatures? this is just one of the supplies your area uses excessively. i’m
open to suggestions.
Item 3
roger Johnson, Md, chief of surgical department
October 24
Ms. Kerr:
i know you have your budget ready to submit, but i just remembered this week that i
forgot to include an arterial pressure monitor. is there another item that we can leave out? i’ll
drop by Monday morning, and we’ll figure something out.
Item 4
October 23

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Chapter 9 Time Management 201
Ms. Kerr:
the following personnel are due for merit raises, and i must have their completed and
signed evaluations by tuesday afternoon: Mary rocas, Jim Newman, Marge Newfield.
M. Jones, personnel manager
Item 5
roger Johnson, Md, chief of surgical department
October 23
Ms Kerr:
the physicians are complaining about the availability of nurses to accompany them on
rounds. i believe you and i need to sit down with the doctors and head nurses to discuss this
recurring problem. i have some free time Monday afternoon.
Item 6
5 am
Joan:
sally Knight (your regular night rN) requested a leave of absence due to her mother’s
illness. i told her it would be OK to take the next three nights off. she is flying out of town on
the 9 am commuter flight to san Francisco, so phone her right away if you don’t want her to
go. i felt i had no choice but to say yes.
Nancy Peters, night supervisor
p.s. You’ll need to find a replacement for her for the next three nights.
Item 7
to: Ms Kerr
From: administrator
re: patient complaint
date: October 23
please investigate the following patient complaint. i would like a report on this matter
this afternoon.
dear sir:
My mother, Gertrude Boswich, was a patient in your hospital, and i just want to tell you
that no member of my family will ever go there again.
she had an operation on Monday, and no one gave her a bath for 3 days. Besides
that, she didn’t get anything to eat for 2 days, not even water. What kind of a hospital do you
run anyway?
elmo Boswich
Item 8
to: Joan Kerr
From: Nancy Newton, rN, head nurse
re: problems with X-ray department
date: October 23
We have been having problems getting diagnostic x-ray procedures scheduled for
patients. Many times, patients have had to stay an extra day to get x-ray tests done. i have
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202 UNIT III ROLES AND FUNCTIONS IN PLANNING
talked to the radiology chief several times, but the situation hasn’t improved. can you do
something about this?
Item 9
to: all department heads
From: storeroom
re: supplies
date: October 23
the storeroom is out of the following items: toilet tissue, paper clips, disposable
diapers, and pencils. We are expecting a shipment next week.
Telephone Messages
Item 10
sam surefoot, superior surgical supplies, inc., returned your call at 7:50 am on
October 27. He will be at the hospital this afternoon to talk about problems with defective
equipment received.
Item 11
donald drinkley, channel 32-tV, called at 8:10 am on October 27 to say he will be here
at 11:30 am to do a feature story on the open-heart unit.
Item 12
Lila Green, director of nurses at st. Joan’s Hospital, called at 8:05 am on October 24
about a phone reference on Jane Jones, rN. Ms. Jones has applied for a job there. isn’t that
the one we fired last year?
Item 13
Betty Brownie, Bluebird troop 35, called at 8 am on October 27 about the Bluebird
troop visit to patients on Halloween with trick-or-treat candy. she will call again.
LeArNiNG eXerCiSe 9.10
Avoiding Crises
some people always seem to manage by crisis. the following scenarios depict situations that
likely could have been avoided with better planning. Write down what could have been done to
prevent the crisis. then outline at least three alternatives to deal with the problem, as it already
exists.
l it is the end of your 8-hour shift. Your team members are ready to go home. You have not yet
begun to chart on any of your six patients. Neither have you completed your intake/output
totals or given patients the medications that were due 1 hour ago. the arriving shift asks you
to give your handoff report now.
l You need to use the home computer to write your midterm essay, which is due tomorrow, but
your mother is online doing the family’s taxes, which must be mailed by midnight. the taxes
will likely take several additional hours.
l Your computer hard drive crashes when you try to print your term paper, which is due
tomorrow.
l an elderly, frail patient pulls out her iV line. You make six attempts, over a 1-hour period, to
restart the line but are unsuccessful. You have missed your lunch break and now must choose
between taking time for lunch and finishing your shift on time.

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Chapter 9 Time Management 203
REFERENCES
Ashurst, A. (2013). Time is of the essence: Working to a
deadline. Nursing & Residential Care, 15(1),
50–52.
Baiyun, Q., & Quanquan, Z. (2012). An issue of public
affairs management: The effect of time slack and
need for cognition on prediction of task
completion. Public Personnel Management,
41(5), 1–8.
Brans, P. (2013, January 1). Twelve time management
habits to master in 2013. Forbes, Retrieved May
20, 2014, from http://www.forbes.com/sites/
patbrans/2013/01/01/twelve-time-management-habits
-to-master-in-2013
Fortier, J. (2012). More time for care. Canadian Nurse,
108(8), 22–27.
Hansen, R. S. (n.d.). Is your life in balance? Work/life
balance quiz. A quintessential careers quiz. Retrieved
May 20, 2013, from http://www.quintcareers.com/
work-life_balance_quiz.html
Homisak, L. (2012). Time and efficiency redux: How do
you take better control of your time? Podiatry
Management, 31(3), 41–44.
Mattison, M. (2013, Feb. 8). Time management tips for
nursing school. Chamberlain School of Nursing.
Retrieved May 21, 2013, from http://blog
.chamberlain.edu/2013/02/08/time-management-tips
-for-nursing-school/
Pugsley, L. (2009, May). How to … study effectively.
Education for Primary Care, 20(3), 195–197.
Svehaug, K. (2013, May 9). 3 easy steps for managing time
and reaching your goals. The Etsy Blog. Retrieved
May 21, 2013, from http://www.etsy.com/blog/
en/2013/time-management/
Time Management Ninja (2013, March 8). Beware: 10 time
management rules that you are breaking. Retrieved
May 21, 2014, from http://timemanagementninja
.com/2013/03/beware-10-time-management-rules-that
-you-are-breaking/
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http://www.forbes.com/sites/patbrans/2013/01/01/twelve-time-management-habits-to-master-in-2013

http://www.quintcareers.com/work-life_balance_quiz.html

http://blog.chamberlain.edu/2013/02/08/time-management-tips-for-nursing-school/

http://www.etsy.com/blog/en/2013/time-management/

Beware: 10 Time Management Rules That You Are Breaking

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204
Fiscal Planning
… nurses are practicing caring in an environment where the economics and costs of health care
permeate discussions and impact decisions.
—Marian C. Turkel
… the trouble with a budget is that it’s hard to fill up one hole without digging another.
—Dan Bennett
CROSSWALK This ChapTer aDDresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential V: health-care policy, finance, and regulatory environments
MSN Essential II: Organizational and systems leadership
MSN Essential III: Quality improvement and safety
MSN Essential VI: health policy and advocacy
QSEN Competency: Quality improvement
QSEN Competency: safety
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l anticipate, recognize, and creatively problem solve budgetary constraints
l accurately compute the standard formula for calculating nursing care hours per patient day
(NCh/ppD)
l demonstrate cost consciousness in identifying personal and organizational needs
l define basic fiscal terminology appropriately
l differentiate among the three major types of budgets (personnel, operating, and capital) and
the two most common budgeting methods (incremental and zero based)
l identify the strengths and weaknesses of flexible budgets
l recognize the need to involve subordinates and followers in fiscal planning whenever possible
l design a decision package to aid in fiscal priority setting
l describe the impetus for the development of diagnosis-related groups (DrGs), the
prospective payment system (pps), and other managed care initiatives
l describe the resulting impact on cost and quality when healthcare reimbursement shifted
from a health-care system dominated by third-party, fee-for-service plans to capitated,
managed care programs
l describe the impact of the increasing shift in government and private insurer reimbursement
from volume to value based
l discuss how spiraling health-care costs that had little relationship to health-care outcomes
led to comprehensive health-care reform in the United states in 2010
l describe key components of the Patient Protection and Affordable Care Act (ppaCa) as well
as its implementation plan between 2010 and 2014
10

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Chapter 10 Fiscal Planning 205
l recognize that rapidly changing federal and state reimbursement policies make long-range
budgeting and planning very difficult for health-care organizations
l describe why nurses need to understand and actively be involved in fiscal planning and
healthcare reform
For at least 30 years, health-care organizations have faced unprecedented financial challenges
as a result of shrinking reimbursement and rising costs. Regulatory controls have tightened,
quality expectations continue to rise, and the public is increasingly demanding more and
higher quality services at little to no out-of-pocket cost. Comprehensive, systematic efforts
to reform this clearly broken health-care system achieved no real momentum, however, until
late in the first decade of the 21st century. Even then, convergence on proposals for reform
was limited so the relatively swift passage of controversial national health-care reform in
the United States in March 2010 came as a surprise to many. This legislation The Patient
Protection and Affordable Care Act (PPACA) provided the first real hope for Americans of
significant reductions in numbers of uninsured, greater access to coverage for those with
preexisting conditions, and mandated health-care insurance provision by employers.
In addition, the shifting in reimbursement from volume to value has accelerated with
health-care reform, with the PPACA mentioning “value” 214 times (Keckley, 2013). Value
can be broadly defined as a function of quality, efficiency, safety, and cost. The idea behind
changing the current payment system to one which focuses on value rather than volume, was
to remove incentives for redundant and inappropriate care, now estimated to account for as
much as a quarter of the nation’s $2.8 trillion in annual health spending (Mitchell, 2013). The
PPACA’s payment reform provisions include value-based purchasing (VBP), accountable
care organizations (ACOs), bundled payments, the medical home, and the health insurance
marketplace, all of which are based on value and discussed later in this chapter. Mitchell
(2013) notes, though, that for all the talk about this shift from volume to value, only 10.9% of
health-care spending in 2012 by employer-sponsored plans was based on “value,” as opposed
to “volume,” or the number of services performed.
In addition, critics suggest that while the PPACA begins to address health-care spending
run amok as well as numerous health-care quality issues, that funding challenges remain.
Indeed, many proposed cuts are simply reductions in projected increases and even with these
cuts, stability of organizations involved in the US health care infrastructure will be at risk
(Examining the Evidence 10.1).
Source: Goozner, M. (2013). Dissecting the president’s budget. Modern healthcare, 43(15), 25.
Goozner critiques the 2013 federal budget related to health care, noting that the President has
called for an additional $401 billion in cuts to health-care programs over the next decade, with
75% of those cuts coming from Medicare. The biggest reductions are in the drug industry and to
post–acute-care providers although other programs facing sizable cuts include graduate medical
education and reimbursement for clinical laboratory services.
Goozner notes, however, that these cuts are actually reductions in projected increases. Medi-
care is slated in the President’s plan to grow from $524 billion in 2014 to $867 billion in 2023,
the end of the 10-year budget window used in Washington. That’s a 65% increase over the
period, or an average of better than 6% a year, a figure that reflects faster growth than the rest
of the economy, even when inflation is taken into account.
Examining the Evidence 10.1
(Continued )
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206 UNIT III ROLES AND FUNCTIONS IN PLANNING
Great change has also occurred in fiscal planning at the organizational level over the past
three decades in terms of scope of responsibility and accountability for cost and outcomes.
Prior to the 1980s, nursing management often played only a limited role in fiscal planning in
health-care organizations. Nurse-managers were frequently given budgets with little rationale
and were allowed only limited input in fiscal decision making. Because nursing was generally
classified as a “non-income-producing service,” nursing input was undervalued. Since that
time, however, health-care organizations have come to recognize the importance of nursing
input in fiscal planning, and nurse-leader-managers in the 21st century are expected to be
expert financial managers. The reality is that nursing budgets generally account for the
greatest share of the total expenses in health-care institutions, and participation in fiscal
planning has become a fundamental and powerful tool for nursing.
Many nurses, however, perceive fiscal planning to be the most difficult type of planning.
This is often the result of inadequate formal education or training on budget preparation as
well as forecasting. It is important to remember that fiscal planning is an acquired skill that
improves with use.
Fiscal planning is not intuitive; it is a learned skill that improves with practice.
Fiscal planning also requires vision, creativity, and a thorough knowledge of the political,
social, and economic forces that shape health care. Fiscal planning, then, must be included in
nursing program curricula and in management preparation programs. This chapter discusses
the leader-manager’s role in fiscal planning, identifies types of budgets, and delineates the
budgetary process. Learners will also examine health-care reimbursement concepts with
specific attention given to the recent change from volume-based reimbursement to value-
based reimbursement. The leadership roles and management functions involved in fiscal
planning are outlined in Display 10.1.
Goozner concludes that the reforms now underway through the PPACA will not harm seniors
or undermine the financial viability of providers but cautions that other health-care agencies
will struggle. For example, the National Institutes of Health will receive only about a 2% a
year increase over the next decade to its current $31 billion budget—barely enough to keep
pace with inflation. The Centers for Disease Control and Prevention will grow from $5.5 billion
in 2013 to $6.1 billion in 2023—a cumulative increase of 11% or barely a percentage point
increase each year on average; The Health Resources and Services Administration budget will
increase by 21.8%, or about 2% a year on average, to $6.7 billion—again barely keeping pace
with inflation.
LEADERSHIP ROLES
1. is visionary in identifying or forecasting short- and long-term unit needs, thus inspiring proactive
rather than reactive fiscal planning.
2. is knowledgeable about political, social, and economic factors that shape fiscal planning and
reimbursement in health care today.
3. Demonstrates flexibility in fiscal goal setting in a rapidly changing system.
4. anticipates, recognizes, and creatively solves budgetary constraints.
5. influences and inspires group members to become active in short- and long-range fiscal planning.
6. recognizes when fiscal constraints have resulted in an inability to meet organizational or unit
goals and communicates this insight effectively, following the chain of command.
7. ensures that patient safety is not jeopardized by cost containment.
DISpLAy 10.1 Leadership Roles and Management Functions in Fiscal Planning

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Chapter 10 Fiscal Planning 207
BALANCING COST AND QUALITy
Complicating fiscal planning in health-care organizations today are the dual goals of
cost containment and quality care, which do not always have a linear relationship. Cost
containment refers to effective and efficient delivery of services while generating needed
revenues for continued organizational productivity. Cost containment is the responsibility of
every health-care provider, and the viability of most health-care organizations today depends
on their ability to use their fiscal resources wisely.
Being cost-effective, however, is not the same as being inexpensive; cost-effective means
producing good results for the amount of money spent; in other words, the product is worth
the price (Your Dictionary, 2013). Expensive items can be cost-effective and inexpensive
items may not. Cost-effectiveness then must take into account factors such as anticipated
length of service, need for such a service, and availability of other alternatives.
In addition, in terms of health care, cost and quality do not have a linear relationship.
Higher spending does not necessarily result in higher quality care. Sometimes, high
spending represents a duplication of services, an overutilization of services, and the use
of technology that exceeds a particular patient’s needs. In fact, numerous studies over
the past decade have examined the relationship between higher spending and the quality
and outcomes of care and found that higher spending does not necessarily result in better
quality care.
Spending more does not always equate to higher quality health outcomes.
These findings are true on the macro-level as well. The United States spends more per capita
on health care than does any other industrialized country, and yet our outcomes in terms of
teenage pregnancy rates, low–birth-weight infants, and access to care are worse than many
countries that spend significantly less. The problem then is not a scarcity of resources. The
problem is that we do not use the resources we have available, in a cost-effective manner.
8. role models leadership in needed health-care reform efforts.
9. proactively prepares followers for the plethora of changes in health care associated with health-
care reform and implementation of the Patient Protection and Affordable Cart Act.
MANAGEMENT FUNCTIONS
1. identifies the importance of and develops short- and long-range fiscal plans that reflect unit
needs.
2. articulates and documents unit needs effectively to higher administrative levels.
3. assesses the internal and external environment of the organization in forecasting to identify
driving forces and barriers to fiscal planning.
4. Demonstrates knowledge of budgeting and uses appropriate techniques to budget effectively.
5. provides opportunities for subordinates to participate in relevant fiscal planning.
6. Coordinates unit-level fiscal planning to be congruent with organizational goals and objectives.
7. accurately assesses personnel needs by using predetermined standards or an established
patient classification system.
8. Coordinates the monitoring aspects of budget control.
9. ensures that documentation of patient’s need for services and services rendered is clear and
complete to facilitate organizational reimbursement.
10. Collaborates with other health-care administrators to proactively determine how health-care
reform initiatives such as VBp, aCOs, bundled payments, the medical home, and the health
insurance marketplace may impact organizational viability and the provision of services.
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208 UNIT III ROLES AND FUNCTIONS IN PLANNING
RESpONSIBILITy ACCOUNTING AND FORECASTING
An essential feature of fiscal planning is responsibility accounting, which means that each
of an organization’s revenues, expenses, assets, and liabilities is someone’s responsibility.
As a corollary, the person with the most direct control or influence on any of these financial
elements should be held accountable for them. At the unit level, this accountability generally
falls to the manager. The leader-manager, then, should be an active participant in unit
budgeting, have a high degree of control over what is included in the unit budget, receive
regular data reports that compare actual expenses with budgeted expenses, and be held
accountable for the financial results of the operating unit.
Because unit managers are involved in daily operations and see firsthand their unit’s
functioning, they often have expertise in forecasting patient census trends as well as supply
and equipment needs for their units. Forecasting involves making an educated budget
estimate by using historical data.
The unit manager also can best monitor and evaluate all aspects of a unit’s budget control.
Like other types of planning, the unit manager has a responsibility to communicate budgetary
planning goals to the staff. The more the staff understands the budgetary goals and the plans
to carry out those goals, the more likely the goal attainment is. Sadly, many nurses have little
knowledge of the nursing budget model used by their hospital system.
BASICS OF BUDGETS
A budget is a financial plan that includes estimated expenses as well as income for a period
of time. Accuracy dictates the worth of a budget; the more accurate the budget blueprint, the
better the institution can plan the most efficient use of its resources.
The budget’s value is directly related to its accuracy.
Because a budget is at best a prediction, a plan, and not a rule, fiscal planning requires
flexibility, ongoing evaluation, and revision. In the budget, expenses are classified as fixed or
variable and either controllable or noncontrollable. Fixed expenses do not vary with volume,
whereas variable expenses do. Examples of fixed expenses might be a building’s mortgage
payment or a manager’s salary; variable expenses might include the payroll of hourly wage
employees and the cost of supplies.
Controllable expenses can be controlled or varied by the manager, whereas noncontrollable
expenses cannot. For example, the unit manager can control the number of personnel working on
a certain shift and the staffing mix; he or she cannot, however, control equipment depreciation,
the number and type of supplies needed by patients, or overtime that occurs in response to an
emergency. A list of the fiscal terminology that a manager needs to know is shown in Display 10.2.
STEpS IN THE BUDGETARy pROCESS
The nursing process provides a model for the steps in budget planning:
1. The first step is to assess what needs to be covered in the budget. Generally, this
determination should reflect input from all levels of the organizational hierarchy,
since budgeting is most effective when all personnel using the resources are involved
in the process. A composite of unit needs in terms of labor, equipment, and operating
expenses can then be compiled to determine the organizational budget.
2. The second step is diagnosis. In the case of budget planning, the diagnosis would be
the goal or what needs to be accomplished, which is to create a cost-effective budget
that maximizes the use of available resources.

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Chapter 10 Fiscal Planning 209
Accountable Care Organizations (aCOs)—Groups of providers and suppliers of service who work
together to better coordinate care for Medicare patients (does not include Medicare advantage)
across care settings.
Acuity index—Weighted statistical measurement that refers to severity of illness of patients for a giv-
en time. patients are classified according to acuity of illness, usually in one of four categories. The
acuity index is determined by taking a total of acuities and then dividing by the number of patients.
Affordable Care Act—Officially known as the Patient Protection and Affordable Care Act, this act
passed in March 2010 to assure that all americans have access to affordable health insurance
by reducing the barriers to obtaining health coverage as well as accessing needed health-care
services.
Assets—Financial resources that a health-care organization receives, such as accounts receivable.
Baseline data—historical information on dollars spent, acuity level, patient census, resources need-
ed, hours of care, and so forth. This information is used as basis on which future needs can be
projected.
Break-even point—point at which revenue covers costs. Most health-care facilities have high fixed
costs. Because per-unit fixed costs in a noncapitated model decrease with volume, health-care
facilities under this model need to maintain a high volume to decrease unit costs.
Bundled payment—a payment structure in which different health-care providers who are treating a
patient for the same or related conditions are paid an overall sum for taking care of that condition
rather than being paid for each individual treatment, test, or procedure. in doing so, providers are
rewarded for coordinating care, preventing complications and errors, and reducing unnecessary
or duplicative tests and treatments (healthcare.gov, 2013b).
Capitation—a prospective payment system (pps) that pays health plans or providers a fixed amount
per enrollee per month for a defined set of health services, regardless of how many (if any) ser-
vices are used.
Case mix—Type of patients served by an institution. a hospital’s case mix is usually defined in
such patient-related variables as acuity levels, diagnosis, personal characteristics, and patterns
of treatment.
Cash flow—rate at which dollars are received and dispersed.
Controllable costs—Costs that can be controlled or that vary. an example would be the number of
personnel employed, the level of skill required, wage levels, and quality of materials.
Cost–benefit ratio—Numerical relationship between the value of an activity or procedure in terms
of benefits and the value of the activity’s or procedure’s cost. The cost–benefit ratio is expressed
as a fraction.
Cost center—smallest functional unit for which cost control and accountability can be assigned.
a nursing unit is usually considered a cost center, but there may be other cost centers within a
DISpLAy 10.2 Fiscal Terminology
(Continued )
LEARNING EXERCISE 10.1
Would You Accept This Gift?
One of the oncologists on your unit (Dr. sam Jones) has offered to give you his old photocopier
because his office is purchasing a new one. as a condition of acceptance, he requires that all
the oncologists and radiologists be allowed to use the copier free of charge.
Assignment:
1. Justify acceptance or rejection of the gift. What influenced your choice?
2. What are the fixed and variable costs?
3. What are the controllable and noncontrollable costs?
4. What factors determine whether the use of Dr. Jones gift is cost effective?
4. how much control will you, as a unit manager, have over the use of the copier?
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210 UNIT III ROLES AND FUNCTIONS IN PLANNING
unit (orthopedics is a cost center, but often the cast room is considered a separate cost center
within orthopedics).
Diagnosis-related groups (DRGs)—rate-setting pps used by Medicare to determine payment
rates for an inpatient hospital stay based on admission diagnosis. each DrG represents a par-
ticular case type for which Medicare provides a flat dollar amount of reimbursement. This set rate
may, in actuality, be higher or lower than the cost of treating the patient in a particular hospital.
Direct costs—Costs that can be attributed to a specific source, such as medications and treat-
ments. Costs that are clearly identifiable with goods or service.
Fee-for-service (FFS) system—a reimbursement system under which insurance companies reim-
burse health-care providers after the needed services are delivered.
Fixed budget—style of budgeting that is based on a fixed, annual level of volume, such as number of
patient-days or tests performed, to arrive at an annual budget total. These totals are then divided
by 12 to arrive at the monthly average. The fixed budget does not make provisions for monthly
or seasonal variations.
Fixed costs—Costs that do not vary according to volume. examples of fixed costs are mortgage or
loan payments.
For-profit organization—Organization in which the providers of funds have an ownership interest
in the organization. These providers own stocks in the for-profit organization and earn dividends
based on what is left when the cost of goods and of carrying on the business is subtracted from
the amount of money taken in.
Full costs—Total of all direct and indirect costs.
Full-time equivalent (FTE)—Number of hours of work for which a full-time employee is scheduled
for a weekly period. For example, 1.0 FTe = five 8-hour days of staffing, which equals 40 hours
of staffing per week. One FTe can be divided in different ways. For example, two part-time
employees, each working 20 hours per week, would equal 1 FTe. if a position requires coverage
for more than 5 days or 40 hours per week, the FTe will be greater than 1.0 for that position.
assume a position requires 7-day coverage, or 56 hours, then the position requires 1.4 FTe cov-
erage (56/40 = 1.4). This means that more than one person is needed to fill the FTe positions
for a 7-day period.
Health maintenance organization (HMO)—historically, a prepaid organization that provided health
care to voluntarily enrolled members in return for a preset amount of money on a per-person, per-
month basis. Often referred to as a managed care organization (MCO).
Hours per patient-day (HPPD)—hours of nursing care provided per patient per day by various
levels of nursing personnel. hppD are determined by dividing total production hours by the
number of patients.
International Classification of Disease (ICD) codes—Coding used to report the severity and
treatment of patient diseases, illnesses, and injuries to determine appropriate reimbursement.
Currently in its 10th revision, iCD-10 will replace iCD-9 in October 2014, and hospitals will be
required to make this transition to comply with health insurance portability and accountability
act of 1996 (hipaa) requirements.
Indirect costs—Costs that cannot be directly attributed to a specific area. These are hidden costs
and are usually spread among different departments. housekeeping services are considered
indirect costs.
Managed care—Term used to describe a variety of health-care plans designed to contain the cost of
health-care services delivered to members while maintaining the quality of care.
Medicaid—Federally assisted and state-administered program to pay for medical services on behalf
of certain groups of low-income individuals. Generally, these individuals are not covered by
social security. Certain groups of people (e.g., the elderly, blind, disabled, members of families
with dependent children, and certain other children and pregnant women) also qualify for cover-
age if their incomes and resources are sufficiently low.
Medicare—Nationwide health insurance program authorized under Title 18 of the social security
act that provides benefits to people aged 65 years or older. Medicare coverage also is available
to certain groups of people with catastrophic or chronic illness, such as patients with renal failure
requiring hemodialysis, regardless of age.
Noncontrollable costs—indirect expenses that cannot usually be controlled or varied. examples
might be rent, lighting, and depreciation of equipment.

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Chapter 10 Fiscal Planning 211
3. The third step is to develop a plan. The budget plan may be developed in many ways.
A budgeting cycle that is set for 12 months is called a fiscal-year budget. This fiscal
year, which may or may not coincide with the calendar year, is then usually broken
down into quarters or subdivided into monthly or semiannual periods. Most budgets
are developed for a 1-year period, but a perpetual budget may be done on a continual
basis each month so that 12 months of future budget data are always available.
Selecting the optimal time frame for budgeting is also important. Errors are more likely
if the budget is projected too far in advance. If the budget is shortsighted, compensating for
unexpected major expenses or purchasing capital equipment may be difficult.
A budget that is predicted too far in advance has greater probability for error.
Not-for-profit organization—This type of organization is financed by funds that come from several
sources, but the providers of these funds do not have an ownership interest. profits generated
in the not-for-profit organization are frequently funneled back into the organization for expansion
or capital acquisition.
Operating expenses—Daily costs required to maintain a hospital or health-care institution.
Patient classification system—Method of classifying patients. Different criteria are used for differ-
ent systems. in nursing, patients are usually classified according to acuity.
Pay for performance (also known as P4P) programs—incentives are paid to providers to achieve
a targeted threshold of clinical performance, typically a process or outcome measure associated
with a specified patient population (Keckley, 2013).
Pay for value programs—Typically, these incentive payments are specific to a provider setting (i.e.,
hospital inpatient or outpatient, physician, home health, skilled nursing facility, and dialysis) and
linked to both quality and efficiency improvements (Keckley, 2013).
Preferred provider organization (PPO)—health-care financing and delivery program with a group
of providers, such as physicians and hospitals, who contract to give services on an FFs basis.
This provides financial incentives to consumers to use a select group of preferred providers and
pay less for services. insurance companies usually promise the ppO a certain volume of patients
and prompt payment in exchange for fee discounts.
Production hours—Total amount of regular time, overtime, and temporary time. This also may be
referred to as actual hours.
Prospective payment system—a hospital payment system with predetermined reimbursement
ratio for services given.
Revenue—source of income or the reward for providing a service to a patient.
Staffing mix—ratio of registered nurses (rNs), licensed vocational nurses (LVNs)/licensed profes-
sional nurses (LpNs), and unlicensed workers (e.g., a shift on one unit might have 40% rNs,
40% LpNs/LVNs, and 20% others). hospitals vary on their staffing mix policies.
Third-party payment system—a system of health-care financing in which providers deliver services
to patients, and a third party, or intermediary, usually an insurance company or a government
agency, pays the bill.
Turnover ratio—rate at which employees leave their jobs for reasons other than death or retirement.
The rate is calculated by dividing the number of employees leaving by the number of workers
employed in the unit during the year and then multiplying by 100.
Value-Based Purchasing—a payment methodology that rewards quality of care through payment
incentives and transparency. in VBp, value can be broadly considered to be a function of quality,
efficiency, safety, and cost (Keckley, 2013).
Variable costs—Costs that vary with the volume. payroll costs are an example.
Workload units—in nursing, workloads are usually the same as patient-days. For some areas, how-
ever, workload units might refer to the number of procedures, tests, patient visits, injections, and
so forth.
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212 UNIT III ROLES AND FUNCTIONS IN PLANNING
4. The fourth step is implementation. In this step, ongoing monitoring and analysis occur
to avoid inadequate or excess funds at the end of the fiscal year. In most health-care
institutions, monthly statements outline each department’s projected budget and
deviations from that budget. Some managers artificially inflate their department
budgets as a cushion against budget cuts from a higher level of administration. If
several departments partake in this unsound practice, the entire institutional budget
may be ineffective. If a major change in the budget is indicated, the entire budgeting
process must be repeated. Top-level managers must watch for and correct unrealistic
budget projections before they are implemented.
5. The last step is evaluation. The budget must be reviewed periodically and modified
as needed throughout the fiscal year. Each unit manager is accountable for budget
deviations in his or her unit. Most units can expect some change from the anticipated
budget, but large deviations must be examined for possible causes and remedial action
taken if necessary.
TypES OF BUDGETS
Three major types of budgets that the nurse-manager may be directly involved in with fiscal
planning are personnel, operating, and capital budgets.
The Personnel Budget
The largest of the budget expenditures is the workforce or personnel budget because health
care is labor intensive. To handle fluctuating patient census and acuity, managers need
to use historical data about unit census fluctuations in forecasting short- and long-term
personnel needs. Likewise, a manager must monitor the personnel budget closely to prevent
understaffing or overstaffing. As patient-days or volume decreases, managers must decrease
personnel costs in relation to the decrease in volume.
The largest of the budget expenditures is the workforce or personnel budget because health
care is labor intensive.
In addition to numbers of staff, the manager must be cognizant of the staffing mix. Staffing
mix refers to the mix (percentages) of licensed (RN and LVN) and unlicensed (certified
nursing assistant [CNA], and unlicensed assistive personnel) staff working at a given time.
The manager must also be aware of the patient acuity so that the most economical level of
nursing care that will meet patient needs can be provided.
Although Unit V discusses staffing, it is necessary to briefly discuss here how staffing
needs are expressed in the personnel budget. Most staffing is based on a predetermined
standard. This standard may be addressed in HPPD (medical units), visits per month (home
health agencies), or minutes per case (the operating room). Because the patient census,
number of visits, or cases per day never remains constant, the manager must be ready to alter
staffing when volume increases or decreases. Sometimes, the population and type of cases
change so that the established standard is no longer appropriate. For example, an operating
room that begins to perform open-heart surgery would involve more nursing time per case;
therefore, the standard (number of nursing minutes per case) would need to be adjusted.
Normally, the standard is adjusted upward or downward once a year, but staffing is adjusted
daily depending on the volume.
The standard formula for calculating nursing care hours (NCH) per patient-day (PPD)
is shown in Figure 10.1. A unit manager in an acute care facility might use this formula to
calculate daily staffing needs. For example, assume that your budgeted NCH are 6 NCH/PPD.

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Chapter 10 Fiscal Planning 213
You are calculating the NCH/PPD for today, January 31; at midnight, it will be February 1.
The patient census at midnight is 25 patients. In checking staffing, you find the following
information:
NCH/PPD =
Nursing hours worked in 24 hours
Patient census
Xll
I
V
Il
IV
Xl
Vll
X
Vlll
IlllX
Vl
Nursing hours worked
in 24 hours
Patient census
=
Xll
I
V
Il
IV
Ill
NCH/PPD
FIGURE 10.1 • standard formula for calculating nursing care
hours per patient-day. Copyright ® 2006 Lippincott Williams
& Wilkins. instructor’s resource CD-rOM to accompany
Leadership roles and Management Functions in Nursing, by
Bessie L. Marquis and Carol J. huston.
Shift Staff on Duty Hours Worked
11 pm (1/30) to 7 am (1/31) 2 rNs 8 h each
1 LVN 8 h
1 CNa 8 h
7 am to 3 pm 3 rNs 8 h each
2 LVNs 8 h each
1 CNa 8 h
1 ward clerk 8 h
3 pm to 11 pm 2 rNs 8 h each
2 LVNs 8 h each
1 CNa 8 h
1 ward clerk 8 h
11 pm (1/31) to 7 am (2/1) 2 rNs 8 h each
2 LVNs 8 h each
1 CNa 8 h
Ideally, you would use 12 midnight to compute the NCH/PPD for January 31, but most
staffing calculations based on traditional 8-hour shifts are made beginning at 11 pm and
ending at 11 pm the following night. Therefore, in this case, it would be acceptable to figure
the NCH/PPD for January 31 by using numerical data from the 11 pm to 7 am shift last night
and the 7 am to 3 pm and 3 pm to 11 pm shifts today. The first step in this calculation requires
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214 UNIT III ROLES AND FUNCTIONS IN PLANNING
a computation of total NCH worked in 24 hours (including the ward clerk’s hours). This
can be calculated by multiplying the total number of staff on duty each shift by the hours
each worked in their shift. Each shift total then is added together to get the total number of
nursing hours worked in all three shifts or 24 hours: The nursing hours worked in 24 hours
are 136 hours.
The second step in solving NCH/PPD requires that you divide the nursing hours worked in
24 hours by the patient census. The patient census in this case is 25. Therefore, 136/25 = 5.44.
The NCH/PPD for January 31 was 5.44, which is less than your budgeted NCH/PPD of
6.0. It would be possible to add up to 14 additional hours of nursing care in the next 24 hours
and still maintain the budgeted NCH standard. However, the unit manager must remember
that the standard is flexible and that patient acuity and staffing mix may suggest the need for
even more staff for February 1 than the budgeted NCH/PPD.
The personnel budget includes actual worked time (also called productive time or salary
expense) and time that the organization pays the employee for not working (nonproductive
or benefit time). Nonproductive time includes the cost of benefits, new employee orientation,
employee turnover, sick and holiday time, and education time. For example, the average
8.5-hour shift includes a 30-minute lunch break and two 15-minute breaks. Thus, this
employee would work 7.5 productive hours and have 1.0 hours of nonproductive time.
LEARNING EXERCISE 10.2
Calculating NCH/PPD
Calculate the NCh/ppD if the midnight census is 25, but use the following as the number of
hours worked:
12 midnight to 12 noon 2 rNs 12 h each
2 LVNs 12 h each
1 can 12 h
1 ward clerk 5 h
12 noon to 12 midnight 3 rNs 12 h each
2 LVNs 12 h each
1 can 12 h
1 ward clerk 12 h
Now, calculate the NCh/ppD if the following staff were working:
12 midnight to 12 noon 3 rNs 12 h each
1 LVN 12 h
12 noon to 12 midnight 2 rNs 12 h each
1 LVN 12 h
1 ward clerk 4 h
The Operating Budget
The operating budget is the second area of expenditure that involves all managers. The
operating budget reflects expenses that change in response to the volume of service, such as
the cost of electricity, repairs and maintenance, and supplies. While personnel costs lead the
hospital budget, the cost of supplies runs a close second.
Next to personnel costs, supplies are the second most significant component in the hospital
budget.
Effective unit managers should be alert to the types and quantities of supplies used in their unit.
They should also understand the relationship between supply use and patient mix, occupancy

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Chapter 10 Fiscal Planning 215
rate, technology requirements, and types of procedures performed on the unit. Saving unused
supplies from packs or trays, reducing obsolete and slow-moving inventory, eliminating
pilferage, and monitoring the uncontrolled usage of supplies and giveaways all represent
potential cost savings. Other ways to cut supply costs might be in rental versus facility-owned
equipment, stocking products on consignment, and just-in-time stockless inventory. Just-in-
time ordering is a process whereby inventory is delivered to the organization by suppliers
only when it is needed and immediately before it is to be used.
LEARNING EXERCISE 10.3
Missing Supplies
You are a unit manager in an acute care hospital. You are aware that staff occasionally leave at
the end of the shift with forgotten hospital supplies in their pockets. You remember how often
as a staff nurse you would unintentionally take home rolls of adhesive tape, syringes, penlights,
and bottles of lotion. Usually, you remembered to return the items, but other times you did not.
recently, however, your budget has shown a dramatic and unprecedented increase in missing
supplies, including gauze wraps, blood pressure cuffs, stethoscopes, surgical instruments, and
personal hygiene kits. although this increase represents only a fraction of your total operating
budget, you believe that it is necessary to identify the source of their use. an audit of patient
charts and charges reveals that these items were not used in patient care.
When you ask your charge nurses for an explanation, they reveal that a few employees have
openly expressed that taking a few small supplies is, in effect, an expected and minor fringe
benefit of employment. Your charge nurses do not believe that the problem is widespread,
and they cannot objectively document which employees are involved in pilfering supplies. The
charge nurses suggest that you ask all employees to document in writing when they see other
employees taking supplies and then turn in the information to you anonymously for follow-up.
Assignment: Because supplies are such a major part of the operating budget, you believe that
some action is indicated. You must determine what that action should be. analyze your actions in
terms of the desirable and undesirable effects on the employees involved in taking the supplies
and those who are not. is the amount of the fiscal debit in this situation a critical factor? is it
worth the time and energy that would be required to truly eliminate this problem?
The Capital Budget
The third type of budget used by managers is the capital budget. Capital budgets plan for
the purchase of buildings or major equipment, which include equipment that has a long life
(usually greater than 5 to 7 years), is not used in daily operations, and is more expensive
than operating supplies. Capital budgets are composed of long-term planning, or a major
acquisitions component, and a short-term budgeting component. The long-term major
acquisitions component outlines future replacement and organizational expansion that will
exceed 1 year. Examples of these types of capital expenditures might include the acquisition
of a positron emission tomography imager or the renovation of a major wing in a hospital.
The short-term component of the capital budget includes equipment purchases within the
annual budget cycle, such as call-light systems, hospital beds, and medication carts.
Often, the designation of capital equipment requires that the value of the equipment
exceed a certain dollar amount. That dollar amount will vary from institution to institution,
but $1,000 to $5,000 is common. Managers are usually required to complete specific capital
equipment request forms either annually or semiannually and to justify their request. Capital
“budget busters” are noted in Display 10.3.
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216 UNIT III ROLES AND FUNCTIONS IN PLANNING
BUDGETING METHODS
Budgeting is frequently classified according to how often it occurs and the base on
which budgeting takes place. Four of the most common budgeting methods are incremental
budgeting (also called flat-percentage increase budgeting), zero-based budgeting, flexible
budgeting, and new performance budgeting.
Incremental Budgeting
Incremental or the flat-percentage increase method is the simplest method for budgeting. By
multiplying current-year expenses by a certain figure, usually the inflation rate or consumer price
index, the budget for the coming year may be projected. Although this method is simple and
quick and requires little budgeting expertise on the part of the manager, it is generally inefficient
fiscally because there is no motivation to contain costs and no need to prioritize programs and
services. Hospitals have historically used incremental budgeting in fiscal planning.
Zero-Based Budgeting
In comparison, managers who use zero-based budgeting must rejustify their program or needs
every budgeting cycle. This method does not automatically assume that because a program
has been funded in the past, it should continue to be funded. Thus, this budgeting process is
labor intensive for nurse-managers. The use of a decision package to set funding priorities is
a key feature of zero-based budgeting. Key components of decision packages are shown in
Display 10.4.
l Going through the difficult process of completing a budget estimate for the coming year but never
using it.
l relying on the current year’s budget numbers as a starting point for the next year’s budget.
l Neglecting or underestimating costs related to capital expenditures.
l ignoring declining patient volumes in the hope that the trend will be temporary.
l Failing to set aside enough money for unexpected capital expenses.
Source: Adapted from Barr, P. (2005). Flexing your budget: Experts urge hospitals, systems to trade in their traditional
budgeting process for a more dynamic and versatile model. Modern healthcare, 35(37), 24, 26.
DISpLAy 10.3 Budget Busters
1. Listing of all current and proposed objectives or activities in the department.
2. alternative plans for carrying out these activities.
3. Costs for each alternative.
4. advantages and disadvantages of continuing or discontinuing an activity.
DISpLAy 10.4 Key Components of Decision Packages in Zero-Based Budgeting
The following is an example of a decision package for implementing a mandatory hepatitis
B vaccination program at a nursing school.
Objective: All nursing students will complete a hepatitis B vaccination series.
Driving forces: Hepatitis B is a severely disabling disease that carries significant
mortality. The Occupational Safety and Health Association (OSHA) requires that
hepatitis B vaccine be offered to health-care workers (which includes student nurses)
who have a reasonable expectation of being exposed to blood on the job. Vaccination
greatly reduces the risk of contracting this disease. The current vaccination series has

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Chapter 10 Fiscal Planning 217
proven to have few serious side effects. The nursing school risks liability if it does not
follow recommendations to have all high-risk groups vaccinated.
Restraining forces: The vaccination series costs $300 per student. Some students do not
want to have the vaccinations and believe that requiring them to do so is a violation
of free choice. It is unclear whether the school is liable if a student experiences a side
effect from the vaccinations.
Alternative 1: Require the vaccinations. Because the school of nursing cannot afford to
pay for the cost of the series, require that the students pay for it.
Advantage: No cost to the school. All students receive the vaccinations.
Disadvantage: Many students cannot afford the cost of the vaccination and believe that
requiring it infringes on their right to control choices about their bodies.
Alternative 2: Do not require the vaccination series.
Advantage: No cost to anyone. Students have choice regarding whether to have the
vaccinations and assume the responsibility of protecting their health themselves.
Disadvantage: Some nursing students will be unprotected against hepatitis B while
working in a high-risk clinical setting.
Alternative 3: Require the vaccination series but share the cost between the student and
the school.
Advantage: Decreased cost to students. All students would be vaccinated.
Disadvantage: Costs and limited choice.
Decision packages and zero-based budgeting are advantageous because they force
managers to set priorities and to use resources most efficiently. This rather lengthy and
complex method also encourages participative management because information from peers
and subordinates is needed to analyze adequately and prioritize the activities of each unit.
LEARNING EXERCISE 10.4
Developing a Decision Package
Given the following objective, develop a decision package to aid you in fiscal priority setting.
Objective: To have reliable, economic, and convenient transportation when you enter nursing
school in 3 months.
additional information: You currently have no car and rely on public transportation, which is
inexpensive and reliable but not very convenient. Your current financial resources are limited,
although you could probably qualify for a car loan if your parents were willing to cosign the loan.
Your nursing school’s policy states that you must have a car available to commute to clinical
agencies outside the immediate area. You know that this policy is not enforced and that some
students do carpool to clinical assignments.
Assignment: identify at least three alternatives that will meet your objective. Choose the best
alternative based on the advantages and disadvantages that you identify. You may embellish
information presented in the case to help your problem solving.
Flexible Budgeting
Flexible budgets are budgets that flex up and down over the year depending on volume. A
flexible budget automatically calculates what the expenses should be, given the volume that
is occurring. This works well in many health-care organizations as a result of changing census
and manpower needs that are difficult to predict, despite historical forecasting tools.
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218 UNIT III ROLES AND FUNCTIONS IN PLANNING
Performance Budgeting
The fourth method of budgeting, performance budgeting, emphasizes outcomes and results
instead of activities or outputs. Thus, the manager would budget as needed to achieve specific
outcomes and would evaluate budgetary success accordingly. For example, a home health
agency would set and then measure a specific outcome in a group, such as diabetic patients,
as a means of establishing and justifying a budget.
CRITICAL pATHWAyS
Critical pathways (also called clinical pathways and care pathways) are a strategy for
assessing, implementing, and evaluating the cost-effectiveness of patient care. These
pathways reflect relatively standardized predictions of patients’ progress for a specific
diagnosis or procedure. For example, a critical pathway for a specific diagnosis might suggest
an average length of stay of 4 days, with certain interventions completed by certain points on
the pathway (much like a PERT diagram; see page 23). Patient progress that differs from the
critical pathway prompts a variance analysis.
Critical pathways are predetermined courses of progress that patients should make after
admission for a specific diagnosis or after a specific surgery.
First developed in the 1980s as a tool to reduce length of stay, critical pathways also provide
a useful tool for monitoring quality of care. Once the cost of a pathway is known, analyzing
the cost-effectiveness of the pathway as well as the associated cost variances is possible. By
using clinical and cost variance data, decisions on changing the pathway can be made with
both clinical and financial outcome projections.
The advantage of critical pathways is that they do provide some means of standardizing care
for patients with similar diagnoses. Their weakness, however, is the difficulties they pose in
accounting for and accepting what are often justifiable differentiations between unique patients
who have deviated from their pathway. Critical pathway documentation also poses one more
paperwork and utilization review function in a system already burdened with administrative
costs. Despite these challenges, research suggests that critical pathways can standardize care
according to evidence-based best practices, leading to improved patient outcomes.
HEALTH-CARE REIMBURSEMENT
Historically, health-care institutions used incremental budgeting and placed little or no
emphasis on budgeting. Because insurance carriers reimbursed fully on virtually a limitless
basis, there was little motivation to save costs and organizations found it unnecessary to
justify charges. Reimbursement was based on costs incurred to provide the service plus profit
(FFS), with no ceiling placed on the total amount that could be charged. Indeed, under FFS,
the more services provided, the greater the amount that could be billed, encouraging the
overtreatment of clients.
The end result of uncontrolled FFS reimbursement was skyrocketing health-care costs
with health care increasingly assuming a greater percentage of gross domestic product (GDP)
each year. Currently, the United States spends more of its GDP on medical care than any other
nation, almost 18%. “After gobbling up a rapidly increasing share of our national economy
over the past three decades, health-care spending has flattened out over the past few years.
It grew from $2.5 trillion in 2009 to $2.7 trillion in 2011, but as a share of GDP it stayed
flat over this 3 year period” (Rosenberg, 2013, para 3). Much of the recent stabilization in
overall health-care spending, however, was not due to increased efficiencies in health-care

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Chapter 10 Fiscal Planning 219
delivery; it was due to the effects of the recession, as people who lost their jobs—and the
health benefits that came with them, with enrollment in private insurance plans dropping by
11.2 million from 2007 to 2010.
The United States spends more of its GDP on medical care than any other nation in the world.
MEDICARE AND MEDICAID
The US federal government became a major insurer of health care with the advent of Medicare
and Medicaid in the mid-1960s. Medicare is a federally sponsored health insurance program
for the elderly (older than 65 years) and for certain groups of people with catastrophic
or chronic illness, regardless of age. Medicare currently provides coverage for items and
services for more than 49 million beneficiaries, approximately 16% of the US population
(Kaiser Family Foundation, 2013). Just over 83% of enrollees are elderly, more than 16% are
disabled, and 0.9% have end-stage renal disease.
Between 2000 and 2010, Medicare spending grew as fast as or faster than increases
in private expenditures (Urban Institute, 2012). But Medicare enrollment increased while
private health insurance coverage fell and participation in Medicare is expected to increase
dramatically in the coming years as the result of the aging population. Indeed, Sahadi (2013)
suggests that the number of Medicare beneficiaries who will enroll in the program will grow
by 36%, or an estimated 18 million people, between 2012 and 2023. That trend is likely to
continue, given that the number of Baby Boomers turning 65 is projected to grow from an
average of about 7,600 per day in 2011 to more than 11,000 per day in 2029 (Sahadi).
Part A Medicare is the hospital insurance program. Part B Medicare is the supplementary
medical insurance program that pays for outpatient care (including laboratory and X-ray
services) and physician (or other primary care provider) services. Part C Medicare (now
called Medicare Advantage) allows patients more choices for participating in managed care
plans. And the newest, Medicare Part D, which became effective January 1, 2006, allows
Medicare patients to purchase at least limited prescription drug coverage. Approximately 12.6
million beneficiaries participate in Medicare Advantage and 39.33% participate in Medicare
Part D (Kaiser Family Foundation). Out-of-pocket costs for Medicare beneficiaries as of 2013
are shown in Table 10.1.
TABLE 10.1 Medicare Costs Per Beneficiary in 2013
MEDICARE INSURANCE PLAN Cost
part B premium Typically $104.90 each month
part B deductible $147 per year
part a premium Most people do not pay a monthly premium for part a. The cost for
part a is up to $441 each month
part a hospital inpatient
deductible
Beneficiaries pay:
• Days 1–60: $1,184 for each benefit period
• Days 61–90: $296 coinsurance per day of each benefit period
• Days 91 and beyond: $592 coinsurance per each “lifetime reserve
day” after day 90 for each benefit period (up to 60 d over your
lifetime)
• Beyond lifetime reserve days: all costs
part C Monthly premium varies by plan
part D Monthly premium varies by plan (higher income consumers may pay
more, up to $66.60 plus plan premium)
Source: Medicare.Gov. (2013). Medicare 2013 Costs at a Glance. Retrieved May 26, 2013 from http://www
.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html
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220 UNIT III ROLES AND FUNCTIONS IN PLANNING
Medicaid is a federal–state cooperative health insurance plan created primarily for the
financially indigent (low-income children and adults) although it also provides medical
and long-term care coverage for people with disabilities, and assistance with health and
long-term care expenses for low-income seniors. Between 2011 and 2020, overall Medicaid
expenditures are projected to grow between 8.1% and 8.7% (Urban Institute, 2012). Increases
in overall Medicaid spending will continue to be driven by enrollment growth largely because
of the Affordable Care Act. Both Medicare and Medicaid are coordinated by the Centers for
Medicare and Medicaid Services (CMS).
THE pROSpECTIVE pAyMENT SySTEM
With the advent of Medicare and Medicaid and FFS reimbursement, health-care costs
skyrocketed as large segments of the population that previously had no or limited coverage
began accessing services. In addition, health-care providers saw the government as having
“deep pockets,” which suggested almost limitless reimbursement and began providing
services accordingly. As a result of rapidly escalating costs, the government began
establishing regulations requiring organizations to justify the need for services and to monitor
the quality of services. Health-care providers were forced for the first time to submit budgets
and justify costs. This new surveillance and existence of external controls had a tremendous
effect on the health-care industry.
The advent of DRGs in the early 1980s added to the need for monitoring cost containment.
DRGs were predetermined payment schedules that reflected historical costs for treatment of
specific patient conditions. Medicare Severity DRGs were implemented in 2007 and have
been updated annually since.
In addition, hospitals use the ICD to code diseases, signs and symptoms, and abnormal
findings. Currently in its 10th revision, ICD-10 will replace ICD-9 in October 2014, and
hospitals will be required to make this transition to comply with HIPAA requirements.
ICD-10 will provide significantly more coding options for treatment, reporting, and payment
processes, including more than 68,000 clinical modification codes as compared with 15,000
in ICD-9 (Centers for Medicare & Medicaid Services, 2013).
With DRGs, hospitals joined the PPS, whereby they receive a specified amount for each
Medicare patient’s admission, regardless of the actual cost of care. Exceptions to this occur
when providers can demonstrate that a patient’s case is an outlier, meaning that the cost of
providing care for that patient justifies extra payment. PPS and consequent cost-containment
efforts lead to decreased length of stays for most patients.
As a result of the PPS and the need to contain costs, the length of stay for most hospital
admissions has decreased greatly.
Many argue that quality standards have been lowered as a result of the PPS and that patients
are being discharged before they are ready. It is the nurse-leader’s responsibility to recognize
when cost containment is impinging on patient safety and to take appropriate action to
guarantee at least a minimum standard of care. Chapter 23 further discusses the PPS and its
impact on quality control.
The government again deeply affected health-care administration in the United
States in 1997 with the passage of the Balanced Budget Act (BBA). This act contained
numerous cost-containment measures, including reductions in provider payments for
traditional FFS Medicare program participants. The bulk of the savings resulted from
limiting the growth rates for hospital and physician payments. A second major source
of savings derived from restructuring the payment methods for rehabilitation hospitals,
home health agencies, skilled nursing facilities, and outpatient services. The BBA also,

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Chapter 10 Fiscal Planning 221
for the first time, authorized payments to nurse practitioners for Medicare-provided
services at 85% of the physician-fee schedule.
The ever-increasing impact of the federal government on how health care is delivered in
the United States must be recognized. Accompanying this funding is an increase in regulations
for facilities treating these patients and a system that rewards cost containment. Health-care
providers are encountering financial crises as they attempt to meet unlimited health-care needs
and services with limited fiscal reimbursement. Competition has intensified, reimbursement
levels have declined, and utilization controls have increased. In addition, rapidly changing
federal and state reimbursement policies make long-range budgeting and planning very
difficult for health-care facilities.
THE MANAGED CARE MOVEMENT
Managed care has been a significant factor affecting health-care delivery and reimbursement
since the early 1990s. Broadly defined, managed care is a system that attempts to integrate
efficiency of care, access, and cost of care. Common denominators in managed care include
the use of primary care providers as “gatekeepers,” a focus on prevention, a decreased
emphasis on inpatient hospital care, the use of clinical practice guidelines for providers, and
selective contracting (whereby providers agree to lower reimbursement levels in exchange for
patient population contracts). Managed care typically uses formularies to manage pharmacy
care and focuses on continuous quality monitoring and improvement.
Utilization review is another common component of managed care. Utilization review is
a process used by insurance companies to assess the need for medical care and to assure that
payment will be provided for the care. Utilization review typically includes precertification
or preauthorization for elective treatments, concurrent review, and, if necessary, retrospective
review for emergency cases.
Another frequent hallmark of managed care is capitation, whereby providers receive a
fixed monthly payment regardless of services used by that patient during the month. If the
cost to provide care to someone is less than the capitated amount, the provider profits. If
the cost is greater than the capitated amount, the provider suffers a loss. The goal, then, for
capitated providers is to see that patients receive the essential services to stay healthy or
to keep from becoming ill but to eliminate unnecessary use of health-care services. Critics
of capitation argue that this reimbursement strategy leads to undertreatment of patients. A
summary of managed care characteristics is found in Display 10.5.
Types of Managed Care Organizations
One of the most common types of MCOs is the HMO. An HMO is a corporate body funded
by insurance premiums. The HMO’s physicians and other professionals practice medicine
within certain financial, geographic, and professional limits to individuals and families who
have enrolled in the HMO. The Health Maintenance Organization Act of 1973 authorized
spending $375 million over 5 years to set up and evaluate HMOs in communities across the
country. Although HMOs originated as an alternative to traditional health insurance plans,
some of the largest private insurers, including Blue Cross and Blue Shield and Aetna, have
created HMOs within their organization while maintaining their traditional indemnity plans.
In discussing HMOs, it is important to remember that there are different types of HMOs
as well as different types of plans within HMOs to which members may subscribe. Several
types of HMOs include (a) staff, (b) independent practice association (IPA), (c) group, and
(d) network. In staff HMOs, physician providers are salaried by the HMO and under direct
control of the HMO. In IPA HMOs, the HMO contracts with a group of physicians through
an intermediary to provide services for members of the HMO. In a group HMO, the HMO
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222 UNIT III ROLES AND FUNCTIONS IN PLANNING
contracts directly with one independent physician group. In network HMOs, the HMO
contracts with multiple independent physician group practices.
The types of plans available within HMOs typically vary according to the degree of
provider choice available to enrollees. Two such plans include point-of-service (POS) and
exclusive provider organization (EPO) options. In POS plans, the patient has the option, at
the time of service, to select a provider outside the network but pays a higher premium as
well as a copayment (amount of money enrollees pay out of their pocket at the time a service
is provided) for the flexibility to do so. In the EPO option, enrollees must seek care from the
designated HMO provider or pay all of the cost out of pocket.
Another common type of MCO is the PPO. PPOs render services on an FFS basis but
provide financial incentives to consumers (they pay less) when the preferred provider is
used. Providers are motivated to become part of a PPO because it ensures them an adequate
population of patients.
More than 70 million Americans have enrolled in HMOs and almost 90 million have
become a part of PPOs since their inception (National Conference of State Legislatures
[NCSL], 2011). As of 2010, the breakdown of enrollment by plan type in the United States
was 19% in HMOs, 58% in PPOs, and 8% in POS plans (NCSL). It should be noted that
“enrollment numbers in HMOs peaked in 2001 and are declining substantially in almost every
area, although managed care generally remains a dominant type of health care and coverage”
(NCSL, para 2).
Medicare and Medicaid Managed Care
Although Medicare and Medicaid patients historically were excluded from managed care
under the free choice of physician rule, these restrictions were lifted in the 1970s and 1980s.
As a result, these patients could participate in private HMOs and other types of managed
care programs through Medicare Part C (formerly the Medicare + Choice program, and now
known as Medicare Advantage). To join a Medicare Advantage Plan, patients must have both
l represents a wide range of financing alternatives that focus on managing the cost and quality of
health care by:
Using panels of selectively contracted providers
Limiting benefits to subscribers who use noncontracted providers
implementing some type of authorization system
Focusing on primary care rather than specialists and inpatient services
emphasizing preventive health care
relying on clinical practice guidelines for providers
regularly reviewing the use of health-care resources
Continuously monitoring and improving the quality of health services
l patients have less choice about the providers they can see and services they can access, in ex-
change for small copayments and no deductibles.
l MCOs often use primary care gatekeepers to:
Be sure that the provider-ordered services are needed and appropriate
see that patients are cared for in outpatient settings whenever possible
ration care by queuing and wait times for authorizations
encourage providers to follow more standardized care pathways and clinical guidelines for treatment
l Managed care is based on the concept of capitation, whereby providers prospectively receive a
fixed monthly payment, regardless of what services are used by that patient during the month. This
encourages providers to treat less, because their potential profits decline as treatment increases.
DISpLAy 10.5 Managed Care at a Glance

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Chapter 10 Fiscal Planning 223
Medicare Part A and Part B. The payment system for these programs (effective 1982) was to
be prospective, and the HMO was at risk for providing all benefits in return for the capitated
payment.
MCOs receive reimbursement for Medicare-eligible patients based on a formula
established by the CMS, which looks at age, gender, geographic region, and the average cost
per patient at a given age. Then, the government gives itself a 5% discount and gives the rest
to the MCO. The BBA of 1997 expanded the role of private plans under Medicare + Choice
to include PPOs, provider-sponsored organizations, private FFS plans, and medical savings
accounts (MSAs), coupled with high-deductible insurance plans.
The CMS is now the largest managed care buyer in the United States. Of the total Medicaid
enrollment in the United States in 2009, approximately 72% of participants are receiving
Medicaid benefits through managed care (NCSL, 2011). In addition, all states except Alaska
and Wyoming have all or a portion of their Medicaid population enrolled in an MCO (NCSL).
The Centers for Medicare and Medicaid Services is now the largest purchaser of managed care
in the country.
pROpONENTS AND CRITICS OF MANAGED CARE SpEAK Up
Proponents of managed care argue that prepaid health-care plans, such as those offered
by HMOs, decrease health-care costs, provide broader benefits for patients than under the
traditional FFS model, appropriately shift care from inpatient to outpatient settings, result in
higher physician productivity, and have high enrollee satisfaction levels.
Critics, however, suggest that participation in MCOs may result in a loss of existing
physician–patient relationships, a limited choice of physicians for consumers, a lower level
of continuity of care, reduced physician autonomy, longer wait times for care, and consumer
confusion about the many rules to be followed. A common complaint heard from managed
care subscribers is that services must be preapproved or preauthorized by a gatekeeper or that
second opinions must be obtained before surgery. Although this loss of autonomy is difficult
for consumers accustomed to an FFS system with few limits on choice and access, such
utilization constraints are necessary due to moral hazard, which is the risk that the insured
will overuse services just because the insurance will pay the costs. Because the copayment is
typically small for patients in managed care programs, the risk of moral hazard rises.
Moral hazard refers to the propensity of insured patients to use more medical services than
necessary because their insurance covers so much of the cost.
Another aspect complicating health-care reimbursement through the PPS, an HMO, or a
PPO is that clear and comprehensive documentation of the need for services and actual
services provided is mandatory. Provision of service no longer guarantees reimbursement.
Thus, the fiscal accountability of nurses goes beyond planning and implementing; it includes
responsible recording and communication of activities.
Provision of service no longer guarantees reimbursement.
Perhaps the most serious concern about the advancement of managed care in this country
is the change in relationships among insurers, physicians, nurses, and patients. The full
impact on clinical judgment of tying physician and nursing salaries to bonuses, incentives,
and penalties designed to reduce utilization of services and resources and increase profit is
unknown. As a result, a need for self-awareness regarding the values that guide individual
professional nursing practice has never been greater.
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224 UNIT III ROLES AND FUNCTIONS IN PLANNING
THE FUTURE OF MANAGED CARE
Managed care continues to change the face of health care in the United States. The contractual
complexity and the use of prospective payment in managed care make it much more difficult
for providers to anticipate potential revenues and then to bill for and collect reimbursement for
services provided. Indeed, some critics of managed care suggest that health-care practitioners
and institutions now bear much more of the financial risk for the cost of care than insurers.
Some declines in managed care participation have occurred in part because these plans
are no longer significantly less expensive for consumers to purchase or for insurers to
provide. In addition, providers have grown increasingly frustrated with limited and delayed
reimbursement for services provided as well as the need to justify need for services ordered.
Indeed, some providers have filed lawsuits against managed care insurers for delay of
payment or nonpayment for services provided. This phenomenon, referred to as managed
care backlash, resulted in some managed care programs beginning “to say ‘yes’ to more
treatments although they have passed the cost along to customers in the form of higher
premiums, co-pays and deductibles” (Freundlich, 2009, para 1). In addition, they began
offering consumers more choice and flexibility in their plans and removing barriers like
gatekeepers and capitation agreements (Freundlich).
Even with this backlash, managed care is not going to go away—at least not any time soon.
It will, however, continue to change. Certainly, in reviewing the health-care reimbursement
milestones of the past 75 years (Display 10.6), one can see that health-care reimbursement
has changed dramatically in a relatively short time and that managed care is just one more
reimbursement schema that has changed the face of health care in the United States.
LEARNING EXERCISE 10.5
Providing Care with Limited Reimbursement
You are the manager at a home health agency. One of your elderly patients has insulin-dependent
diabetes. he has no family support. he speaks limited english and has little understanding of
his disease. he lives alone. Your reimbursement from a government agency pays $90 per visit.
Because this gentleman needs so much care, you find that the actual cost to your agency is
$130 for each visit to him. What will be the impact to your agency if this patient is seen twice a
week for 3 months? how can you recover the lost revenue? how can you make each visit less
costly and still meet the needs of the patient?
1929 First hMO, the ross-Loos Clinic, established in Los angeles.
1929 Origins of Blue Cross, when Baylor University hospital agreed to provide 1,500 school teach-
ers up to 21 days of hospital care for $6.00 per year.
1935 passage of Social Security Act. This act originally included compulsory health insurance for
states that voluntarily chose to participate, but the american Medical association fought it and the
health insurance provisions were omitted from the act.
1942 First nationwide hospital insurance bill introduced into Congress, but it failed to pass.
1946 hill Burton act promoted hospital development and renovation after World War ii. authorized
$75 million yearly for 5 years to aid in hospital construction.
1965 passage of Medicare and Medicaid as part of Lyndon B. Johnson’s Great society. resulted in
50% increase in the number of medical schools in the United states.
1972 Professional Standards Review Organizations (psrOs) established by Congress to prevent
excess hospitalization and utilization by Medicare and Medicaid patients.
DISpLAy 10.6 US Health-Care Milestones: 75 Years of Reimbursement

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Chapter 10 Fiscal Planning 225
1973 The Health Maintenance Act authorized the spending of $375 million over 5 years to set up and
evaluate hMOs in communities across the country.
1974 The National planning act created a system of state and local health planning agencies largely
supported by federal funds. This created Health Systems Agencies (hsas) to inventory each com-
munity’s health-care resources and to issue Certificates of Need.
1974 The Employment Retirement Income and Security Act (erisa) passed, generally preempting
state regulation of self-insuring employee benefit plans.
1983 Diagnosis-Related Groups (DRGs) established, which changed the structure of Medicare pay-
ments from a retrospectively adjusted cost-reimbursement system to a prospective, risk-based
one.
1986 act of 1986 passed. allowed terminated employees or those who lose coverage because of
reduced work hours to buy group coverage for themselves and their families for limited periods of
time (up to 60 days to decide).
1988 Medicare Catastrophic Coverage Act (MCCa) enacted, which expanded Medicare benefits
greatly to include a portion of out-of-pocket drug and physician expenses.
1989 Medicare system of paying physician charges was changed to a resource-based relative value
scale (rBrVs) to be phased in starting in 1992.
1993 president William J. Clinton introduced the Health Security Act, legislation assuring universal
access to all americans. The act failed to pass.
1996 Health Insurance Portability and Accountability Act passed. Created Medical Savings Ac-
counts (Msas) and required the Department of health and human services to establish national
standards for electronic health-care transactions and national identifiers for providers, health
plans, and employers. it also addressed the security and privacy of health data.
1997 approximately one-quarter of americans enrolled in hMOs. almost 6 million Medicare benefi-
ciaries enrolled in hMOs. Balanced Budget Act gives states the authority to implement managed
care programs without federal waivers.
1999 health-care spending comprises approximately 15% of the GDp of the United states, exceed-
ing $1 trillion in annual health-care expenditures. approximately 37 million americans are unin-
sured and between 50 and 70 million are inadequately insured.
2001 More than 1.5 million elderly Medicare hMO patients forced to find new insurance arrange-
ments as their hMOs pulled out of the Medicare program after losing money on Medicare enroll-
ees. increasing disenchantment noted with managed care.
2003 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 passes, provid-
ing a voluntary program for prescription drug coverage under the Medicare program.
2003 The Medicare Modernization Act (MMA) of 2003 passes and commissions the IOM to “identify
and prioritize options to align performance to payment in Medicare.” The iOM reports provided the
rationale to reconfigure the U.S. health care payment system, supporting a “pay for performance”
(p4p) approach (Keckley, 2013, p. 3).
2009 Congressional committees begin active debate of a comprehensive health-care reform pack-
age. president Barack Obama announces the release of nearly $600 million in funding to strength-
en community health centers that will serve 500,000 additional patients and use health information
technology (healthreform.GOV, 2013).
2010 president Barack Obama’s health Care reform bill Patient Protection and Affordable Care Act
(ppaCa) passes, resulting in sweeping overhauls of the Us health-care system and the introduc-
tion of a new patient Bill of rights related to insurance coverage. provisions related to eliminating
lifetime limits on insurance coverage, extending coverage to young adults, and providing new cov-
erage to individuals who have been uninsured for at least 6 months due to a preexisting condition
are implemented.
2011 The Obama administration launches the Partnership for Patients: Better Care, Lower Costs, a
new public–private partnership (major hospitals, employers, health plans, physicians, nurses, and
patient advocates along with state and federal governments) to help improve the quality, safety,
and affordability of health care for all americans.
2011 ppaCa provisions related to providing free preventive care to seniors, the establishment of a
Community Care Transitions Program, and the creation of a new Center for Medicare & Medicaid
Innovation are put into place.
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226 UNIT III ROLES AND FUNCTIONS IN PLANNING
To provide care and appropriately advocate for patients in the 21st century, all nurses
need at least a basic understanding of health-care costs. They also need to know how
reimbursement strategies directly and indirectly affect their practice. Only then can nurses
be active participants in the proactive and visionary fiscal planning required to survive in the
current health-care marketplace.
All nurses need at least a basic understanding of health-care costs as well as how
reimbursement strategies directly and indirectly affect their practice.
HEALTH-CARE REFORM AND THE pATIENT pROTECTION AND
AFFORDABLE CARE ACT
In March, 2010, President Barack Obama signed the PPACA (often shortened to the
Affordable Care Act) that put in place comprehensive insurance reforms that were to be
phased in over a 4-year period. The act included a new Patient Bill of Rights (see Chapter 6)
implemented in 2010; a provision for Medicare beneficiaries to get preventive services for
free and discounts on brand name drugs for some patients using Medicare Part D beginning
in 2011 as well as the introduction of “bundled payments”; the addition of ACOs and other
programs help doctors and health-care providers work together to deliver better care in 2012;
hospital VBP and open enrollment in the Health Insurance Marketplace beginning in October
2013; and greater access for most Americans to affordable health insurance options in 2014
(Healthcare.gov, 2013a).
Bundled Payments
Passed in October 2011 and implemented in 2013, the Bundled Payments Initiative gave
providers flexibility to work together to coordinate care for patients over the course of a
single episode of an illness. There are four broadly defined models of bundled care: three
of these models involve retrospective payment and one is prospective. In the retrospective
payment models, CMS and providers set a target payment amount for a defined episode of
care. This target amount would reflect a discount to total costs for a similar episode of care
as determined from historical data. Participants then would be paid for their services under
the Original Medicare FFS system, but at a negotiated discount. Models 2 and 3 may include
clinical laboratory services and durable medical equipment (Healthcare.gov, 2013c).
The prospective payment model differs in that CMS makes a single, prospectively
determined bundled payment to a hospital that would encompass all services furnished during
the inpatient stay by the hospital, physicians, and other practitioners. “Physicians and other
practitioners would submit ‘no-pay’ claims to Medicare and would be paid by the hospital out
of the bundled payment”(Healthcare.gov, 2013c, para 9).
2012 The ppaCa establishes hospital Value-Based Purchasing programs (VBP) in traditional Medi-
care, provides incentives for physicians to join together to form accountable Care Organizations,
and provides new, voluntary options for long-term care insurance.
2013 The ppaCa provides new funding to state Medicaid programs that choose to cover preventive
services for patients at little or no cost, expands the authority to bundle payments, increases medi-
cal payments for primary care doctors, and begins open enrollment in the healthcare insurance
Marketplace.
2014 The final provisions of the ppaCa are phased in, including the implementation of the healthcare
insurance Marketplace, prohibition of discrimination due to preexisting conditions or gender, the
elimination of annual limits on insurance coverage, and ensuring coverage for individuals partici-
pating in clinical trials.

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Chapter 10 Fiscal Planning 227
Accountable Care Organizations
ACOs are groups of providers and suppliers of service who work together to better coordinate
care for Medicare patients (does not include Medicare Advantage) across care settings. The
goal of an ACO is to deliver seamless, high quality care in an environment that is truly patient
centered and where patients and providers are partners in decision making.
While patient and provider participation in ACOs are voluntary at this time, the Medicare
Shared Savings Program will reward ACOs that lower growth in health-care costs while
meeting performance standards on quality of care and putting patients first (Healthcare.
gov, 2013a). ACOs would only be entitled to these shared savings when savings exceed the
minimum sharing rate and if the ACO meets or exceeds the quality performance standards.
Additional shared savings can be earned by ACOs that include beneficiaries who receive
services from a Federally Qualified Health Center or Rural Health Clinic during the
performance year (Healthcare.gov, 2013a).
Hospital Value-Based Purchasing
Beginning in 2013, for the first time, the hospital VBP program paid inpatient acute care
services partially on care quality, not just on the quantity of the services they provide
(Healthcare.gov, 2013c). In VBP, providers are held accountable for the quality and cost of
the health-care services they provide by a system of rewards and consequences, conditional
upon achieving prespecified performance measures. Incentives are structured to discourage
inappropriate, unnecessary, and costly care (Keckley, 2013). Critical to VBP are standardized,
comparative, and transparent information on patient outcomes; health-care status; patient
experience (satisfaction); and costs (direct and indirect) of services provided (Keckley, 2013).
VBP payment reform is expected to reduce Medicare spending by almost $214 billion over
the first 10 years of its implementation.
The Medical Home
The medical home, also known as the patient-centered medical home (PCMH), “is designed
around patient needs and aims to improve access to care (e.g. through extended office hours
and increased communication between providers and patients via email and telephone),
increase care coordination and enhance overall quality, while simultaneously reducing costs”
(NCSL, 2012, para 2). The medical home relies on a team of providers—such as physicians,
nurses, nutritionists, pharmacists, and social workers—to integrate all aspects of health care,
including physical health, behavioral health, access to community-based social services,
and the management of chronic conditions. Communication occurs through well-developed
health information technology including electronic health records.
Payment reform is also a critical part of the medical home initiative as financial incentives are
offered to providers to focus on the quality of patient outcomes rather than the volume of services
they provide. While the model is still evolving, national and state medical home accreditation is
available, facilitating payment from both public and private payers (NCSL, 2012).
Health Insurance Marketplaces
As of October 2103, new health insurance marketplaces, also called exchanges, were
created for individuals without access to health insurance through a job, for implementation
in January 2014. Small businesses were also eligible to buy affordable and qualified health
benefit plans in this competitive insurance marketplace. In essence, health insurance
marketplaces are online insurance supermalls that cannot turn down prospective clients
as a result of preexisting conditions (Zamosky, 2013). Every health insurance plan in the
marketplace offers comprehensive coverage from doctors to medications to hospital visits
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228 UNIT III ROLES AND FUNCTIONS IN PLANNING
and options can be compared based on price, benefits, and quality (Healthcare.gov, 2013d).
Tax credits are provided to lower insurance costs for individuals and families earning below
certain levels.
INTEGRATING LEADERSHIp ROLES AND MANAGEMENT
FUNCTIONS IN FISCAL pLANNING
Managers must understand fiscal planning and health-care reimbursement, be aware of their
budgetary responsibilities, and be cost-effective in meeting organizational goals. The ability
to forecast unit fiscal needs with sensitivity to the organization’s political, economic, social,
and legislative climate is a high-level management function. Managers also must be able
to articulate unit needs through budgeting to ensure adequate nursing staff, supplies, and
equipment. Finally, managers must be skillful in the monitoring aspects of budget control.
Leadership skills allow the manager to involve all appropriate stakeholders in developing
the budget and implementing needed reforms. This has likely never been as important as it
currently is, given the current climate of health-care reform with almost countless initiatives
and phased-in implementation. Other leadership skills required in fiscal planning include
flexibility, creativity, and vision regarding future needs. The skilled leader is able to anticipate
budget constraints and act proactively. In contrast, many managers allow budget constraints
to dictate alternatives. In an age of inadequate fiscal resources, the leader is creative in
identifying alternatives to meet patient needs.
The skilled leader, however, also ensures that cost containment does not jeopardize patient
safety. As well, leaders are assertive, articulate people who ensure that their department’s
budgeting receives a fair hearing. Because leaders can delineate unit budgetary needs in an
assertive, professional, and proactive manner, they generally obtain a fair distribution of
resources for their unit.
KEY CONCEPTS
l Fiscal planning, as in all types of planning, is a learned skill that improves with practice.
l historically, nursing management played a limited role in determining resource allocation in health-care
institutions.
l The personnel–workforce budget often accounts for the majority of health-care organization’s expenses
because health care is labor intensive.
l personnel budgets include actual worked time (productive time or salary expense) and time that the
organization pays the employee for not working (nonproductive or benefit time).
l a budget is at best a forecast or prediction; it is a plan and not a rule. Therefore, a budget must be
flexible and open to ongoing evaluation and revision.
l a budget that is predicted too far in advance is open to greater error. if the budget is shortsighted,
compensating for unexpected major expenses or capital equipment purchases may be difficult.
l The desired outcome of budgeting is maximal use of resources to meet organizational short- and
long-term needs. its value to the institution is directly related to its accuracy.
l The operating budget reflects expenses that flex up or down in a predetermined manner to reflect
variation in volume of service provided.
l Capital budgets plan for the purchase of buildings or major equipment. This includes equipment that has
a long life (usually greater than 5 years), is not used daily, and is more expensive than operating supplies.
l Managers must rejustify their program or needs every budgeting cycle in zero-based budgeting. Using a
decision package to set funding priorities is a key feature of zero-based budgeting.

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Chapter 10 Fiscal Planning 229
ADDITIONAL LEARNING EXERCISES AND AppLICATIONS
l With the advent of state and federal reimbursement for health care in the 1960s, providers were forced
to submit budgets and costs to payers that more accurately reflected their actual cost to provide these
services.
l With DrGs, hospitals join the pps, whereby they receive a specified amount for each Medicare
patient’s admission, regardless of the actual cost of care. exceptions occur when the provider can
demonstrate that a patient’s case is an outlier, meaning that the cost of providing care for that patient
justifies extra payment.
l Key principles of managed care include the use of primary care providers as gatekeepers, a focus on
prevention, a decreased emphasis on inpatient hospital care, the use of clinical practice guidelines for
providers, selective contracting, capitation, utilization review, the use of formularies to manage pharmacy
care, and continuous quality monitoring and improvement.
l The types of plans available within hMOs typically vary according to the degree of provider choice
available to enrollees.
l Managed care has altered the relationships among insurers, physicians, nurses, and patients, with
providers today often having to assume a role as an agent for the patient as well as an agent of resource
allocation for an insurance carrier, hospital, or particular practice plan.
l provision of service no longer guarantees reimbursement. Clear and comprehensive documentation of
the need for services and actual services provided is needed for reimbursement.
l The 2010 pPACA (often shortened to the Affordable Care Act) put in place comprehensive insurance
reforms, which were to be phased in over a 4-year period.
l With bundled payments, providers agree to accept a discounted payment either retrospectively or
prospectively, which represents a coordinated plan of care for patients over the course of a single
episode of an illness.
l accountable Care Organizations (aCOs) are groups of providers and suppliers of service who work
together to better coordinate care for Medicare patients (does not include Medicare advantage) across
care settings with the expectation that efficiency as well as quality of care will result in shared savings.
l in VBp, providers are held accountable for the quality and cost of the health-care services they provide by
a system of rewards and consequences, conditional upon achieving prespecified performance measures.
l The medical home, or pCMh, relies on a team of providers to integrate all aspects of health care
through well-developed health information technology, including electronic health records.
l health insurance marketplaces, also called exchanges, are online insurance supermalls, created for
individuals without access to health insurance through a job or for small businesses who wish to buy
affordable and qualified health benefit plans in a competitive insurance marketplace.
LEARNING EXERCISE 10.6
How Does Policy Influence Your Decision?
You are the evening house supervisor of a small, private, rural hospital. in your role as house
supervisor, you are responsible for staffing the upcoming shift and for troubleshooting any and
all problems that cannot be handled at the unit level.
Tonight, you receive a call to come to the emergency department (ED) to handle a “patient
complaint.” When you arrive, you find a hispanic woman in her mid-20s arguing vehemently
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230 UNIT III ROLES AND FUNCTIONS IN PLANNING
with the eD charge nurse and physician. When you intercede, the patient introduces herself as
Teresa Garcia and states, “There is something wrong with my father, and they won’t help him
because we only have Medicaid insurance. if we had private insurance, you would be willing to
do something.” The charge nurse intercedes by saying, “Teresa’s father began vomiting about
2 hours ago and blacked out approximately 45 minutes ago, following a 14-hour drinking binge.”
The ED physician added, “Mr. Garcia’s blood alcohol level is 0.25 (two and one-half times the
level required to be declared legally intoxicated), and my baseline physical examination would
indicate nothing other than he is drunk and needs to sleep it off. Besides, i have seen Mr. Garcia
in the eD before, and it’s always for the same thing. he does not need further treatment.”
Teresa persists in her pleas to you that “there is something different this time” and that she
believes this hospital should evaluate her father further. she intuitively feels that something
terrible will happen to her father if he is not cared for immediately. The eD physician becomes
even angrier after this comment and states to you, “I am not going to waste my time and energy
on someone who is just drunk, and i refuse to order any more expensive lab tests or x-rays on
this patient. if you want something else done, you will have to find someone else to order it.”
With that, he walks off and returns to the examination room, where other patients are waiting to
be seen. The eD nurse turns to look at you and is waiting for further directions.
Assignment: how will you handle this situation? Would your decision be any easier if there
were no limitations in resource allocation? are your values to act as an agent for the patient or
for the agency more strongly developed?
LEARNING EXERCISE 10.7
Weighing Choices in Budget Spending
One of your goals as the unit manager of a critical care unit is to prepare all your nurses to
be certified in advanced cardiac life support. You currently have five staff nurses who need
this certification. You can hire someone to teach this class locally and rent a facility for $800;
however, the cost will be taken out of the travel and education budget for the unit, and this will
leave you short for the rest of the fiscal year. it also will be a time-consuming effort because
you must coordinate the preparation and reproduction of educational materials needed for the
course and make arrangements for the rental facility. a certification class also will be provided in
the near future in a large city approximately 150 miles from the hospital. The cost per participant
will be $200. in addition, there would be travel and lodging expenses.
Assignment: You have several decisions to make. should the class be held locally? if so, how
will you organize it? are you going to require your staff to have this certification or merely highly
recommend that they do so? if it is required, will the unit pay the costs of the certification? Will
you pay the staff nurses their regular hourly wage for attending the class on regularly scheduled
work hours? Can this certification be cost-effective? Use group process in some way to make
your decision.
LEARNING EXERCISE 10.8
How Will You Meet New Budget Restrictions?
You are the director of the local agency that cares for ill and well elderly patients. You are
funded by a private corporation grant, which requires matching of city and state funds. You
received a letter in the mail today from the state that says state funding will be cut by $35,000,

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Chapter 10 Fiscal Planning 231
effective in 2 weeks, when the state’s budget year begins. This means that your private funding
also will be cut $35,000, for a total revenue loss of $70,000. it is impossible at this time to seek
alternative funding sources.
in reviewing your agency budget, you note that, as in many health-care agencies, your budget
is labor intensive. More than 80% of your budget is attributable to personnel costs, and you
believe that the cuts must come from within the personnel budget. You may reduce the patient
population that you serve, although you do not really want to do so. You briefly discuss this
communication with your staff; no one is willing to reduce his or her hours voluntarily, and no
one is planning to terminate his or her employment at any time in the near future.
Assignment: Given the following brief description of your position and each of your five
employees, decide how you will meet the new budget restrictions. What is the rationale for your
choice? Which decision do you believe will result in the least disruption of the agency and of the
employees in the agency? should group decision making be involved in fiscal decisions such as
this one? Can fiscal decisions such as this be made without value judgments?
Your position is project director. as the project director, you coordinate all the day-to-day activities
in the agency. You also are involved in long-term planning, and a major portion of your time is
allotted to securing future funding for the agency to continue. as the project director, you have
the authority to hire and fire employees. You are in your early 30s and have a master’s degree in
nursing and health administration. You enjoy your job and believe that you have done well in this
position since you started 4 years ago. Your yearly salary as a full-time employee is $80,000.
Employee #1 is Mrs. potter. Mrs. potter has worked at the agency since it started 7 years
ago. she is an rN with 30 years of experience working with the geriatric population in public
health nursing, care facilities, and private duty. she plans to retire in 7 years and travel with her
independently wealthy husband. Mrs. potter has a great deal of expertise that she can share
with your staff, although at times you believe she overshadows your authority because of her
experience and your young age. her yearly salary as a full-time employee is $65,000.
Employee #2 is Mr. Boone. Mr. Boone has Bs degrees in both nursing and dietetics and food
management. as an rN and registered dietician, he brings a unique expertise to your staff, which
is highly needed when dealing with a chronically ill and improperly nourished elderly population.
in the 6 months since he joined your agency, he has proven to be a dependable, well-liked, and
highly respected member of your staff. his yearly salary as a full-time employee is $55,000.
Employee #3 is Miss Barns. Miss Barns is the receptionist-secretary in the agency. in addition
to all the traditional secretarial duties, such as typing, filing, and transcription of dictation, she
screens incoming telephone calls and directs people who come to the agency for information.
her efficiency is a tremendous attribute to the agency. her full-time yearly salary is $26,000.
Employee #4 is Ms. Lake. Ms. Lake is an LpN/LVN with 15 years of work experience in a variety
of health-care agencies. she is especially attuned to patient needs. although her technical
nursing skills are also good, her caseload frequently is more focused around elderly patients
who need companionship and emotional support. she does well at patient teaching because of
her outstanding listening and communication skills. Many of your patients request her by name.
she is a single mother, supporting six children, and you are aware that she has great difficulty in
meeting her personal financial obligations. her full-time yearly salary is $48,000.
Employee #5 is Mrs. Long. Mrs. Long is an “elderly help aide.” She has completed nurse aide
training, although her primary role in the agency is to assist well elderly with bathing, meal preparation,
driving, and shopping. The time that Mrs. Long spends in performing basic care has decreased the
average visit time for each member of your staff by 30%. she is widowed and uses this job to meet
her social and self-esteem needs. Financially, her resources are adequate, and the money she earns
is not a motivator for working. Mrs. Long works 3 days a week, and her yearly salary is $23,000.
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232 UNIT III ROLES AND FUNCTIONS IN PLANNING
LEARNING EXERCISE 10.9
Identifying, Prioritizing, and Choosing Program Goals
Jane is the supervisor of a small cardiac rehabilitation program. The program includes inpatient
cardiac teaching and an outpatient exercise rehabilitation program. Because of limited
reimbursement by third-party insurance payers for patient education, there has been no direct
charge for inpatient education. Outpatient program participants pay $240 per month to attend
three 1-hour sessions per week, although the revenue generated from the outpatient program
still leaves an overall budget deficit for the program of approximately $6,800 per month.
Today, Jane is summoned to the associate administrator’s office to discuss her budget for
the upcoming year. at this meeting, the administrator states that the hospital is experiencing
extreme financial difficulties due to declining reimbursements. he states that the program must
become self-supporting in the next fiscal year; otherwise, services must be cut. On returning to
her office, Jane decided to make a list of several alternatives for problem solving and to analyze
each for driving and restraining factors. These alternatives include the following:
1. Implement a charge for inpatient education. This would eliminate the budget deficit, but
the cost would probably have to be borne by the patient. (Implication: Only patients with
adequate fiscal resources would elect to receive vital education.)
2. Reduce department staffing. There are currently three staff members in the department,
and it would be impossible to maintain the same level or quality of services if staffing were
reduced.
3. Reduce or limit services. The inpatient education program or educational programs
associated with the outpatient program could be eliminated. These are both considered to
be valuable aspects of the program.
4. The fee for the outpatient program could be increased. This could easily result in a decrease
in program participation, because many outpatient program participants do not have
insurance coverage for their participation.
Assignment: identify at least five program goals, and prioritize them as you would if you were
Jane. Based on the priorities that you have established, which alternative would you select?
explain your choice.
LEARNING EXERCISE 10.10
Addressing Conflicting Values
You are a single parent of two children younger than 5 years and are currently employed as
a pediatric office nurse. You enjoy your job, but your long-term career goal is to become a
pediatric nurse practitioner, and you have been taking courses part-time preparing to enter
graduate school in the fall. Your application for admission has been accepted, and the next
cycle for admissions will not be for another 3 years. Your recent divorce and assignment of sole
custody of the children have resulted in a need for you to reconsider your plan.
restraining Forces: You had originally planned to reduce your work hours to part time to allow
time for classes and studying, but this will be fiscally impossible now. You also recognize that
tuition and educational expenses will place a strain on your budget even if you continue to work
full time. You have not looked into the availability of scholarships or loans and have missed the
deadline for the upcoming fall. in addition, you have not yet overcome your anxiety and guilt
about leaving your small children for even more time than you do now.

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Chapter 10 Fiscal Planning 233
Driving Forces: You also recognize, however, that gaining certification as a pediatric nurse
practitioner should result in a large salary increase over what you are able to make as an office
nurse and that it would allow you to provide resources for your children in the future that you
otherwise may be unable to do. as well, you recognize that although you are not dissatisfied with
your current job, you have a great deal of ability that has gone untapped and that your potential
for long-term job satisfaction is low.
Assignment: Fiscal planning always requires priority setting, and often this priority setting
is determined by personal values. priority setting is made even more difficult when there are
conflicting values. identify the values involved in this case. Develop a plan that addresses these
value conflicts and has the most desirable outcomes.
LEARNING EXERCISE 10.11
How Would You Change This Budget?
Today is april 1, and you have received the following budget printout. Your charge nurses are
requesting an additional rN on each shift since the acuity has increased dramatically over the
last 2 years. Dr. robb has requested two new continuous limb movement machines for the
postoperative orthopedic patients on your unit at a cost of $3,000 each. in addition, you would
like to attend a national orthopedics conference in New York in august at a projected cost of
$1,500. The registration fee is $350 and is due now.
Annual Budget Expended in
March
Expended Year
to Datea
Amount
Remaining
personnel 300,000 25,000 175,000 125,000
Overtime 50,000 3,800 50,000 0
supplies 18,000 1,500 13,500 4,500
Travel (personal) 2,200 0 1,700 500
equipment 5,000 0 5,000 0
staff development 1,000 200 800 200
aFiscal year begins July 1.
Assignment: how will you deal with these requests based on the budget printout? What
expenses can and should be deferred to the new fiscal year? in what budgeting area were your
previous projections most accurate? Most inaccurate? What factors may have contributed to
these inaccuracies? Were they controllable or predictable?
REFERENCES
Barr, P. (2005). Flexing your budget: Experts urge hospitals,
systems to trade in their traditional budgeting process
for a more dynamic and versatile model. Modern
Healthcare, 35(37), 24, 26.
Centers for Medicare & Medicaid Services (2013). ICD-10.
Retrieved May 27, 2013, from http://www.cms.gov/
Medicare/Coding/ICD10/index.html?redirect=/icd10
Freundlich, N. (2009, May 7). Taking note: Provider
backlash. A Century Foundation Group Blog.
Retrieved May 25, 2013, from http://takingnote.tcf
.org/2009/05/provider-backlash.html
Goozner, M. (2013). Dissecting the president’s budget.
Modern Healthcare, 43(15), 25.
Healthcare.gov (2013a). Key features of the Affordable Care
Act, by year. Retrieved May 27, 2013, from http://
www.healthcare.gov/law/timeline/full.html
Healthcare.gov (2013b). Payment bundling. Definition.
Retrieved May 27, 2013, from http://www.healthcare
.gov/glossary/p/payment-bundling.html
Healthcare.gov (2013c). Improving care coordination and
lowering costs by bundling payments. Retrieved May
27, 2013, from http://www.healthcare.gov/news/
factsheets/2011/08/bundling08232011a.html
Healthcare.gov. (2013d). About the health insurance
marketplace. Retrieved May 27, 2013, from http://
www.healthcare.gov/marketplace/about/index.html
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http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10

http://takingnote.tcf.org/2009/05/provider-backlash.html

http://www.healthcare.gov/law/timeline/full.html

http://www.healthcare.gov/glossary/p/payment-bundling.html

http://www.healthcare.gov/news/factsheets/2011/08/bundling08232011a.html

http://www.healthcare.gov/marketplace/about/index.html

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234 UNIT III ROLES AND FUNCTIONS IN PLANNING
HealthReform.GOV. (2013). Strengthening community health
centers. HealthReform.GOV-a U.S. Government
Web site managed by the U.S. Department of Health
& Human Services. Retrieved May 25, from http://
www.healthreform.gov/
Kaiser Family Foundation (2013). Medicare beneficiaries
as a percent of total population. Retrieved May 24,
2013, from http://kff.org/medicare/state-indicator/
medicare-beneficiaries-as-of-total-pop/
Keckley, P. H. (2013). Value-based purchasing: A strategic
overview for health care industry stakeholders.
Deloitte. Retrieved May 26, 2013, from http://www
.deloitte.com/assets/Dcom-UnitedStates/Local%20
Assets/Documents/Health%20Reform%20Issues%20
Briefs/US_CHS_ValueBasedPurchasing_031811
Medicare.Gov. (2013). Medicare 2013 Costs at a Glance.
Retrieved May 26, 2013, from http://www.medicare
.gov/your-medicare-costs/costs-at-a-glance/costs-at-
glance.html
Mitchell, R. (2013, March 26). Slow progress on efforts to
pay docs, hospitals for ’value,’ not volume. Kaiser
Health News. Retrieved May 26, 2013, from http://
www.kaiserhealthnews.org/stories/2013/march/26/
employers-value-volume-purchasing.aspx
National Conference of State Legislatures. (2011, May).
Managed care and the states. Retrieved May
25, 2013, from http://www.ncsl.org/Default
.aspx?TabId=14470
National Conference of State Legislatures (2012, September).
The medical home model of care. Retrieved May
27, 2013, from http://www.ncsl.org/issues-research/
health/the-medical-home-model-of-care.aspx
Rosenberg (2013, January 13). The real reason Medicare
costs will explode. The Fiscal Times. Retrieved
My 26, 2013, from http://www.thefiscaltimes.com/
Articles/2013/01/13/The-Real-Reason-Medicare-
Costs-Will-Explode.aspx#page1
Sahadi. J. (2013, February 7). The real Medicare spending
problem. CNN Money. Retrieved May 25, 2013, from
http://money.cnn.com/2013/02/07/news/economy/
medicare-spending/index.html
Urban Institute (2012, April). Medicare, Medicaid and the
deficit debate. Retrieved May 26, 2013, from http://
www.urban.org/UploadedPDF/412544-Medicare
-Medicaid-and-the-Deficit-Debate
Your Dictionary. (2013). Cost effectiveness-definition.
LoveToKnow Corp. Retrieved May 25, 2013, from
http://www.yourdictionary.com/cost-effective
Zamosky, L. (2013, March 22). What’s ahead for the Affordable
Care Act in 2013? WEB MD. Retrieved May 27,
2013 from http://www.webmd.com/health-insurance/
news/20130322/affordable-care-act-whats-next

http://www.healthreform.gov/

Medicare Beneficiaries as a Percent of Total Population

http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Health%20Reform%20Issues%20Briefs/US_CHS_ValueBasedPurchasing_031811

http://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-atglance.html

http://www.kaiserhealthnews.org/stories/2013/march/26/employers-value-volume-purchasing.aspx

http://www.ncsl.org/Default.aspx?TabId=14470

http://www.ncsl.org/issues-research/health/the-medical-home-model-of-care.aspx

http://www.thefiscaltimes.com/Articles/2013/01/13/The-Real-Reason-Medicare-Costs-Will-Explode.aspx#page1

http://money.cnn.com/2013/02/07/news/economy/medicare-spending/index.html

http://www.urban.org/UploadedPDF/412544-Medicare-Medicaid-and-the-Deficit-Debate

http://www.webmd.com/health-insurance/news/20130322/affordable-care-act-whats-next

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235
Career Development: From New Graduate
to Retirement
… every individual you hire for a leadership role should have the capability to grow into that role.
—Carolyn Hope Smeltzer
… career plans are about where you are today and, more importantly, where you’re going tomorrow.
—Phil McPeck
CROSSWALK tHiS CHaPter addreSSeS:
BSN Essential I: Liberal education for baccalaureate generalist nursing practice
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VIII: Professionalism and professional values
BSN Essential IX: Baccalaureate generalist nursing practice
MSN Essential I: Background for practice from sciences and humanities
MSN Essential II: Organizational and systems leadership
MSN Essential IX: advanced generalist nursing practice
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: Professionalism
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l describe the impact of a career development program on employee attrition, future
employment opportunities, quality of work life, and competitiveness of the organization
l differentiate among stages of a career
l differentiate between the employer’s and employee’s responsibilities for career development
l describe three phases of long-term coaching for career development
l identify support by top management, systematic planning and implementation, and inclusion
of social learning activities as integral components of management development programs
l recognize lifelong learning as a professional expectation and responsibility
l define competency and identify strategies for assuring and measuring it
l identify driving and restraining forces for specialty certification in professional nursing
l identify factors creating the current, pressing need for transition-to-practice programs to
retain new graduate nurses and prepare them for employment
l develop a personal career plan
l create and/or critique a resumé for content, format, grammar, punctuation, sentence
structure, and appropriate use of language
11
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236 UNIT III ROLES AND FUNCTIONS IN PLANNING
To be a fully engaged professional requires commitment to career development. Career
development is intentional career planning and should be viewed as a critical and deliberate
life process involving both the individual and the employer. It provides individuals with
choices about career outcomes rather than leaving it to chance. Thus, career development is
about career exploration, opportunities, and change. Before the 1970s, organizations did little
to help employees plan and develop their careers. Now, subordinate career development is
essential to organizational success, and most organizations accept at least some responsibility
for assisting employees with this function.
For the most part, however, organizational career development efforts have centered on
management development rather than activities that promote growth in nonmanagement
employees. Given that more than 80% of an organization’s employees are typically
nonmanagement, this is often a neglected part of career development.
Career development in an organization must include more than management employees.
This chapter examines organizational justifications for employee career development, suggests
the existence of career stages, and emphasizes the need for career coaching. The use of
competency assessment, professional certification, and transition-to-practice programs are
identified as strategies for career management with the ultimate goal of lifelong learning. Finally,
professional resumés, reflection, and portfolios are discussed as career-planning tools. The
leadership roles and management functions for career development are shown in Display 11.1.
LEADERSHIP ROLES
1. is self-aware of personal values influencing career development.
2. encourages employees to take responsibility for their own career planning.
3. identifies, encourages, and develops future leaders.
4. Shows a genuine interest in the career planning and career development of all employees.
5. encourages and supports the development of career paths within and outside the organization.
6. Supports employees’ personal career decisions based on each employee’s needs and values.
7. is a role model for continued professional development via specialty certification, continuing
education (Ce), and portfolio development.
8. emphasizes the need for employees to develop the skill set necessary for evidence-based practice.
9. Supports new graduate nurses in their transition to practice through positive role modeling as
well as the creation of nurse residencies, internships, and externships.
10. role models lifelong learning as a professional expectation and responsibility.
11. encourages others to continue their formal education as part of their career ladder and profes-
sional journey.
MANAGEMENT FUNCTIONS
1. develops fair policies related to career development opportunities and communicates them
clearly to subordinates.
2. Provides fiscal resources and release time for subordinate training and education.
3. Uses a planned system of short- and long-term coaching for career development and documents
all coaching efforts.
4. disseminates career and job information.
5. Works with employees to establish career goals that meet both employee and organizational needs.
6. Works cooperatively with other departments in arranging for the release of employees to take
other positions within the organization.
7. Views transition-to-practice programs as an investment strategy to mitigate nurse turnover and
promote employee satisfaction.
DISPLAY 11.1 Leadership Roles and Management Functions Associated with Career
Development

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Chapter 11 Career Development: From New Graduate to Retirement 237
CAREER STAGES
Before individuals can plan a successful career development program, they need to understand
the normal career stages of individuals. Shirey (2009) suggests that there are three different
career phases or stages among nurses: promise, momentum, and harvest. Promise is the
earliest of the career phases and typically reflects the first 10 years of nursing employment.
Individuals in this stage are less experienced and tend to experience reality overload as a
result. Making wise early career choices is critical in this phase. Milestones to be attained
include socialization to the nursing role (becoming an insider); building knowledge, skills,
abilities, credentials, and an education base; gaining exposure to a variety of experiences;
identifying strengths and building confidence; and positioning for the future.
Momentum is the middle career phase and typically reflects the nurse with 11 to 29 years
of experience. Nurses in this phase are experienced clinicians with expert knowledge, skills,
abilities, credentials, and education base. This is a time of accomplishment, challenge, and a sense
of purpose, and the individual often achieves a high enough level of expertise to be a role model
to others. Milestones to be surpassed include further building confidence in one’s competence;
developing experience, gaining mastery, and establishing a professional track record; and finding
a voice through aligning strengths with passion. The most significant challenge to nurses in this
phase, however, is likely creating possibilities for career progression, rather than stagnation. A
commitment to lifelong learning and being willing to seize unexpected opportunities that may
present themselves over time are often key to career divergence at this point in life.
The last stage, harvest, commences in late career. Shirey labels nurses with 30 to 40 years
as having “prime” experience and nurses with more than 40 years of experience as being
“legacy” clinicians. Although viewed as expert clinicians, the experiential value of nurses in
the harvest phase may begin to decline if others perceive them as obsolescent. These prime
or legacy nurse-leaders then must actively strive for ongoing “reinvention” to renew their
potential value to their coworkers. Success then is defined not only by being knowledgeable
but also by being savvy and adaptable. The potential for career divergence in this phase is
mixed, depending upon choices made in the momentum phase. Milestones to be conquered
include elevating their mastery to sage practice for advancing the profession and positioning
as a professional statesperson and establishing a legacy.
Finally, an argument might be made that another career stage exists in nursing—that of reentry.
Concurrent with nursing shortages, many nurses who were no longer working in the profession,
but who possess the necessary training and experience to do so, may reenter the work setting.
8. Coaches employees to create professional portfolios that demonstrate reflection as well as the
maintenance of continued competence.
9. attempts to match position openings with capable employees who seek new learning opportunities.
10. Creates possibilities for career progression.
11. Provides opportunities for “legacy” clinicians to “reinvent” themselves to renew their potential
value to the organization and their coworkers.
LEARNING EXERCISE 11.1
Exploring Career Stages
in a group, discuss the job stages described by Shirey (2009). What stage most closely reflects
your present situation? in what stages of their careers are nurses who you know (colleagues,
managers, your nursing instructors)? do you believe that male and female nurses have similar
or dissimilar career stages?
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238 UNIT III ROLES AND FUNCTIONS IN PLANNING
JUSTIFICATIONS FOR CAREER DEVELOPMENT
The following, summarized in Display 11.2, is a list of justifications for career development
programs:
1. reduces employee attrition
2. Provides equal employment opportunity
3. improves use of personnel
4. improves quality of work life
5. improves competitiveness of the organization
6. avoids obsolescence and builds new skills
7. Promotes evidence-based practice
DISPLAY 11.2 Justifications for Career Development
• Reduced employee attrition. Career development can reduce the turnover of ambitious
employees who would otherwise be frustrated and seek other jobs because of a lack of
job advancement.
• Equal employment opportunity. Minorities and other underserved groups will have a
better opportunity to move up in an organization if they are identified and developed
early in their careers.
• Improved use of personnel. When employees are kept in jobs that they have outgrown,
their productivity is often reduced. People perform better when they are placed in jobs
that fit them and provide new challenges.
• Improved quality of work life. Nurses increasingly desire to control their own careers.
They are less willing to settle for just any role or position that comes their way. They
want greater job satisfaction and more career options.
• Improved competitiveness of the organization. Highly educated professionals often
prefer organizations that have a good track record of career development. During
nursing shortages, a recognized program of career development can be the deciding
factor for professionals selecting a position.
• Obsolescence avoided and new skills acquired. Because of the rapid changes in health
care, especially in the areas of consumer demands and technology, employees may
find that their skills have become obsolete. A successful career development program
begins to retrain employees proactively, providing them with the necessary skills to
remain current in their field and, therefore, valuable to the organization. Some of
the most basic career development programs, such as financial planning and general
equivalency diploma programs, can be the most rewarding programs for the staff.
• Evidence-based practice promoted. Evidence-based practice is now the gold standard
for nursing practice, yet many nurses still lack both skill and confidence in knowing how
to use research and best practices to inform their practice. The astute leader-manager
recognizes this knowledge deficit and uses career planning and goal setting to allow
these nurses the time and resources needed to acquire these skills.
INDIVIDUAL RESPONSIBILITY FOR CAREER DEVELOPMENT
Despite the many obvious benefits of career development programs, some nurses never
create a personal career plan or set goals they wish to accomplish during their career.
Instead, nursing becomes just a job and not a career. This viewpoint limits opportunities

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Chapter 11 Career Development: From New Graduate to Retirement 239
for professional advancement and personal growth, since what cannot be imagined, rarely
becomes a reality. Indeed, Shirey (2009, p. 400) suggests that “extraordinary careers do
not just happen; they are cultivated and planned.” The impact of positive role modeling by
nurse-leaders in influencing this perception cannot be understated.
Career development should begin with an assessment of self as well as one’s work
environment, job analysis, education, training, job search and acquisition, and work
experience. This is known as career planning. Career planning includes evaluating one’s
strengths and weaknesses, setting goals, examining career opportunities, preparing for
potential opportunities, and using appropriate developmental activities.
Career planning in nursing should begin with an individual’s decision about educational
entry level for practice and quickly expand to developing advanced skills in an area of
nursing practice. Even for the entry-level nurse, career planning should include, at minimum,
a commitment to the use of evidence-based practice, learning new skills or bettering practice
by using role models and mentors, staying aware of and being involved in professional issues,
and furthering one’s education. At best, it should include long-term career goals as well as a
specific plan to achieve lifelong learning.
Every nurse should proactively develop a career plan that provides opportunities for new
learning, challenges, and opportunities for career divergence.
THE ORGANIZATION’S RESPONSIBILITY FOR CAREER DEVELOPMENT
Organizations also have responsibilities for career development. One of the organization’s
responsibilities for career development is the creation of career paths and advancement/
career ladders (“a structured sequence of job positions through which a person can progress
in an organization”) (BusinessDictionary.com, 2013a) for employees. It must also attempt
to match position openings with appropriate people. This includes accurately assessing
employees’ performance and potential in order to offer the most appropriate career guidance,
education, and training. Other organizational responsibilities include the following:
• Integrating needs. The human resources department, nursing division, nursing units, and
education department must work and plan together to match job openings with the skills
and talents of present employees.
• Establishing career paths. Career paths must not only be developed but also be
communicated to the staff and implemented consistently. When designing career paths,
each successive job in each path should contain additional responsibilities and duties
that are greater than the previous jobs in that path. Each successive job also must be
related to and use previous skills.
Once career paths are established, they must be communicated effectively to all
concerned staff. What employees must do to advance in a particular path should be
very clear. Although various forms of career ladders have existed for some time, they
are still not widely used. This problem is not unique to nursing. Even when health-care
organizations design and use a career structure, the system often breaks down once the
nurse leaves that organization. For example, nurses at the level of Clinical Nurse 3 in one
hospital will usually lose that status when they leave the organization for another position.
• Disseminating career information. The education department, human resources
department, and unit manager are all responsible for sharing career information;
however, employees should not be encouraged to pursue unrealistic goals.
• Posting job openings. Although this is usually the responsibility of the human resources
department, the manager should communicate this information, even when it means that
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240 UNIT III ROLES AND FUNCTIONS IN PLANNING
one of the unit staff may transfer to another area. Effective managers know who needs to be
encouraged to apply for openings and who is ready for more responsibility and challenges.
• Assessing employees. One of the benefits of a good appraisal system is the important
information that it gives the manager on the performance, potential, and abilities of all
staff members. The use of short- and long-term coaching will give managers insight into
their employees’ needs and wants so that appropriate career counseling can proceed.
• Providing challenging assignments. Planned work experience is one of the most
powerful career development tools. This includes jobs that temporarily stretch
employees to their maximum skill, temporary projects, assignment to committees, shift
rotation, assignment to different units, and shift charge duties.
• Giving support and encouragement. Because excellent subordinates make managers’
jobs easier, managers are often reluctant to encourage these subordinates to move up
the corporate ladder or to seek more challenging experiences outside the manager’s
span of control. Thus, many managers hoard their talent. A leadership role requires that
managers look beyond their immediate unit or department and consider the needs of the
entire organization. Leaders recognize and share talent.
• Developing personnel policies. An active career development program often results in
the recognition that certain personnel policies and procedures are impeding the success
of the program. When this occurs, the organization should reexamine these policies and
make necessary changes.
• Providing education and training. The impact of education and training on career
development and retention of subordinate staff is discussed more fully in Chapter 16. The
need for organizations to develop leaders and managers is presented later in this chapter.
A comparison of individual and organizational responsibilities for career development is
shown in Display 11.3.
Career Planning (Individual) Career Management (Organizational)
l Self-assess interests, skills, strengths,
with weaknesses, and values
l determine goals
l assess the organization for opportunities
l assess opportunities outside
l develop strategies
l implement plans
l evaluate plans
l reassess and make new plans as
necessary, at least biannually
l integrate individual employee needs and
organizational needs
l establish, design, communicate, and implement
career paths
l disseminate career information
l Post and communicate all jobs for the
organization openings
l assess employees’ career needs
l Provide work experience for development
l Give support and encouragement
l develop new personnel policies as necessary,
at least biannually
l Provide training and education
DISPLAY 11.3 Responsibilities for Career Development
CAREER COACHING
Organizations also have some responsibility to assist employees with career coaching. Unit
managers sometimes take on this role but it may also be provided by informal organization
leaders who are willing to act in a mentoring capacity. Career coaching involves helping
others to identify professional goals and career options and then designing a career plan to

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Chapter 11 Career Development: From New Graduate to Retirement 241
achieve those goals. The Executive Coaching Network (n.d.) suggests that career coaches
serve as “facilitators, motivators, consultants and sounding boards dealing with business
goals, people interaction and self-management issues. While behavior change will often be a
key focus, the coach’s role is not that of a therapist. It is not about unraveling personalities,
but often involves people doing things differently in the workplace” (para 4). Raffals (n.d.)
suggests that career coaching involves “enabling others to see fresh perspectives, make new
decisions, take new actions, and move forward ‘growthfully’ and productively from these
freshly exposed perspectives and choices” (para 14).
LEARNING EXERCISE 11.2
Encouragement and Coaching for Goal Achievement
in your employment, has someone ever coached you, either formally or informally, to develop
your career? For example, has an employer told you about career or educational opportunities?
Have they offered tuition reimbursement? if so, how did you find out about such policies? Have
you ever coached (something more than just encouraging) someone to pursue educational or
career goals? Share the answers to these questions in class.
Career coaching typically has three steps:
1. Gathering data. One of the best ways to gather data about employees is to observe their
behavior. When managers spend time observing employees, they are able to determine
who has good communication skills, who is well organized, who uses effective
negotiating skills, and who works collaboratively. Managers also should seek information
about the employee’s past work experience, performance appraisals, and educational
experiences. Data also should include academic qualifications and credentials. Most
of this information is retrievable in the employee’s personnel file. Finally, employees
themselves are an excellent source of information about career needs and wants.
2. Asking what is possible. As part of career planning, the manager should assess the
department for possible changes in the future, openings or transfers, and potential
challenges and opportunities. The manager should anticipate what type of needs lie ahead,
what projects are planned, and what staffing and budget changes will occur. After carefully
assessing the employee’s profile and future opportunities, managers should consider each
staff member and ask the following questions: How can this employee be helped so that
he or she is better prepared to take advantage of the future? Who needs to be encouraged
to return to school, to become credentialed, or to take a special course? Which employees
need to be encouraged to transfer to a more challenging position, given more responsibility
on their present unit, or moved to another shift? Managers can create a stimulating
environment for career development by being aware of the uniqueness of their employees.
3. Conducting the coaching session. The goals of career coaching include helping
employees increase their effectiveness; identifying potential opportunities in the
organization; and advancing their knowledge, skills, and experience. It is important
not to intimidate employees when questioning them about their future and their goals.
Although there is no standard procedure for career coaching, the main emphasis should
be on employee growth and development. The manager can assist the employee in
exploring future options. Coaching sessions give the manager a chance to discover
potential future managers—employees who should then begin to be groomed for a
future managerial role in subsequent coaching sessions.
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242 UNIT III ROLES AND FUNCTIONS IN PLANNING
Career coaching, then, can be either short or long term. In short-term career coaching,
the manager regularly asks the employees questions to develop and motivate them. Thus,
short-term coaching is a spontaneous part of the experienced manager’s repertoire.
Long-term career coaching, on the other hand, is a planned management action that occurs
over the duration of employment. Because this type of coaching may cover a long time, it
is frequently neglected unless the manager uses a systematic scheduling plan and a form for
documentation. Because employees and managers move frequently within an organization,
the lack of record keeping regarding employees’ career needs has deterred nursing career
development. In the present climate of organizational restructuring and downsizing, a manager’s
staff is even more in need of career coaching, and documentation of the career coaching takes
on an even more important role. Display 11.4 is an example of a long-term coaching form.
Name of employee ___________________________________________________________________
Name of supervisor _________________________________________________________________
date _______________ date of last coaching interview____________________________________
1. What new challenges and responsibilities could be given to this employee that would
utilize his or her special talents?
___________________________________________________________________________
___________________________________________________________________________
2. What events happening in the organization do you foresee affecting this employee?
(examples would be plans to go to an all-rN staff, changing the mode of patient
care delivery, increasing emphasis on credentialing by the new CeO of the nursing
division, changing the medication system, and changing the ratio of nonprofessionals to
professionals for nurse staffing.)
___________________________________________________________________________
___________________________________________________________________________
3. How should the employee be preparing to meet new or changing expectations?
___________________________________________________________________________
___________________________________________________________________________
4. What specific suggestions and guidance for the future can you give this employee?
(examples would be taking specific courses to prepare for change, urging them to
pursue an advanced degree, considering changing shifts, urging them to seek challenges
outside of your unit, and suggesting that they apply for the next management opening.)
___________________________________________________________________________
___________________________________________________________________________
5. What specific organizational resources can you offer the employee?
___________________________________________________________________________
___________________________________________________________________________
6. What new information regarding this employee’s long-term plans, aspirations, and potential
have your review of the personnel record, your observations, and this interview given?
___________________________________________________________________________
___________________________________________________________________________
DISPLAY 11.4 Sample Long-Term Coaching Form

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Chapter 11 Career Development: From New Graduate to Retirement 243
MANAGEMENT DEVELOPMENT
Management development is a planned system of training and developing people so that they
acquire the skills, insights, and attitudes needed to manage people and their work effectively
within the organization. Management development is often referred to as succession planning.
7. do the organizational and professional career plans held by the individual match your
vision of his or her future? if not, how do they differ?
___________________________________________________________________________
___________________________________________________________________________
8. What developmental and professional growth has taken place since the last coaching?
___________________________________________________________________________
___________________________________________________________________________
9. date of next coaching interview ________________________________________________
Long-term coaching, however, is a major step in building an effective team and an excellent
strategy to increase productivity and retention. The effective manager should have at least one
coaching session with each employee annually, in addition to any coaching that may occur during
the appraisal interview. Although some coaching should occur during the performance appraisal
interview, additional coaching should be planned at a less stressful time. Coaching provides
opportunities to assist employees in the growth and development necessary for expanded roles
and responsibilities. A major leadership role is the development of subordinate staff. This interest
in the future of individual employees plays a vital role in retention and productivity.
LEARNING EXERCISE 11.3
Career Coaching a Bored Employee
You are the registered nurse (rN) team leader on a busy step-down critical care unit. One of the
certified nursing assistants (CNas) assigned to your team is technically very competent, always
completes her work on time, but frequently appears to be bored. the only time she seems to be
excited about work is when she is assisting you or the other rNs with more complex skills such
as central line dressing changes, peripherally inserted central catheters (PiCC), and complex
wound packings. She has shared at times, her long-term career goal to become an rN but has
never verbalized any specific plan to achieve this. although she is highly capable, her formal
education to date is limited to a high school diploma she earned 3 years ago. She currently
provides full-time financial support for herself and her 3-year-old daughter.
Assignment:
1. identify questions you might ask the CNa that could be a part of both short- and long-term
career coaching for this employee.
2. What resources might be explored to support this employee in attaining higher education?
3. What leadership role modeling could be made available to this employee to encourage her
in furthering her career goals?
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244 UNIT III ROLES AND FUNCTIONS IN PLANNING
Many nurses feel uncertain that they have the skills needed to be effective managers, and they
lack confidence that the decision making, interpersonal, and organizational skills they learned
as staff nurses can translate to the management role.
Many nurses feel that they lack the knowledge and experience necessary to become a manager.
While many of these skills do transfer, becoming an effective manager is generally
not intuitive. With the flattening of organizational hierarchies, an expected increase in
nursing management vacancies due to retirement, and a continued increase in managerial
responsibilities, new leader-managers will likely need the formal education and training that
are a part of a management development program. The program must include a means of
developing appropriate attitudes through social learning theory as well as adequate content
on management theory.
Huston (2008) suggests that the skill sets needed by leader-managers in the year 2020 will
be even more complex than they are today and that contemporary nursing and health-care
organizations must begin now to create the educational models and management development
programs necessary to prepare the next generation of leader-managers. Essential nurse-leader
competencies for 2020 identified by Huston include having a global perspective or mindset
regarding health-care and professional nursing issues; technology skills that facilitate
mobility and portability of relationships, interactions, and operational processes; expert
decision-making skills rooted in empirical science; the ability to create organization cultures
that permeate quality health care and patient/worker safety; understanding and appropriately
intervening in political processes; highly developed collaborative and team building skills;
the ability to balance authenticity and performance expectations; and being able to envision
and proactively adapt to a health-care system characterized by rapid change and chaos.
Support for such management development programs by the organization should occur
in two ways. First, top-level management must do more than bear the cost of management
development classes. They must create an organizational structure that allows managers to
apply their new knowledge. Therefore, for such programs to be effective, the organization must
be willing to practice a management style that incorporates sound management principles.
Second, training outcomes improve if nursing executives are active in planning and
developing a systematic and integrated program. Whenever possible, nursing administrators
should teach some of the classes and, at the very least, make sure that the program supports
top management philosophy. Just as nurses are required to be certified in critical care before
they accept a position in a CCU, so too should nurses be required to take part in a management
development program before their appointment to a management position. This requires early
identification and grooming of potential management candidates.
The first step in the process would be an appraisal of the present management team and
an analysis of possible future needs. The second step would be the establishment of a training
and development program. This would require decisions such as the following: How often
should the formal management course be offered? Should outside educators be involved, or
should in-house staff teach it? Who should be involved in teaching the didactic portion? Should
there be two levels of classes, one for first-level and one for middle-level managers? Should
the management development courses be open to all, or should people be recommended by
someone from management? In addition to formal course content, what other methods should
be used to develop managers? Should other methods be used, such as job rotation through an
understudy system of pairing selected people with a manager and management coaching?
The inclusion of social learning activities also is a valuable part of management
development. Management development will not be successful unless learners have ample
chance to try out new skills. Providing potential managers with didactic management theory
alone inadequately prepares them for the attitudes, skills, and insights necessary for effective

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Chapter 11 Career Development: From New Graduate to Retirement 245
management. Case studies, management games, transactional analysis, and sensitivity
training are also effective in changing attitudes and increasing self-awareness. All of these
techniques appropriately use social learning theory strategies.
COMPETENCY ASSESSMENT AS PART OF CAREER DEVELOPMENT
Competency assessment and professional specialty certification are also a part of career
management. BusinessDictionary.com (2013b) suggests that the definition of a professional
is “a person formally certified by a professional body or belonging to a specific profession
by virtue of having completed a required course of studies and/or practice, and whose
competence can usually be measured against an established set of standards” (para 1).
Huston (2014) notes that unfortunately, in many states, a practitioner is determined to
be competent when initially licensed and thereafter, unless proven otherwise. Yet, clearly,
passing a licensing exam and continuing to work as a clinician does not assure competence
throughout a career. Competence requires continual updates to knowledge and practice,
and this is difficult in a health-care environment characterized by rapidly emerging new
technologies, chaotic change, and perpetual clinical advancements.
The Institute of Medicine (IOM) (2010) report The Future of Nursing agrees, suggesting
that nursing graduates now need competency in a variety of areas, including continuous
improvement of the quality and safety of health-care systems; informatics; evidence-based
practice; a knowledge of complex systems; skills and methods for leadership and management
of continual improvement; population health and population-based care management; and
health policy knowledge, skills, and attitudes (Cronenwett, 2011). One must at least question
how many nurses currently in practice would be able to demonstrate competency in these areas.
Assessing, maintaining, and supporting maintaining continued competence is also a
challenge in professional nursing. For example, Huston (2014) notes that some nurses
develop high levels of competence in specific areas of nursing practice as a result of work
experience and specialization at the expense of staying current in other areas of practice. In
addition, employers often ask nurses to provide care in areas of practice outside their area
of expertise because a nursing shortage encourages them to do so. In addition, many current
competence assessments focus more on skills than they do on knowledge (Huston). The issue
is also complicated by the fact that there are no national standards for defining, measuring, or
requiring continuing competence in nursing.
Current competence assessments often focus more on skills than they do on knowledge.
Managers should appraise each employee’s competency level not only as part of performance
appraisal but also as part of career development. This appraisal should lead to the development
of a plan that outlines what the employee must do to achieve desired competencies in both
current and future positions. Often, however, competency assessment focuses only on
whether the employee has achieved required minimal competency levels to meet current
federal, state, or organizational standards and not on how to exceed these competency levels.
Thus, competency assessment and goal setting in career planning is proactive, with the
employee identifying areas of potential future growth and the manager assisting in identifying
strategies that can help the employee achieve that goal.
Competency assessment and goal setting in career planning should help the employee identify
how to exceed these levels of competency.
Certainly, some individual responsibility for maintaining competence and pursuing lifelong
learning is suggested by the American Nurses Association (ANA) Code of Ethics for Nurses
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246 UNIT III ROLES AND FUNCTIONS IN PLANNING
with Interpretive Statements in its assertion that nurses are obligated to provide adequate and
competent nursing care (ANA, 2001). State Nurse Practice Acts also hold nurses accountable
for being reasonable and prudent in their practice. Both standards require the nurse to
have at least some personal responsibility for continually assessing his or her professional
competence through reflective practice (Huston, 2014).
In addition, the Institute of Medicine (2010) report The Future of Nursing calls for
nursing schools and nurses to pursue learning. Foster (2012, p. 115) notes that health-care
organizations must provide an environment that promotes lifelong learning, with the resources
to make this a reality for practicing nurses. “This will help to ensure nurses are capable and
qualified to manage the diverse patient populations that are recipients of nursing care.”
The individual RN has a professional obligation to seek lifelong learning and maintain competence.
LEARNING EXERCISE 11.4
Does Mandatory Continuing Education (CE) Assure Competence in Nursing?
a majority of the states in the United States have some kind of requirements for Ce for
professional nurse license renewal. these requirements typically vary from a few hours to 30
hours every 2 years. Huston (2014) notes that use of mandatory Ce to document continuing
competence in nursing continues to be very controversial because there is limited research
demonstrating correlation among Ce, continuing competence, and improved patient outcomes.
in addition, many professional organizations have expressed concern about the quality of
mandated Ce courses and the lack of courses for experts and specialists. Likewise, there is no
agreement on the optimal number of annual credits needed to ensure competence.
Assignment: in small groups, debate the use of Ce as a valid and reliable measure of continuing
competence in nursing.
PROFESSIONAL SPECIALTY CERTIFICATION
Professional specialty certification is one way an employee can demonstrate advanced
achievement of competencies. To achieve professional certification, nurses must meet
eligibility criteria that may include years and types of work experience, as well as minimum
educational levels, active nursing licenses, and successful completion of a nationally
administered examination (Huston, 2014). Certifications normally last 5 years.
Professional associations grant specialty certification as a formal but voluntary
process of demonstrating expertise in a particular area of nursing. For example, the ANA
established the ANA Certification Program in 1973 to provide tangible recognition of
professional achievement in a defined functional or clinical area of nursing. The American
Nurses Credentialing Center (ANCC), a subsidiary of ANA, became its own corporation
in 1991 and since then has certified hundreds of thousands of nurses throughout the United
States and its territories in more than 40 specialty and advanced practice areas of nursing.
In 2012 alone, 16,575 individuals applied for their initial certification (ANCC, 2012). A
few of the other organizations offering specialty certifications for nurses are the American
Association of Critical Care Nursing, the American Association of Nurse Anesthetists, the
American College of Nurse Midwives, the Board of Certification for Emergency Nursing,
and the Rehabilitation Nursing Certification Board.
Huston (2014) notes that it is middle- and top-level nurse-managers who play the most
significant role in creating work environments that value and reward certification. For example,

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Chapter 11 Career Development: From New Graduate to Retirement 247
nurse-managers can grant tuition reimbursement or salary incentives to workers who seek
certification. This is critical since the greatest barrier to nurses obtaining specialty certification
in a recent study was the cost of the examination and the greatest barrier to recertification was
the fee for renewal (Haskins, Hnatiuk, & Yoder, 2011). Managers can also show their support
for professional certification by giving employees paid time off to take the certification exam
and by publicly recognizing employees who have achieved specialty certification.
Managers should also encourage certified nurses to promote their achievements by
introducing themselves as certified nurses to patients, wearing their certification pins, and
publicly displaying their credentials (Haskins et al., 2011). In doing so, the certified nurse
acts as a leader and role model to other nurses considering specialty certification. In addition,
Altman (2011) suggests that many nurses do not seek certification due to a fear of test taking
or failure and she suggests that nurse-leaders can play a pivotal role in supporting employees
to overcome these fears. It may be as simple as providing study resources, granting time off
to study, supporting nurses verbally during their certification journey, and rewarding and
recognizing staff who do become certified.
Personal Benefits of Specialty Certification
The certified nurse often finds many personal benefits related to the attainment of such
status, including more rapid promotions on career ladders, advancement opportunities into
management, and personal or professional feelings of accomplishment (Knudson, 2013).
In addition, they often earn more than their noncertified counterparts. Specialty-certified
critical care nurses in the United States make an average of $18,000 more per year than
their noncertified counterparts (Certification: Promoting Excellence in Nursing, 2013).
The difference is especially pronounced in the West, where the difference is $51,000 per
year between certified and noncertified critical care nurses. Some of the personal benefits
associated with professional certification are shown in Display 11.5.
l Provides a sense of accomplishment and achievement
l Validation of specialty knowledge and competence to peers and patients
l increased credibility
l increased self-confidence
l Promotes greater autonomy of practice
l Provides for increased career opportunities and greater competitiveness in the job market
l May result in salary incentives
Source: Huston, C. (2014). Assuring provider competence through licensure, continuing education, and certification. In
C. Huston (Ed.), Professional issues in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins 292–307.
DISPLAY 11.5 Personal Benefits of Professional Certification
Patient Outcomes and Specialty Certification
Boltz, Capezuti, Wagner, Rosenberg, and Secic (2013) suggest that while many positive
professional and process outcomes associated with certification exist, the relationship
between specialty certification and patient outcomes is less clear. Research done by Krapohl,
Manojlovich, Redman, and Zhang (2010) found no correlation between the proportion of
certified nurses on an intensive care unit and three nursing-sensitive patient outcomes, although
educational levels of the nurses were not considered. The association between nurses’ perception
of overall workplace empowerment and certification, however, was positive. Boltz et al. (2013)
showed an inverse relationship between certification and patient falls, but no relationship with
injurious falls, unit-acquired pressure ulcer prevalence, and restraint prevalence.
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248 UNIT III ROLES AND FUNCTIONS IN PLANNING
A study by Kendall-Gallagher, Aiken, Sloane, and Cimiotti (2011), however, found
that nurse specialty certification was associated with better patient outcomes; however,
certification had no impact on mortality and failure to rescue when the nurse did not have
a baccalaureate degree. The researchers suggested then that since certification was not a
substitute for education, employers might want to invest in improving nursing education levels
for staff without BSN degrees, rather than investing in specialty certification for these nurses.
REFLECTIVE PRACTICE AND THE PROFESSIONAL PORTFOLIO
Kinsella (2010) suggests that “reflective practice,” a term coined by Donald Schon, is one of
the most popular theories of professional knowledge in the last 20 years. Reflective practice
is defined by the North Carolina Board of Nursing (NCBN) (2011, para 7) as “a process for
the assessment of one’s own practice to identify and seek learning opportunities to promote
continued competence.” Inherent in the process is the evaluation and incorporation of this
learning into one’s practice. Such self-assessment is gaining popularity as a way to promote
professional practice and maintain competence, which has paved the way for the creation of
reflective practice/professional portfolio model for competence assessment.
A professional portfolio, which all nurses should maintain, can be described as a collection
of materials that document a nurse’s competencies and illustrate the expertise of the nurse.
The professional portfolio typically contains a number of core components; biographical
information, educational background, certifications achieved and employment history;
a one- to two-page resumé; a competency record or checklist; personal and professional
goals; professional development experiences, presentations, consultations, and publications;
professional activities; community activities; honors and awards; and letters of thanks from
patients, families, peers, organizations, and others (Sherrod, 2007). The individual needs
to be selective in collecting best-work documentation and only include those materials that
illustrate competency and highlight achievement.
All nurses should maintain a portfolio to reflect their professional growth throughout their career.
Maintaining a professional portfolio avoids lost opportunities to save documents since
professional nurses should always have documentation readily available to pursue a promotion,
to consider a new position, or to apply for another position in their present employment.
Sinclair, Bowen, and Donkin (2013) note, however, that for the professional portfolio to
truly have value, it must be more than just a collection of evidence of accomplishments;
it must include reflection and be actively used as a tool to promote professional growth
throughout one’s career. Only then will it promote a continuous cyclic process of professional
development that supports the maintenance of continued competence.
LEARNING EXERCISE 11.5
Creating a Professional Portfolio
Assignment:
1. identify the categories of evidence you would use to organize a professional portfolio if you
were to create one today.
2. identify specific evidence you could include in each of these categories. What evidence
currently exists and what would need to be created?
3. How would you incorporate reflection in creating a personal professional portfolio?

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Chapter 11 Career Development: From New Graduate to Retirement 249
CAREER PLANNING AND THE NEW GRADUATE NURSE
During the current economic downturn, many new graduates have rushed to find a “job”—
any job—in nursing, forgetting that even early employment decisions are critical to the
achievement of their long-term career plans. Shirey (2009) suggests new graduates must
select their first employment wisely and seek work in a facility with a strong reputation for
supportive work environments and a reputation of excellence in multiple arenas.
Finding work in a facility with orientation programs, internships, residencies, and
fellowships is also important to the new graduate since it takes time to gain the expertise and
self-confidence that is a part of being an expert nurse. Mentors and preceptors should also be
available to support the new graduate nurse and to role model high-quality, evidence-based
decision making and clinical practice. If the new graduate has a positive, nurturing first
employment experience, he or she is much more likely to take future career risks, to pursue
lifelong learning, and to have the energy and commitment to become involved in the bigger
issues of their profession.
New graduates also have responsibility during the crucial first few years of employment
to gain the expertise they need to have more opportunities for career divergence in the future.
This includes becoming an expert in one or more areas of practice, gaining professional
certifications, and being well informed about professional nursing and health-care issues.
This is also a time where participation in professional associations has great value as a
result of the opportunities for mentoring and networking. Finally, all new graduates should
consider at what point, continued formal education will be a part of their career ladder and
professional journey.
TRANSITION-TO-PRACTICE PROGRAMS/RESIDENCIES FOR NEW GRADUATE NURSES
Arguments have grown over the last decade regarding the need for transition-to-practice
programs (also known as residences, externships, or internships) for new graduates of
nursing programs. Jones and West (2014) note that new graduate nurses often begin
working with little more than a few weeks of orientation, in contrast to most other
professions, which require formal and often standardized internships or residencies. This is
largely a residual outcome of the traditional nursing educational system that was grounded
in apprenticeship and hospital-based training programs which led to the student receiving
a diploma in nursing.
Jones and West (2014) suggest the ever-changing health-care delivery care system, with
its increasing complexity of patient care, evolving technology, and focus on patient safety,
has raised the bar in terms of expectations for new graduate nurses. New graduates must now
hit the ground running with well-developed critical thinking and problem-solving skills; the
ability to exercise clinical judgment with know-how to practice from an evidence-based and
outcome-driven perspective; and the ability to develop effectively from a novice to an expert
in competency.
Such high expectations accompanied by inadequate advanced apprenticeship training often
leads to high turnover rates for new graduate nurses. In addition, patient safety and quality
of care are at risk if new graduates do not have the critical thinking skills or competencies
needed to apply critical judgments to patient situations. Jones and West (2014) suggest that
transition-to-practice programs bridge the gap by providing the new graduate opportunities to
take the learning from nursing school and apply it in an expanded, intensive, and integrated
clinical learning situation while providing direct patient care—much in the same way that the
internship of physicians is based upon applying academic learning to actual care of patients
and transition into the professional role.
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250 UNIT III ROLES AND FUNCTIONS IN PLANNING
A well-designed transition-to-practice program strengthens new graduates’ skills and
competencies and prepares the new nurse for the demands of caring for patients. Furthermore, a
systematic approach to transition not only facilitates “on-boarding” (integration into staffing on
the nursing unit to provide direct patient care), it reduces turnover by decreasing the toll associated
with insufficient preparation for the work environment (Examining the Evidence, 11.1).
Source: Trepanier, S., Early, S., Ulrich, B., & Cherry, B. (2012). New graduate nurse residency program: A cost-
benefit analysis based on turnover and contract labor usage. Nursing economics, 30(4), 207–214.
The purpose of this study, which included data from 15 hospitals in California, Florida, Geor-
gia, Nebraska, Missouri, Tennessee, and Texas, was to conduct a cost–benefit analysis of
new graduate nursing residency programs utilizing turnover rates and contract labor usage.
Secondary data analysis of 524 new graduate RNs was conducted including descriptive and
step-wise regression analyses. Findings indicated new graduate residency programs were
associated with a decrease in the 12-month turnover rate from 36.08% to 6.41% ( p < 0.05) and reduction in contract labor usage from $19,099 to $5,490 per average daily census ( p < 0.05). These cost–benefit analyses suggest net savings between $10 and $50 per pati- ent day when compared with traditional methods of orientation. The researchers concluded that new graduate nurse residency programs offer a cost-effective innovative approach and should be valued as an investment as opposed to an expense. Examining the Evidence 11.1 Jones and West (2014) suggest that employers and academe share the obligation to provide bridges from student to practicing nurse and that the inclusion of transition-to-practice programs is increasingly considered an expectation of the nursing education process and career development. Indeed, the Institute of Medicine (IOM) (2010) report on The Future of Nursing identified transition-to-practice programs/residencies as one of the eight key recommendations to actualize nursing contributions to the demands of health-care reform. The IOM suggests “state Boards of Nursing, accrediting bodies, the federal government, and health care organizations should take action to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a pre-licensure or advanced practice degree program or when they are transitioning into new clinical practice areas” (IOM, 2010, p. 280). Multiple types of transition-to-practice programs exist (Jones & West, 2014). There are programs that begin in the final year of nursing school and continue through licensure, although these programs are generally not intended to take the place of employer-based residencies, which often extend to 1 year and have a planned structured, mentored experience. Most transition-to-practice programs are employer-based “new graduate classes” within a hospital or employer (hospital) based programs that take up to a year to complete. Still others are for new graduates who have yet to be hired, so they may gain skills in order to become more employable. Traditional transition-to-practice programs (residencies) are funded and provided by employers (usually hospitals). The hospital hires a group of new graduate RNs and provides a curriculum over the first 6 months to 1 year of their employment. The new graduate hires receive full pay, though they do not have a full patient load for some time into their residency. Transition-to-practice programs are also found, however, in nonacute settings, such as primary care clinics, behavior health clinics, long-term care, home health, corrections, school nursing, and public health, and they provide exposure to career paths that new graduates may not have previously considered, and also provide an opportunity for nonacute employers to consider hiring new graduate nurses (Jones & West, 2014). free ebooks ==> www.ebook777.com
Chapter 11 Career Development: From New Graduate to Retirement 251
LEARNING EXERCISE 11.6
Addressing Nurse Residency Concerns
Jones and West (2014) note that while many groups are actively working to assure that nurse
residences exist to provide a solid foundation for successful career development in nursing,
many questions continue to exist about resource allocation (human and fiscal).
Assignment: Select any two of the following four questions and write a one-page essay
defending your answers.
1. Schools have voiced concerns that transition-to-practice programs are taking
preceptorship slots that have been historically allocated to pre-licensure students. do you
support this reallocation of resources?
2. Should transition-to-practice programs/residencies be a requirement for completion of
nursing education?
3. residencies have historically been a cost hospitals or employers have assumed. Should
this cost be shared and why?
4. Would you participate in a school-based transition-to-practice program without an
associated stipend, if it could help you gain experience? Would you pay to participate?
RESUMé PREPARATION
Despite the best efforts of organizations to help subordinates identify career needs, wants,
and opportunities, it is how employees represent themselves that often determines whether
desired career opportunities become a reality. Creating a positive image often depends on
having well-developed interviewing skills (Chapter 15) and a well-prepared resumé. The
resumé is an important career-planning tool. It is also a screening tool used by employers to
select applicants and make promotion decisions; therefore, maintaining a current, professional
resumé is a career-planning necessity for health-care professionals and should not be
undertaken lightly.
Resumé Structure
Various acceptable styles and formats of resumés exist. However, because the resumé
represents the professionalism of the applicant and recruiters use it to summarize an applicant’s
qualifications, it must be professionally prepared, make an impression, and quickly capture
the reader’s attention. The following are the general guidelines for resumé preparation:
• Keep your writing concise and clear.
• Type the document in a single-font format that is easy to read (12-point font or larger is
recommended).
• Use bulleted points or sentences.
• Include educational background, work history, awards or honors received, scholarly
achievements such as publications and presentations, and community service activities.
• Do not include personal information such as marital status, age, whether you have
children, ethnicity, or religious affiliations.
• Maximize your strong points and minimize your weaknesses.
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252 UNIT III ROLES AND FUNCTIONS IN PLANNING
• Never lie or overstretch your accomplishments because doing so places your credibility
at great risk.
• Use good grammar, correct punctuation, and proper sentence structure. Typographic
errors suggest you may not be serious about the job application or that the quality of
your work will be substandard.
• Use high-quality, heavy white, or off-white paper to print the resumé.
• Include a cover letter (whether by mail or e-mail), addressed to a specific individual
when possible, to introduce yourself, briefly highlight key points of the resumé, and
make a positive first impression.
Additional strategies for resumé preparation were identified by GE Healthcare (2009):
• Know what you want to do so that you can tailor your resumé accordingly. In other
words, identify the job you really want to have and then create a resumé around the
qualifications you have to perform that job. GE Healthcare suggests that when resumés
are not tailored, “you come across as someone who has sent out a hundred resumés,
willing to take any job at all” (p. 79). Do include a professional objective or goal
statement specific to your desired job.
• Know what recruiters are looking for. Look at sample job descriptions online and note
their preferred hiring criteria. Then create a resumé that highlights those qualifications
and the work experience you have that have given you that expertise.
• Highlight your accomplishments. The average resumé receives less than 10 seconds of
attention from recruiters so you need to make important points stand out.
A sample resumé is shown in Figure 11.1.
SUSAN CARMEL GUEVARA
628 Normal Street
Chico, CA 95928
Home phone: (530) 555-3718
sguevara©emailaccount.com
CAREER GOAL: To practice professional nursing within a progressive environment that provides
challenges and opportunities for professional and personal growth.
EDUCATION
• Bachelor of Science in Nursing, California State University, Chico (CSUC), May 2009.
California Public Health Certificate. Cumulative GPA 3.48; Nursing GPA 3.54.
HONORS
• Sigma Theta Tau International Society of Nursing, Kappa Omicron Chapter.
• CSUC School of Nursing Scholarship Award 2007 and 2008.
• Publication of “An Expression of Nursing, A Journal of Student Writing” in The CSUC School
of Nursing Alumni newsletter, spring 2007.
WORK EXPERIENCE
• June 2006–Present:
Nurse Attendant. Memorial Hospital, Chico, CA. Performed direct patient care under the
supervision and guidance of a registered nurse. (Job description available on request.)
• July 2004–May 2006
Home Health Aide/Respite Worker. Sommers Elder Services, Chico, CA. Performed custodial
care and light housekeeping duties for home-bound elderly and the disabled.
REFERENCES: Available on request.
FIGURE 11.1 • Sample nursing resumé.

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Chapter 11 Career Development: From New Graduate to Retirement 253
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN CAREER
DEVELOPMENT
It is clear that appropriate career management should foster positive career development,
alleviate burnout, reduce attrition, and promote productivity. Management functions in
career development include disseminating career information and posting job openings.
The manager should have a well-developed, planned system for career development for all
employees; this system should include long-term coaching, the appropriate use of transfers,
and how promotions are to be handled. These policies should be fair and communicated
effectively to all employees.
With the integration of leadership, managers become more aware of how their own values
shape personal career decisions. In addition, the leader-manager shows genuine interest in the
career development of all employees. Career planning is encouraged, and potential leaders are
identified and developed. Present leaders are rewarded when they see those, whom they have
helped to develop, advance in their careers and in turn develop leadership and management
skills in others.
Effective managers recognize that in all career decisions, the employee must decide when
he or she is ready to pursue promotions, return to school, or take on greater responsibility.
Leaders are aware that every person perceives success differently. Although career
development programs benefit all employees and the organization, there is an added bonus
for the professional nurse. When professional nurses have the opportunity to experience a
well-planned career development program, a greater viability for and increased commitment
to the profession are often evident.
KEY CONCEPTS
l there are many outcomes of a career development program that justify its implementation.
l Career job sequencing should assist the manager in career management.
l Career development programs consist of a set of personal responsibilities called career planning and a
set of management responsibilities called career management.
l employees often need to be encouraged to make more formalized long-term career plans.
l Career planning should include, at minimum, a commitment to the use of evidence-based practice,
learning new skills or bettering practice through the use of role models and mentors, staying aware of
and being involved in professional issues, and furthering one’s education.
l designing career paths is an important part of organizational career management.
l Managers should plan specific interventions that promote growth and development in each of their
subordinates.
l Most individuals progress through normal and predictable career stages.
l Career coaching involves helping others to identify professional goals and career options and designing
a career plan to achieve those goals. this coaching should be both short and long terms.
l Competency assessment and goal setting in career planning should help the employee identify how to
exceed the minimum levels of competency required by federal, state, or organizational standards.
l Professional specialty certification is one way that an employee can demonstrate advanced achievement
of competencies.
(Continued)
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254 UNIT III ROLES AND FUNCTIONS IN PLANNING
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
l to be successful, management development must be planned and supported by top-level management.
this type of planned program is called succession management.
l if appropriate management attitudes and insight are goals of a management development program,
social learning techniques need to be part of the teaching strategies used.
l Multiple types of transition-to-practice programs exist, but all are focused on helping nursing students
bridge from school into employment.
l Maintaining a current, professional resumé is a career-planning necessity for the health-care professional
and should not be undertaken lightly.
l Cover letters (whether by mail or e-mail) should always be used when submitting a resumé. their
purpose is to introduce the applicant, briefly highlight key points of the resumé, and make a positive first
impression.
l all nurses should maintain a professional portfolio (a collection of materials that document a nurse’s
competencies and illustrate the expertise of the nurse) to reflect their professional growth over their
career.
LEARNING EXERCISE 11.7
Developing a Realistic 20-Year Career Plan
develop a 20-year career plan, taking into account the constraints of family responsibilities such
as marriage, children, and aging parents. Have your career plan critiqued to determine whether
it is feasible and whether the timelines and goals are realistic.
LEARNING EXERCISE 11.8
Listing Policies Relating to Reimbursement of Educational Expenses for Career
Advancement
You have been appointed to a committee of staff nurses in your home health agency to
assist in developing a set of policies regarding the reimbursement of employee expenses for
educational or career advancement. employees have suggested that support for educational
advancement is not appropriated uniformly and no criteria exist to determine who should be
eligible.
Assignment: develop a list of five to seven policies regarding who and what should be
eligible for educational expenses for career advancement. Be able to justify your criteria and
policies.

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Chapter 11 Career Development: From New Graduate to Retirement 255
LEARNING EXERCISE 11.10
Constructing a Management Development Program
You are serving on an ad hoc committee to construct a management development program. Your
organization has requested that the charge nurses work with staff development and plan a 1-week
training and education program that would be required of all new charge nurses before their
appointment. Because the organization will be bearing the cost of the program (i.e., paying for
the educators and employee time), you are required to select appropriate content and educational
methods that will not exceed 40 hours, including actual orientation time by a charge nurse.
Assignment: develop and write up such a plan, and share it with the class. Your plan should
depict hours, content, and educational methods.
LEARNING EXERCISE 11.9
Preparing a Resumé
the medical center where you have applied for a position has requested that you submit a
resumé along with your application. Prepare a professional resumé, using your actual experience
and education. You may use any style and format that you desire. the resumé will be critiqued
on its professional appearance and appropriateness of included content.
LEARNING EXERCISE 11.11
Career Mapping
Career planning is often made easier when a career map is created to assist in developing a
long-term master plan. Use the career guide shown in Figure 11.2, along with the individual
responsibilities for career development outlined in display 11.3, to assist with developing the
personal plan described in Learning exercise 11.7.
(Continued)
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256 UNIT III ROLES AND FUNCTIONS IN PLANNING
Phase 1:
Defining
Phase 2:
Structuring
Goal priorities set
Alternative solutions
proposed
Preferred alternative selected
Needs identified
Needs assessed
Gaps identified
Goals formulated
Phase 3:
Implementing
Action steps described
Activities for each action
step identified
Resource needs indicated
Time requirements indicated
Phase 4:
Validating
Activities monitored
Assessments made
of activities
Activities evaluated
Career
Goal
FILL IN THE
MISSING INFORMATION
Where I am Where I
want to be
FIGURE 11.2 • a career-planning guide for a professional nurse.
REFERENCES
Altman, M. (2011). Let’s get certified: Best practices for
nurse leaders to create a culture of certification. AACN
Advanced Critical Care, 22(1), 68–75.
American Nurses Association (ANA) (2001). Code of ethics
for nurses with interpretive statements. Washington,
DC: American Nurses Association.
American Nurses Credentialing Center. (2012). American
Nurses Credentialing Center—Annual report
2012. Retrieved May 23, 2013, from http://www
.nursecredentialing.org/Documents/Annual-Reports
-Archive/2012-AnnualReport
Boltz, M., Capezuti, E., Wagner, L., Rosenberg, M., &
Secic, M. (2013). Patient safety in medical-surgical
units: Can nurse certification make a difference?
MEDSURG Nursing, 22(1), 26–37.
BusinessDictonary.com (2013a). Career ladder. Definition.
Retrieved May 24, 2013, from http://www.busindess
-dictionary.com/definition/career-ladder.html
BusinessDictionary.com (2013b). Professional. Definition.
Retrieved May 23, 2013, from http://www.business
-dictionary.com/definition/professional.html
Certification: Promoting Excellence in Nursing. (2013).
AACN Bold Voices, 5(2), 13.
Cronenwett, L.R. (2011). The future of nursing education.
Excerpted from Appendix I of the Future of Nurs-
ing: Leading Change, Advancing Health (Institute

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Chapter 11 Career Development: From New Graduate to Retirement 257
of Medicine, 2011). Retrieved May 23, 2013 from
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Workforce/Nursing/Future%20of%20Nursing%20
Education
Executive Coaching Network. (n.d.). What is executive
coaching? Retrieved May 24, 2013, from http://www
.execcoachnetwork.com.au/whatis.html
Foster, C. (2012). Institute of Medicine The Future of
Nursing report, lifelong learning, and certification.
MEDSURG Nursing, 21(2), 115–116.
GE Healthcare. (2009, March–April). Showcase yourself in
resumé. Healthcare Executive, 24(2), 79.
Haskins, M., Hnatiuk, C., & Yoder, L. H. (2011). Medical-
surgical nurses’ perceived value of certification study.
MEDSURG Nursing, 20(2), 71–93.
Huston, C. (2008, November). Preparing nurse leaders for
2020. Journal of Nursing Management, 16(8), 905–911.
Huston, C. (2014). Assuring provider competence through
licensure, continuing education, and certification.
In C. Huston (Ed.), Professional issues in nursing
(3rd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins 292–307.
Institute of Medicine (IOM). (2010). The future of nursing:
Leading change, advancing health. Washington, DC:
The National Academies.
Jones, D., & West, N. (2014). New graduate RN transition to
practice programs. Chapter 10. In C. Huston (Ed.),
Professional issues in nursing (3rd ed.). Philadelphia,
PA: Lippincott Williams & Wilkins 156–169.
Kendall-Gallagher, D., Aiken, L. H., Sloane, D. M., &
Cimiotti, J. P. (2011). Nurse specialty certification,
inpatient mortality, and failure to rescue. Journal of
Nursing Scholarship, 43(2), 188–194.
Kinsella, E. (2010). Professional knowledge and the episte-
mology of reflective practice. Nursing Philosophy,
11(1), 3–14.
Knudson, L. (2013). Nursing certification provides recogni-
tion for nurses, employers. AORN Journal, 97(3),
C1–C10.
Krapohl, G., Manojlovich, M., Redman, R., & Zhang, L.
(2010). Nursing specialty certification and nursing-
sensitive patient outcomes in the intensive care unit.
American Journal of Critical Care, 19(6), 490–499.
North Carolina Board of Nursing (NCBN) (2011). Continu-
ing competence. Retrieved May 24, 2013, from http://
www.ncbon.com/content.aspx?id=664
Raffals, R. (n.d.) What is coaching? Retrieved May 24, 2013,
from http://www.awakenthemagic.com/coach/whatis
.html
Sherrod, D. (2007). Professional portfolio: A snapshot of
your career. Nursing 2007 Career Directory, 37, 18.
Shirey, M. (2009, September). Building an extraordinary career
in nursing: Promise, momentum, and harvest. Journal
of Continuing Education in Nursing, 40(9), 394–402.
Sinclair, P., Bowen, L., & Donkin, B. (2013). Professional ne-
phrology nursing portfolios: Maintaining competence
to practice. Renal Society of Australasia Journal, 9(1),
35–40.
Trepanier, S., Early, S., Ulrich, B., & Cherry, B. (2012). New
graduate nurse residency program: A cost-benefit
analysis based on turnover and contract labor usage.
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Roles and Functions
in Organizing
Unit iv
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260
Organizational Structure
… The days of the traditional pyramid shaped corporate hierarchy as a viable business model are
coming to an end.
—Michael Hugos
… in a changing world, organizations must change as surely as individuals must change. Recent
years have seen an increase in organizational “flattening,” the tendency to shrink the organizational
structure through the removal of layers of hierarchy.
—Charles R. McConnell
CROSSWALK tHis CHapteR addResses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential III: Quality improvement and safety
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: teamwork and collaboration
QSEN Competency: Quality improvement
QSEN Competency: safety
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency IV: professionalism
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l describe how the structure of an organization facilitates or impedes communication, flexibility,
and job satisfaction
l identify characteristics of a bureaucracy as defined by Max Weber
l identify line-and-staff relationships, span of control, unity of command, and scalar chains on
the organization chart
l describe components of the informal organization structure including employee interpersonal
relationships, the formation of primary and secondary groups, and group leaders without
formal authority
l differentiate between first, middle, and top levels of management
l compare and contrast centralized and decentralized decision making
l analyze how position on the organization chart is related to centrality
l describe common components of shared governance models and differentiate shared
governance from participatory decision making
12

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Chapter 12 Organizational Structure 261
l contrast individual authority, responsibility, and accountability in given scenarios
l identify appropriate strategies the leader/manager may take to create a constructive
organizational culture
l describe characteristics of effective committees and committee members
l define “group think” and discuss the impact of group think on organizational decision making
and risk taking
l identify symptoms of poorly designed organizations
l describe characteristics of magnet designated health-care organizations that exemplify the
14 forces of magnetism
l provide examples of an organization’s potential stakeholders
Unit III provided a background in planning, the first phase of the management process.
Organizing follows planning as the second phase of the management process and is explored in
this unit. In the organizing phase, relationships are defined, procedures are outlined, equipment
is readied, and tasks are assigned. Organizing also involves establishing a formal structure that
provides the best possible coordination or use of resources to accomplish unit objectives. This
chapter looks at how the structure of an organization facilitates or impedes communication,
flexibility, productivity, and job satisfaction. Chapter 13 examines the role of authority and
power in organizations and how power may be used to meet individual, unit, and organizational
goals. Chapter 14 looks at how human resources can be organized to accomplish patient care.
FORMAL AND INFORMAL ORGANIZATIONAL STRUCTURE
Fayol (1949) suggested that an organization is formed when the number of workers is large
enough to require a supervisor. Organizations are necessary because they accomplish more work
than can be done by individual effort. Because people spend most of their lives in social, personal,
and professional organizations, they need to understand how organizations are structured—their
formation, methods of communication, channels of authority, and decision-making processes.
Each organization has a formal and an informal organizational structure. “Essentially,
in the formal organization, the emphasis is on organizational positions and formal power,
whereas in the informal organization, the focus is on the employees, their relationships, and
the informal power that is inherent within those relationships” (Education Portal, 2003–2013,
para 3). In addition, the formal structure is generally highly planned and visible, whereas the
informal structure is unplanned and often hidden.
Formal structure, through departmentalization and work division, provides a framework
for defining managerial authority, responsibility, and accountability. In a well-defined formal
structure, roles and functions are defined and systematically arranged, different people have
differing roles, and rank and hierarchy are evident.
Organizational structure refers to the way in which a group is formed, its lines of
communication, and its means for channeling authority and making decisions.
Informal structure is generally a naturally forming social network of employees. Education
Portal (2003–2013) suggests that it is the informal structure that fills in the gaps with
connections and relationships that illustrate how employees network with one another to get
work done. Because informal structures are typically based on camaraderie, they often result
in a more immediate response from individuals, saving people’s time and effort (Schatz,
2013). People also rely on informal structure if the formal structure has stopped being
effective, which often happens as an organization grows or changes but does not reevaluate
its hierarchy or work groups (Schatz).
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262 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
The informal structure even has its own communication network, known as the grapevine.
Education Portal (2003–2013) suggests that grapevine communication is at the heart of the
informal organization; it is the conversations that occur in the break room, down the halls,
during the carpool, and in between work that allows the relationships of informal groups to
develop. In addition, social media sites and electronic communication such as e-mail and text
messages are also used to facilitate communication among informal group members.
While grapevine communication is fast and can facilitate information upward, downward,
and horizontally, it is difficult to control or to stop. With little accountability for the message,
grapevine communication often becomes a source for rumor or gossip.
The informal structure also has its own leaders. In addition, it also has its own communication
channels, often referred to as the grapevine.
People need to be aware that informal authority and lines of communication exist in every
group, even when they are never formally acknowledged. The primary emphasis of this chapter,
however, is the identification of components of organizational structure, the leadership roles
and management functions associated with formal organizational structure, and the proper
utilization of committees to accomplish organizational objectives (Display 12.1).
LEADERSHIP ROLES
1. evaluates the organizational structure frequently to determine if management positions should
be eliminated to shorten the chain of command.
2. encourages and guides employees to follow the chain of command and counsels employees
who do not do so.
3. supports personnel in advisory (staff) positions.
4. Models responsibility and accountability for subordinates.
5. assists staff to see how their roles are congruent with and complement the organization’s
mission, vision, and goals.
6. Facilitates constructive informal group structure.
7. encourages upward communication.
8. Fosters a positive organizational culture between work groups and subcultures that facilitates
shared values and goals.
9. promotes participatory decision making and shared governance to empower subordinates.
10. Uses committees to facilitate group goals, not to delay decisions.
MANAgEMENT FUNCTIONS
1. is knowledgeable about the organization’s internal structure, including personal and depart-
ment authority and responsibilities within that structure.
2. Facilitates constructive formal group structure.
3. provides the staff with an accurate unit organization chart and assists with interpretation.
4. When possible, maintains unity of command.
5. Clarifies unity of command when there is confusion.
6. Follows appropriate subordinate complaints upward through chain of command.
7. establishes an appropriate span of control.
8. strives to create a constructive organizational culture and positive organizational climate.
9. Uses the informal organization to meet organizational goals.
10. Uses committee structure to increase the quality and quantity of work accomplished.
11. Works, as appropriate, to achieve a level of operational excellence befitting an organization that
would be eligible for magnet status or some other recognition of excellence.
12. Continually identifies, analyzes, and promotes stakeholder interests in the organization.
DISPLAY 12.1 Leadership Roles and Management Functions Associated with
Organizational Structure

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Chapter 12 Organizational Structure 263
ORGANIZATIONAL THEORY AND BUREAUCRACY
Max Weber, a German social scientist, is known as the father of organizational theory.
Generally acknowledged to have developed the most comprehensive classic formulation on
the characteristics of bureaucracy, Weber wrote from the vantage point of a manager instead
of that of a scholar. During the 1920s, Weber saw the growth of the large-scale organization
and correctly predicted that this growth required a more formalized set of procedures for
administrators. His statement on bureaucracy, published after his death, is still the most
influential statement on the subject.
Weber postulated three “ideal types” of authority or reasons why people throughout
history have obeyed their rulers. One of these, legal-rational authority, was based on a belief
in the legitimacy of the pattern of normative rules and the rights of those elevated to authority
under such rules to issue commands. Obedience, then, was owed to the legally established
impersonal set of rules rather than to a personal ruler. It is this type of authority that is the
basis for Weber’s concept of bureaucracy.
Weber argued that the great virtue of bureaucracy—indeed, perhaps its defining
characteristic—was that it was an institutional method for applying general rules to specific
cases, thereby making the actions of management fair and predictable. Other characteristics
of bureaucracies as identified by Weber include the following:
• There must be a clear division of labor (i.e., all work must be divided into units that can
be undertaken by individuals or groups of individuals competent to perform those tasks).
• A well-defined hierarchy of authority must exist in which superiors are separated
from subordinates; on the basis of this hierarchy, remuneration for work is dispensed,
authority is recognized, privileges are allotted, and promotions are awarded.
• There must be impersonal rules and impersonality of interpersonal relationships. In
other words, bureaucrats are not free to act in any way they please. Bureaucratic rules
provide superiors systematic control over subordinates, thus limiting the opportunities
for arbitrary behavior and personal favoritism.
• A system of procedures for dealing with work situations (i.e., regular activities to get a
job done) must exist.
• A system of rules covering the rights and duties of each position must be in place.
• Selection for employment and promotion is based on technical competence.
Bureaucracy was the ideal tool to harness and routinize the energy and prolific production
of the Industrial Revolution. Weber’s work did not, however, consider the complexity
of managing organizations in the 21st century. Weber wrote during an era when worker
motivation was taken for granted, and his simplification of management and employee roles
did not examine the bilateral relationships between employee and management prevalent in
most organizations today.
Since Weber’s research, management theorists have learned much about human behavior,
and most organizations have modified their structures and created alternative organizational
designs that reduce rigidity and impersonality. Yet, almost 100 years after Weber’s findings,
components of bureaucratic structure continue to be found in the design of most large
organizations.
Current research suggests that changing an organization’s structure in a manner that increases
autonomy and work empowerment for nurses will lead to more effective patient care.
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264 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
COMPONENTS OF ORGANIZATIONAL STRUCTURE
Weber is also credited with the development of the organization chart to depict an
organization’s structure. Because the organization chart (Fig. 12.1) is a picture of an
organization, the knowledgeable manager can derive much information from reading the
chart. For example, an organization chart can help identify roles and their expectations.
In addition, by observing elements, such as which departments report directly to the
chief executive officer (CEO), the novice manager can make some inferences about the
organization. For instance, reporting to a middle level manager rather than an executive
officer suggests that person has less status and influence than someone who reports to an
individual higher on the organization chart. Managers who understand an organization’s
structure and relationships will be able to expedite decisions and have a greater understanding
of the organizational environment.
Relationships and Chain of Command
The organization chart defines formal relationships within the institution. Formal relationships,
lines of communication, and authority are depicted on a chart by unbroken (solid) lines.
These line positions can be shown by solid horizontal or vertical lines. Solid horizontal
lines represent communication between people with similar spheres of responsibility and
power but different functions. Solid vertical lines between positions denote the official chain
of command, the formal paths of communication and authority. Those having the greatest
decision-making authority are located at the top; those with the least are at the bottom. The
level of position on the chart also signifies status and power.
Dotted or broken lines on the organization chart represent staff positions. Because these
positions are advisory, a staff member provides information and assistance to the manager
but has limited organizational authority. Used to increase his or her sphere of influence, staff
positions enable a manager to handle more activities and interactions than would otherwise be
Unit Supervisors
Shift Charge Nurses
Director of Nursing
Recovery
Room
Labor and
Delivery
Social
Services
Nursing Office
Shift Supervisor
Director of General Services Director of Auxiliary Services
Accounting
Payroll
Business
Office
Switchboard
Laundry
Housekeeping
Maintenance
Dietary
Purchasing
Clinical Lab
Central Supply
Medical
Records
Pharmacy
Respiratory
Therapy
Physical
Therapy
Emergency
Room
Operating
Room
Administrator
Memorial Hospital
Board of Directors
Medical Staff
Controller of Fiscal Affairs
Newborn Nursery
1 unit 14 beds
Obstetrics
1 unit 14 beds
Medical/surgical
3 units 42 beds
Psychiatric
1 unit 14 beds
Pediatrics
1 unit 14 beds
FIGURE 12.1 • sample organizational chart. Copyright ® 2006 Lippincott Williams &
Wilkins. instructor’s Resource Cd-ROM to accompany Leadership Roles and
Management Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.

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Chapter 12 Organizational Structure 265
possible. These positions also provide for specialization that would be impossible for any one
manager to achieve alone. Although staff positions can make line personnel more effective,
organizations can function without them.
Advisory (staff) positions do not have inherent legitimate authority. Clinical specialists
and in-service directors in staff positions often lack the authority that accompanies a line
relationship. Accomplishing the role expectations in a staff position may therefore be more
difficult because formal authority is limited. Because only line positions have authority for
decision making, staff positions may result in an ineffective use of support services unless job
descriptions and responsibilities for these positions are clearly spelled out.
Unity of command is indicated by the vertical solid line between positions on the
organizational chart. This concept is best described as one person/one boss in which
employees have one manager to whom they report and to whom they are responsible.
This greatly simplifies the manager–employee relationship because the employee needs
to maintain only a minimum number of relationships and accept the influence of only one
person as his or her immediate supervisor.
Unity of command is difficult to maintain in some large health-care organizations because the
nature of health care requires an interprofessional approach.
Nurses frequently feel as though they have many individuals to account to because health care
often involves an interprofessional approach. Additional individuals the nurse may need to
be accountable to include the immediate supervisor, the patient, the patient’s family, central
administration, and the physician. All have some input in directing a nurse’s work. Weber
was correct when he determined that a lack of unity of command results in some conflict and
lost productivity. This is demonstrated frequently when health-care workers become confused
about unity of command.
LEARNING EXERCISE 12.1
Who Is the Boss?
in groups or individually, analyze the following and give an oral or written report.
1. Have you ever worked in an organization in which the lines of authority were unclear? Have
you been a member of a social organization in which this happened? How did this interfere
with the organization’s functioning?
2. do you believe that the “one boss/one person” rule is a good idea? do hospital clerical
workers frequently have many bosses? if you have worked in a situation in which you had
more than one boss, what was the result?
Span of Control
Span of control also can be determined from the organization chart. The number of people
directly reporting to any one manager represents that manager’s span of control and
determines the number of interactions expected of him or her. Thus, there is an inverse
relation between the span of control and the number of levels in hierarchy in an organization,
i.e., narrower the span, the greater is the number of levels in an organization (Juneja, 2013).
Theorists are divided regarding the optimal span of control for any one manager.
Quantitative formulas for determining the optimal span of control have been attempted,
with suggested ranges from 3 to 50 employees. In reality, the ideal span of control in an
organization depends upon various factors, such as the nature of the job, the manager’s
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266 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
abilities, the employees’ maturity, the task complexity, and the level in the organization at
which the work occurs. The number of people directly reporting to any one supervisor must
be the number that maximizes productivity and worker satisfaction.
Too many people reporting to a single manager delays decision making, whereas too few results
in an inefficient, top-heavy organization.
Until the last decade, the principle of narrow spans of control at top levels of management,
with slightly wider spans at other levels, was widely accepted. Indeed, Juneja (2013) suggests
that most modern management theorists would suggest an ideal span of control as 15 to
20 subordinates per manager, as compared with the 6 subordinates per manager touted in
the past. With increased financial pressures on health-care organizations to remain fiscally
solvent and electronic communication technology advances, many have increased their spans
of control and reduced the number of administrative levels in the organization. This is often
termed flattening the organization.
Managerial Levels
In large organizations, several levels of managers often exist. Top-level managers look at the
organization as a whole, coordinating internal and external influences, and generally make
decisions with few guidelines or structures. Examples of top-level managers include the
organization’s chief operating officer or CEO and the highest level nursing administrator.
Current nomenclature for top-level nurse-managers varies; they might be called vice
president of nursing or patient care services, nurse administrator, director of nursing, chief
nurse, assistant administrator of patient care services, or chief nurse officer (CNO).
Some top-level nurse-managers may be responsible for non-nursing departments. For
example, a top-level nurse-manager might oversee the respiratory, physical, and occupational
therapy departments in addition to all nursing departments. Likewise, the CEO might have
various titles, such as president and director. It is necessary to remember only that the
CEO is the organization’s highest ranking person, and the top-level nurse-manager is its
highest ranking nurse. Responsibilities common to top-level managers include determining
the organizational philosophy, setting policy, and creating goals and priorities for resource
allocation. Top-level managers have a greater need for leadership skills and are not as
involved in routine daily operations as are lower level managers.
Middle-level managers coordinate the efforts of lower levels of the hierarchy and are the
conduit between lower and top-level managers. Middle-level managers carry out day-to-day
operations but are still involved in some long-term planning and in establishing unit policies.
Examples of middle-level managers include nursing supervisors, nurse-managers, head
nurses, and unit managers.
Currently, there are many health facility mergers and acquisitions, and reduced levels of
administration are frequently apparent within these consolidated organizations. Consequently,
many health-care facilities have expanded the scope of responsibility for middle-level
managers and given them the title of “director” as a way to indicate new roles. The old term
director of nursing, still used in some small facilities to denote the CNO, is now used in many
health-care organizations to denote a middle-level manager. The proliferation of titles among
health-care administrators has made it imperative that individuals understand what roles and
responsibilities go with each position.
First-level managers are concerned with their specific unit’s work flow. They deal
with immediate problems in the unit’s daily operations, with organizational needs, and
with personal needs of employees. The effectiveness of first-level managers tremendously
affects the organization. First-level managers need good management skills. Because they
work so closely with patients and health-care teams, first-level managers also have an

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Chapter 12 Organizational Structure 267
excellent opportunity to practice leadership roles that will greatly influence productivity and
subordinates’ satisfaction. Examples of first-level managers include primary care nurses,
team leaders, case managers, and charge nurses. In many organizations, every registered
nurse (RN) is considered a first-level manager. All nurses in every situation must manage
themselves and those under their care. A composite look at top-, middle-, and first-level
managers is shown in Table 12.1.
One of the leadership responsibilities of organizing is to periodically examine the number
of people in the chain of command. Organizations frequently add levels until there are too
many managers. Therefore, the leader-manager should carefully weigh the advantages and
disadvantages of adding a management level. For example, does having a charge nurse on
each shift aid or hinder decision making? Does having this position solve or create problems?
Centrality
Centrality, or where a position falls on the organizational chart, is determined by
organizational distance. Employees with relatively small organizational distance can receive
more information than those who are more peripherally located. This is why the middle
manager often has a broader view of the organization than other levels of management. A
middle manager has a large degree of centrality because this manager receives information
upward, downward, and horizontally.
Centrality refers to the location of a position on an organization chart where frequent and
various types of communication occur.
Because all communication involves a sender and a receiver, messages may not be received
clearly because of the sender’s hierarchical position. Similarly, status and power often
influence the receiver’s ability to hear information accurately. An example of the effect of
status on communication is found in the “principal syndrome.” Most people can recall panic,
when they were school age, at being summoned to the principal’s office. Thoughts of “what
did I do?” travel through one’s mind. Even adults find discomfort in communicating with
certain people who hold high status. This may be fear or awe, but both interfere with clear
communication. The difficulties with upward and downward communication are discussed in
more detail in Chapter 19.
TABLE 12.1 Levels of Managers
Top Level Middle Level First Level
examples Chief nursing officer
Chief executive officer
Chief financial officer
Unit supervisor
department head
director
Charge nurse
team leader
primary nurse
scope of responsibility Look at organization
as a whole as well as
external influences
Focus is on integrating
unit-level day-to-day
needs with organizational
needs
Focus primarily on
day-to-day needs
at unit level
primary planning focus strategic planning Combination of long- and
short-range planning
short-range,
operational
planning
Communication flow More often top-down but
receives subordinate
feedback both directly
and via middle-level
managers
Upward and downward
with great centrality
More often upward;
generally relies
on middle-
level managers
to transmit
communication to
top-level managers
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268 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
It is important, then, to be aware of how the formal structure affects overall relationships
and communication. This is especially true because organizations change their structure
frequently, resulting in new communication lines and reporting relationships. Unless one
understands how to interpret a formal organization chart, confusion and anxiety will result
when organizations are restructured.
LEARNING EXERCISE 12.2
Change Is Coming
this learning exercise refers to the organization chart in Figure 12.1. Because Memorial Hospital
is expanding, the Board of directors has made several changes that require modification of the
organization chart. the directors have just announced the following changes:
● the name of the hospital has been changed to Memorial General Hospital and Medical
Center.
● state approval has been granted for open-heart surgery.
● One of the existing medical–surgical units will be remodeled and will become two critical
care units (one six-bed coronary and open-heart unit and one six-bed trauma and surgical
unit).
● a part-time medical director will be responsible for medical care on each critical care unit.
● the hospital administrator’s title has been changed to executive director.
● an associate hospital administrator has been hired.
● a new hospital-wide educational department has been created.
● the old pediatric unit will be remodeled into a seven-bed pediatric wing and a seven-bed
rehabilitation unit.
● the director of nursing’s new title is vice president of patient care services.
Assignment: if the hospital is viewed as a large, open system, it is possible to visualize areas
where problems might occur. in particular, it is necessary to identify changes anticipated in the
nursing department and how these changes will affect the organization as a whole. depict all of
these changes on the old organization chart, delineating both staff and line positions. Give the
rationale for your decisions. Why did you place the education department where you did? What
was the reasoning in your division of authority? Where do you believe there might be potential
conflict in the new organization chart? Why?
LEARNING EXERCISE 12.3
Cultures and Hierarchies
Having been with the county health department for 6 months, you are very impressed with the
physician who is the county health administrator. she seems to have a genuine concern for
patient welfare. she has a tea for new employees each month to discuss the department’s
philosophy and her own management style. she says that she has an open-door policy, so
employees are always welcome to visit her.
since you have been assigned to the evening immunization clinic as charge nurse, you have
become concerned with a persistent problem. the housekeeping staff often spends part of
the evening sleeping on duty or socializing for long periods. You have reported your concerns
to your health department supervisor twice. Last evening, you found the housekeeping staff

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Chapter 12 Organizational Structure 269
Is it ever appropriate to go outside the chain of command? Of course, there are isolated
circumstances when the chain of command must be breached. However, those rare conditions
usually involve a question of ethics. In most instances, those being bypassed in a chain of
command should be forewarned. Remember that unity of command provides the organization
with a workable system for procedural directives and orders so that productivity is increased
and conflict is minimized.
LIMITATIONS OF ORGANIZATION CHARTS
Because organization charts show only formal relationships, what they can reveal about an
institution is limited. The chart does not show the informal structure of the organization. Every
institution has in place a dynamic informal structure that can be powerful and motivating.
Knowledgeable leaders never underestimate its importance because the informal structure
includes employees’ interpersonal relationships, the formation of primary and secondary
groups, and the identification of group leaders without formal authority.
These groups are important in organizations because they provide workers with a feeling
of belonging. They also have a great deal of power in an organization; they can either
facilitate or sabotage planned change. Their ability to determine a unit’s norms and acceptable
behavior has a great deal to do with the socialization of new employees. Informal leaders are
frequently found among long-term employees or people in select gatekeeping positions, such
as the CNO’s secretary. Frequently, the informal organization evolves from social activities
or from relationships that develop outside the work environment.
Organization charts are also limited in their ability to depict each line position’s degree
of authority. Authority is defined as the official power to act. It is power given by the
organization to direct the work of others. A manager may have the authority to hire, fire, or
discipline others.
Equating status with authority, however, frequently causes confusion. The distance from
the top of the organizational hierarchy usually determines the degree of status: the closer to
the top, the higher the status. Status also is influenced by skill, education, specialization, level
of responsibility, autonomy, and salary accorded a position. People frequently have status
with little accompanying authority.
Because organizations are dynamic environments, an organization chart becomes obsolete
very quickly. Grover (1999–2013) suggests that most organizations are constantly changing,
with people taking on new jobs, getting hired, and getting fired, so trying to keep an
organization chart current is almost impossible.
having another get together. this mainly upsets you because the clinic is chronically in need of
cleaning. sometimes, the public bathrooms get so untidy that they embarrass you and your staff.
You frequently remind the housekeepers to empty overflowing wastepaper baskets. You believe
that this environment is demeaning to patients. this also upsets you because you and your staff
work hard all evening and rarely have a chance to sit down. You believe it is unfair to everyone
that the housekeeping staff is not doing its share.
On your way to the parking lot this evening, the health administrator stops to chat and asks you
how things are going. should you tell her about the problem with the housekeeping staff? is this
following an appropriate chain of command? do you believe that there is a conflict between the
housekeeping unit’s culture and the nursing unit’s culture? What should you do? List choices
and alternatives. decide what you should do, and explain your rationale.
Note: Attempt to solve this problem before referring to a possible solution posted in the Appendix.
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270 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
It is also possible that the organization chart may depict how things are supposed to be,
when in reality, the organization is still functioning under an old structure because employees
have not yet accepted new lines of authority.
In addition, organization charts may too rigidly define the jobs of people working in that
organization (Grover, 1999–2013). Some employees may look at the organization chart and
determine that the responsibilities there are their only responsibilities, when the reality is that
most employees will on occasion, have to assist with work that is not a formal part of their
job description.
Another limitation of the organization chart is that although it defines authority, it does
not define responsibility and accountability. A responsibility is a duty or an assignment.
It is the implementation of a job. For example, a responsibility common to many charge
nurses is establishing the unit’s daily patient care assignment. Individuals should always be
assigned responsibilities with concomitant authority. If authority is not commensurate to the
responsibility, role confusion occurs for everyone involved. For example, supervisors may
have the responsibility of maintaining high professional care standards among their staff.
If the manager is not given the authority to discipline employees as needed, however, this
responsibility is virtually impossible to implement.
Accountability is similar to responsibility, but it is internalized. Thus, to be accountable
means that individuals agree to be morally responsible for the consequences of their actions.
Therefore, one individual cannot be accountable for another. Society holds us accountable
for our assigned responsibilities, and people are expected to accept the consequences of their
actions. A nurse who reports a medication error is being accountable for the responsibilities
inherent in the position. Display 12.2 discusses the advantages and limitations of an
organization chart.
The leader-manager should understand the interrelationships and differences among
these three terms. Because the use of authority, power building, and political awareness
are so important to functioning effectively in any structure, Chapter 13 discusses these
organizational components in depth.
TYPES OF ORGANIZATIONAL STRUCTURES
Traditionally, nursing departments have used one of the following structural patterns:
bureaucratic, ad hoc, matrix, flat, or various combinations of these. The type of structure
used in any health-care facility affects communication patterns, relationships, and authority.
ADVANTAgES
1. Maps lines of decision-making authority.
2. Helps people understand their assignments and those of their coworkers.
3. Reveals to managers and new personnel how they fit into the organization.
4. Contributes to sound organizational structure.
5. shows formal lines of communication.
LIMITATIONS
1. shows only formal relationships.
2. does not indicate degree of authority.
3. are difficult to keep current.
4. May show things as they are supposed to be or used to be rather than as they are.
5. May define roles too narrowly.
6. possibility exists of confusing authority with status.
DISPLAY 12.2 Advantages and Limitations of the Organization Chart

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Chapter 12 Organizational Structure 271
Line Structures
Bureaucratic organizational designs are commonly called line structures or line organizations.
Those with staff authority may be referred to as staff organizations. Both of these types of
organizational structures are found frequently in large health-care facilities and usually
resemble Weber’s original design for effective organizations. Because of most people’s
familiarity with these structures, there is little stress associated with orienting people to these
organizations. In these structures, authority and responsibility are clearly defined, which leads
to efficiency and simplicity of relationships. The organization chart in Figure 12.1 is a line-
and-staff structure.
These formal designs have some disadvantages. They often produce monotony,
alienate workers, and make adjusting rapidly to altered circumstances difficult. Another
problem with line and line-and-staff structures is their adherence to chain of command
communication, which restricts upward communication. Good leaders encourage upward
communication to compensate for this disadvantage. However, when line positions are
clearly defined, going outside the chain of command for upward communication is usually
inappropriate.
Ad Hoc Design
The ad hoc design is a modification of the bureaucratic structure and is sometimes used on
a temporary basis to facilitate completion of a project within a formal line organization. The
ad hoc structure is a means of overcoming the inflexibility of line structure and serves as a
way for professionals to handle the increasingly large amounts of available information. Ad
hoc structures use a project team or task approach and are usually disbanded after a project
is completed. This structure’s disadvantages are decreased strength in the formal chain of
command and decreased employee loyalty to the parent organization.
Matrix Structure
A matrix organization structure is designed to focus on both product and function. Function
is described as all the tasks required to produce the product, and the product is the end result
of the function. For example, good patient outcomes are the product, and staff education and
adequate staffing may be the functions necessary to produce the outcome.
The matrix organization structure has a formal vertical and horizontal chain of command.
Figure 12.2 depicts a matrix organizational structure and shows that the Manager of Nursing
Women’s Services care could report both to a Vice President for Maternal and Women’s
Services (Product Manager) and a Vice President for Nursing Services (Functional Manager).
Although there are less formal rules and fewer levels of the hierarchy, a matrix structure
is not without disadvantages. For example, in this structure, decision making can be slow
because of the necessity of information sharing, and it can produce confusion and frustration
for workers because of its dual-authority hierarchical design. The primary advantage of
centralizing expertise is frequently outweighed by the complexity of the communication
required in the design.
Service Line Organization
Similar to the matrix design is service line organization, which can be used in some large
institutions to address the shortcomings that are endemic to traditional large bureaucratic
organizations. Service lines, sometimes called care-centered organizations, are smaller in
scale than a large bureaucratic system. For example, in this organizational design, the overall
goals would be determined by the larger organization, but the service line would decide on
the processes to be used to achieve the goals.
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272 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
Flat Designs
Flat organizational designs are an effort to remove hierarchical layers by flattening
the chain of command and decentralizing the organization. Thus, a single manager or
supervisor would oversee a large number of subordinates and have a wide span of control
(Juneja, 2013). In good times, when organizations are financially well off, it is easy to
add layers to the organization in order to get the work done, but when the organization
begins to feel a financial pinch, they often look at their hierarchy to see where they can
cut positions.
In flattened organizations, there continues to be line authority, but because the
organizational structure is flattened, more authority and decision making can occur where
the work is being carried out. Figure 12.3 shows a flattened organizational structure. Many
managers have difficulty letting go of control, and even very flattened types of structure
organizations often retain many characteristics of a bureaucracy.
DECISION MAKING WITHIN THE ORGANIZATIONAL HIERARCHY
The decision-making hierarchy, or pyramid, is often referred to as a scalar chain. By
reviewing the organization chart in Figure 12.1, it is possible to determine where decisions
are made within the organizational hierarchy. Although every manager has some decision-
making authority, its type and level are determined by the manager’s position on the chart.
Product Manager
President
Functional Manager
Manager
of Nursing
Pediatrics
Vice President
Finance
Vice President
Nursing
Services
Vice President
Human
Resources
Manager
of Nursing
Women’s
Services
Manager
of Nursing
Oncology
Services
Vice President
Pediatric
Services
Vice President
Maternal and
Women’s
Services
Vice President
Oncology
Services
FIGURE 12.2 • Matrix organizational structure. Copyright ® 2006 Lippincott
Williams & Wilkins. instructor’s Resource Cd-ROM to accompany Leadership
Roles and Management Functions in Nursing, by Bessie L. Marquis and Carol
J. Huston.

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Chapter 12 Organizational Structure 273
In organizations with centralized decision making, a few managers at the top of the
hierarchy make the decisions and the emphasis is on top-down control. In other words, the
vision or thinking of one or a few individuals in the organization guides the organization’s
goals and how those goals are accomplished. Execution of decision making in centralized
organizations is fairly rapid.
Decentralized decision making diffuses decision making throughout the organization and
allows problems to be solved by the lowest practical managerial level. Often, this means that
problems can be solved at the level at which they occur, although some delays may occur
in decision making if the problem must be transmitted through several levels to reach the
appropriate individual to solve the problem. As a rule, however, larger organizations benefit
from decentralized decision making.
This occurs because the complex questions that must be answered can best be addressed
by a variety of people with distinct areas of expertise. Leaving such decisions in a large
organization to a few managers burdens those managers tremendously and could result in
devastating delays in decision making.
In general, the larger the organization, the greater the need to decentralize decision making.
Rai (2013) suggests, however, that centralized decision making can and does work well
in organizations where staff want more direction, guidance, and coordination of activities
from upper management. Rai notes that the use of bureaucratic rules and procedures can
actually be healthy for an organization since it minimizes role conflict and clarified role
expectations.
STAKEHOLDERS
Stakeholders are those entities in an organization’s environment that play a role in the
organization’s health and performance or that are affected by the organization. Stakeholders
may be both internal and external, they may include individuals and large groups, and they
may have shared goals or diverse goals. Internal stakeholders, for example, may include the
nurse in a hospital or the dietitian in a nursing home. Examples of external stakeholders for an
acute care hospital might be the local school of nursing, home health agencies, and managed
care providers who contract with consumers in the area. Even the Chamber of Commerce in
a city could be considered a stakeholder for a health-care organization.
Every organization should be viewed as being part of a greater community of stakeholders.
Chief Nursing Officer
Staff Staff StaffStaff Staff
Nurse-Manager Nurse-Manager Nurse-Manager Nurse-Manager Nurse-Manager
FIGURE 12.3 • Flattened organizational structure. Copyright ® 2006 Lippincott Williams &
Wilkins. instructor’s Resource Cd-ROM to accompany Leadership Roles and Management
Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.
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274 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
Stakeholders have interests in what the organization does but may or may not have the power
to influence the organization to protect their interests. Stakeholders’ interests are varied,
however, and their interests may coincide on some issues and not others. Organizations do
not generally choose their own stakeholders; rather, the stakeholders choose to have a stake
in the organizations’ decisions. Stakeholders may have a supportive or threatening influence
on organizational decision making. For many decisions an organization makes, it may face a
diverse set of stakeholders with varied and conflicting interest and goals.
As a part of planned change, discussed in Chapter 8, and decision making, discussed in
Chapter 1, a stakeholder analysis is an important aspect of the management process. Such an
analysis should be performed when there is a need to clarify the consequences of decisions
and changes. In addition to identifying stakeholders who will be impacted by a change, it is
necessary to prioritize them and determine their influence. Astute leaders must always be
cognizant of who their stakeholders are and the impact they may have on an organization.
A depiction of some possible stakeholders for a local community hospital appears in
Display 12.3.
ORGANIZATIONAL CULTURE
Organizational culture is the total of an organization’s values, language, traditions, customs,
and sacred cows—those few things present in an institution that are not open to discussion
or change. For example, the hospital logo that had been designed by the original board of
trustees is an item that may not be considered for updating or change.
Similarly, BusinessDictionary.com (2013) defines organizational culture as “the values
and behaviors that contribute to the unique social and psychological environment of an
organization. The organizational culture includes an organization’s expectations, experiences,
philosophy, and values that hold it together, and is expressed in its self-image, inner workings,
interactions with the outside world, and future expectations. It is based on shared attitudes,
beliefs, customs, and written and unwritten rules that have been developed over time and are
considered valid” (para 1). Both of these definitions impart a sense of the complexity and
importance of organizational culture.
Organizational culture is a system of symbols and interactions unique to each organization. It is
the ways of thinking, behaving, and believing that members of a unit have in common.
Organizational culture should not, however, be confused with organizational climate—
how employees perceive an organization. For example, an employee might perceive an
organization as fair, friendly, and informal or as formal and very structured. The perception
may be accurate or inaccurate, and people in the same organization may have different
perceptions about the same organization. Therefore, since the organizational climate is
the view of the organization by individuals, the organization’s climate and its culture may
differ.
External Stakeholders Internal Stakeholders
Local businesses Hospital employees
area colleges and universities physicians
insurance companies and HMOs patients
Community leaders patients’ families
Unions Union shop stewards
professional organizations Board of directors
DISPLAY 12.3 Examples of Stakeholders in a Community Hospital

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Chapter 12 Organizational Structure 275
Although assessing unit culture is a management function, building a constructive culture,
particularly if a negative culture is in place, requires the interpersonal and communication
skills of a leader. The leader must take an active role in creating the kind of organizational
culture that will ensure success. The more entrenched the culture and pattern of actions, the
more challenging the change process is for the leader. Given such entrenchment of culture,
success in building a new culture may require new leadership and/or assistance by the use of
outside analysis.
For example, many health-care organizations continue to report challenges in establishing
a culture where evidence-based practice (EBP) is the norm. Often this is because senior
management or organization leaders have not taken an active role in emphasizing the
importance of this culture change or have not provided adequate resources (fiscal or human)
to support the culture change. Examining the Evidence 12.1 details a case study where the
leadership skills of vision, change agent, and team building were critical requisites to a
successful organizational culture effort to incorporate EBP into the existing culture.
Source: Plath, D. (2013). Organizational processes supporting evidence-based practice. administration in social
Work, 37(2), 171–188.
this research examined organizational processes that supported and facilitated an EBP approach
in a large, nongovernmental Australian human service organization. A case study methodology
was employed, incorporating multiple sources of data to inform understanding of the organizatio-
nal context and processes. Based on their understanding of what had and could be done within
the organization, participants discussed strategies for engaging staff across the organization in
EBP implementation. While there were differing views on the degree to which these strategies
were already evident in the organization, participants spoke about the need for an organizational
culture where staff understand, appreciate, and feel a part of EBP implementation. Strong
leadership, targeted management, and marketing of EBP were identified as strategies to achieve
such a culture.
Fundamentally, these strategies aim to better engage frontline staff with the EBP process,
promoting a culture within the organization where research evidence is valued and used to inform
practice. these strategies rely on strong leadership that entails communicating a vision for EBP
through a range of forums throughout the organization. this vision for EBP is aligned with both
effective client outcomes and practitioner satisfaction grounded in a solid evidence base. Such
statements of organizational vision need to be backed up with the allocation of resources to
support dissemination of research evidence and the production of practice frameworks and tools
for frontline staff. the researcher concluded that considerable responsibility for EBP imple-
mentation lies with senior management in human service organizations, where leadership and
resource commitment are required in culture change.
Examining the Evidence 12.1
Organizations, if large enough, also have many different and competing value systems
that create subcultures. These subcultures shape perceptions, attitudes, and beliefs and
influence how their members approach and execute their particular roles and responsibilities.
A critical challenge then for the nurse-leader is to recognize these subcultures and to do
whatever is necessary to create shared norms and priorities. Managers must be able to assess
their unit’s culture and choose management strategies that encourage a shared culture. Such
transformation requires both management assessment and leadership direction.
In addition, much of an organization’s culture is not available to staff in a retrievable
source and must be related by others. For example, feelings about collective bargaining,
nursing education levels, nursing autonomy, and nurse–physician relationships differ from
one organization to another. These beliefs and values, however, are rarely written down
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276 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
or appear in a philosophy. Therefore, in addition to creating a constructive culture, a
major leadership role is to assist subordinates in understanding the organization’s culture.
Display 12.4 identifies questions that leaders and followers should ask when assessing
organizational culture.
WHAT IS THE ORgANIZATION’S PHYSICAL ENVIRONMENT?
1. is the environment attractive?
2. does it appear that there is adequate maintenance?
3. are nursing stations crowded or noisy?
4. is there an appropriate-sized lobby? are there quiet areas?
5. is there sufficient seating for families in the dining room?
6. are there enough conference rooms? a library? a chapel or place of worship?
WHAT IS THE ORgANIZATION’S SOCIAL ENVIRONMENT?
1. are many friendships maintained beyond the workplace?
2. is there an annual picnic or holiday party that is well attended by the employees?
3. do employees seem to generally like each other?
4. do all shifts and all departments get along fairly well?
5. are certain departments disliked or resented?
6. are employees on a first-name basis with coworkers, doctors, charge nurses, and supervisors?
7. How do employees treat patients and visitors?
HOW SUPPORTIVE IS THE ORgANIZATION?
1. is educational reimbursement available?
2. are good, low-cost meals available to employees?
3. are there adequate employee lounges?
4. are funds available to send employees to workshops?
5. are employees recognized for extra effort?
6. does the organization help pay for the holiday party or other social functions?
WHAT IS THE ORgANIZATIONAL POWER STRUCTURE?
1. Who holds the most power in the organization?
2. Which departments are viewed as powerful? Which are viewed as powerless?
3. Who gets free meals? Who gets special parking places?
4. Who carries beepers? Who wears laboratory coats? Who has overhead pages?
5. Who has the biggest office?
6. Who is never called by his or her first name?
HOW SAFE IS THE ORgANIZATION?
1. is there a well-lighted parking place for employees arriving or departing when it is dark?
2. is there an active and involved safety committee?
3. are security guards needed?
WHAT IS THE COMMUNICATION ENVIRONMENT?
1. is upward communication usually written or verbal?
2. is there much informal communication?
3. is there an active grapevine? is it reliable?
4. Where is important information exchanged—in the parking lot? the doctors’ surgical dressing
room? the nurses’ station? the coffee shop? during surgery or during the delivery room?
WHAT ARE THE ORgANIZATIONAL TABOOS? WHO ARE THE HEROES?
1. are there special rules and policies that can never be broken?
2. are certain subjects or ideas forbidden?
3. are there relationships that cannot be threatened?
DISPLAY 12.4 Assessing the Organizational Culture

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Chapter 12 Organizational Structure 277
SHARED GOVERNANCE: ORGANIZATIONAL DESIGN FOR THE 21ST CENTURY?
Shared governance, one of the most innovative and empowering organization structures, was
developed in the mid-1980s as an alternative to the traditional bureaucratic organizational
structure. A flat type of organizational structure is often used to describe shared governance
but differs somewhat, as shown in Figure 12.4. In shared governance, the organization’s
governance is shared among board members, nurses, physicians, and management. Thus,
decision making and communication channels are altered. Group structures, in the form of
joint practice committees, are developed to assume the power and accountability for decision
making, and professional communication takes on an egalitarian structure.
In health-care organizations, shared governance empowers decision makers, and this
empowerment is directed at increasing nurses’ authority and control over nursing practice.
Shared governance thus gives nurses more control over their nursing practice by being an
accountability-based governance system for professional workers. This staff empowerment
is fundamental to shared governance, as is collaborative decision making (Bennett, Ockerby,
Begbie, Chalmers & O’Connell, 2012).
The stated aim of shared governance is the empowerment of employees within the decision-
making system.
Although participatory management lays the foundation for shared governance, they are not
the same. Participatory management implies that others are allowed to participate in decision
making over which someone has control. Thus, the act of “allowing” participation identifies
the real and final authority for the participant.
There is no single model of shared governance, although all models emphasize
the empowerment of staff nurses. Generally, issues related to nursing practice are the
responsibility of nurses, not managers, and nursing councils are used to organize governance.
C
o
m
m
itt
e
e
s
CHIEF NURSE ADMINISTRATOR
secivreS evitartsinimdAecitcarP gnisruN lacinilC
Information
Systems
Personnel
Services
Budget and
Supplies
Clerical
Services
Ancillary
Nursing Staff
Director of
Nonclinical
Services
Nurse
Educator
Quality
Control
Nurse
Infection
Control
Nurse
Associate
Nursing
Administrator
Primary Nurse
Case Managers
Registered Nurse
Organization
Clinical Nursing
Division
Coordinators
Professional Performance
(standards, peer review)
Quality Assurance
Infection Control
Patient Care
(policies, procedures)
Knowledge and Staff Development
(continuing education/research)
Nursing Opportunities
(retention, recruitment)
Nonclinical
(support staff, budget,
equipment specifications)
FIGURE 12.4 • shared governance model. Copyright ® 2006 Lippincott Williams
& Wilkins. instructor’s Resource Cd-ROM to accompany Leadership Roles and
Management Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.
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278 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
These nursing councils, elected at the organization and unit levels, use a congressional format
organized like a representative form of government, with a president and cabinet.
Typical governance councils include a nursing practice council, a research council, and
professional development and/or education council, a nursing performance improvement or
quality council, and a leadership council. Sometimes, organizations will have a retention
council as well. The councils participate in decision making and coordination of the
department of nursing and provide input through the shared governance process in all other
areas where nursing care is delivered.
The number of health-care organizations using shared governance models is continuing
to increase. However, a major impediment to the implementation of shared governance
has been the reluctance of managers to change their roles. The nurse-manager’s role becomes
one of consulting, teaching, collaborating, and creating an environment with the structures
and resources needed for the practice of nursing and shared decision making between
nurses and the organization. This new role is foreign to many managers and difficult to accept.
In addition, consensus decision making takes more time than autocratic decision making, and
not all nurses want to share decisions and accountability. Although many positive outcomes
have been attributed to implementation of shared governance, the expense of introducing
and maintaining this model also must be considered because it calls for a conscientious
commitment both on the part of the workers and the organization.
Shared governance requires a substantial and long-term commitment on the part of the workers
and the organization.
MAGNET DESIGNATION AND PATHWAY TO EXCELLENCE
During the early 1980s, the American Academy of Nursing (AAN) began conducting
research to identify the characteristics of hospitals that were able to successfully recruit and
retain nurses. What they found were high-performing hospitals with well-qualified nurse
executives in a decentralized environment, with organizational structures that emphasized
open, participatory management.
A desire to formally recognize these high-performing hospitals was accomplished when
the American Nurses Association (ANA) established the American Nurses Credentialing
Center (ANCC) in 1990. Later the same year, the ANA Board of Directors approved the
establishment of the Magnet Hospital Recognition Program for Excellence in Nursing
Services. The term magnet was used to denote organizations that were able to attract and
retain professional nurses. “Magnet status is not a prize or an award. Rather, it is a credential
of organizational recognition of nursing excellence” (ANCC, 2013b, para 2). Being a
magnet institution requires a culture shift since the entire organization must demonstrate a
commitment to excellence (Budin, 2012).
Earning a magnet designation is not easy. Currently, only about 6.9% of all registered
hospitals in the United States have achieved ANCC Magnet Recognition® status (ANCC,
2013b). To achieve designation as an organization, the organization must create and promote
a comprehensive professional practice culture. Then, it must apply to ANCC, submit
comprehensive documentation that demonstrates its compliance with standards in the ANA
Scope and Standards for Nurse Administrators, and undergo a multiday onsite evaluation
to verify the information in the documentation submitted and to assess the presence of the
14 “forces of magnetism” (Display 12.5) within the organization (Pinkerton, 2008). Magnet
status is awarded for a 4-year period, after which the organization must reapply.
Currently, magnet recognition is awarded to both individual organizations (not just
hospitals) and systems (Pinkerton, 2008). To achieve designation as a system, the system must

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Chapter 12 Organizational Structure 279
not only retain the 14 forces of magnetism required for individual organizations, they must
also demonstrate empirical modeling of five key components: transformational leadership;
structural empowerment; exemplary professional practice; new knowledge innovation and
improvements; and empirical quality results (Pinkerton). In addition, all parts of the system
are judged as one when seeking system designation, so if one entity within the system fails,
the entire system application will be denied (Pinkerton).
A driving force to achieve magnet status is the clear link between this designation and
improved outcomes. US News & World Report utilizes Magnet designation as a primary
competence indicator in its assessment of almost 5,000 hospitals to rank and report the best
medical centers in 16 specialties. Twelve of the 17 medical centers on the exclusive US News
Best Hospitals in America Honor Roll, and all 12 of the US News Best Children’s Hospital
Honor Roll, were ANCC Magnet-recognized organizations (ANCC, 2013a).
In addition, ANCC established the Pathway to Excellence program in 2003, based on
findings from the Texas Nurse-Friendly™ Program for Small/Rural Hospitals. The Pathway
to Excellence designation recognizes health-care organizations and long-term care institutions
for positive practice environments where nurses excel (ANCC, 2013c). To earn the Pathway
to Excellence designation, organizations must undergo a thorough review process that meet
12 practice standards essential to an ideal nursing practice environment. “Applicants conduct
a review process to fully document the integration of those standards in the organization’s
practices, policies and culture. Pathway designation can only be achieved if an organization’s
nurses validate the data and other evidence submitted, via an independent, confidential
survey. This critical element exemplifies the theme of empowering and giving nurses a voice”
(ANCC, 2013c, para 2).
LEARNING EXERCISE 12.4
Why Work for Them?
a list of current magnet-recognized organizations and their contact information can be found at
the aNCC web site: http://www.nursecredentialing.org/Magnet/FindaMagnetFacility
Assignment: select one of the current organizations and prepare a one-page written report
about how that particular organization demonstrates the excellence exemplified by magnet
status. speak to at least five of the “forces of magnetism.” Would you want to work for this
particular organization?
1. Quality of nursing leadership
2. Organizational structure
3. Management style
4. personnel policies and programs
5. professional models of care
6. Quality of care
7. Quality improvement
8. Consultation and resources
9. autonomy
10. Community and the hospital
11. Nurses as teachers
12. image of nursing
13. interdisciplinary relationships
14. professional development
DISPLAY 12.5 The 14 Forces of Magnetism for Magnet Hospital Status
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280 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
COMMITTEE STRUCTURE IN AN ORGANIZATION
Managers are also responsible for designing and implementing appropriate committee
structures. Poorly structured committees can be nonproductive for the organization and
frustrating for committee members. However, there are many benefits to and justifications
for well-structured committees. To compensate for some of the difficulty in organizational
communication created by line and line-and-staff structures, committees are used widely
to facilitate upward communication. The nature of formal organizations dictates a need for
committees in assisting with management functions. In addition, as organizations seek new
ways to revamp old bureaucratic structures, committees may pave the road to increased
staff participation in organization governance. Committees may be advisory or may have
a coordinating or informal function. They generate ideas and creative thinking to solve
operational problems or improve services and often improve the quality and quantity of
work accomplished. Committees also can pool specific skills and expertise and help reduce
resistance to change.
Because committees communicate upward and downward and encourage the participation of
interested or affected employees, they assist the organization in receiving valuable feedback
and important information.
However, all of these positive benefits can be achieved only if committees are appropriately
organized and led. If not properly used, the committee becomes a liability to the organizing
process because it wastes energy, time, and money and can defer decisions and action. One
of the leadership roles inherent in organizing work is to ensure that committees are not used
to avoid or delay decisions but to facilitate organizational goals. Display 12.6 lists factors to
consider when organizing committees.
RESPONSIBILITIES AND OPPORTUNITIES OF COMMITTEE WORK
Committees present the leader-manager with many opportunities and responsibilities.
Managers need to be well grounded in group dynamics because meetings represent a
major time commitment. Managers serve as members of committees and as leaders or
chairpersons of committees. Because committees make major decisions, managers should
use the opportunities available at meetings to become more visible in the larger organization.
The manager has a responsibility to select appropriate power strategies, such as coming to
meetings well prepared, and to use skill in the group process to generate influence and gain
power at meetings.
l the committee should be composed of people who want to contribute in terms of commitment,
energy, and time.
l the members should have a variety of work experience and educational backgrounds. Composi-
tion should, however, ensure expertise sufficient to complete the task.
l Committees should have enough members to accomplish assigned tasks but not so many that
discussion cannot occur. six to eight members in a committee are usually ideal.
l the tasks and responsibilities, including reporting mechanisms, should be clearly outlined.
l assignments should be given ahead of time, with clear expectations that assigned work will be
discussed at the next meeting.
l all committees should have written agendas and effective committee chairpersons.
DISPLAY 12.6 Factors to Consider When Organizing Committees and Making
Appointments

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Chapter 12 Organizational Structure 281
Another responsibility is to create an environment at unit committee meetings that leads
to shared decision making. Encouraging an interaction free of status and power is important.
Likewise, an appropriate seating arrangement, such as a circle, will increase motivation
for committee members to speak up. The responsible manager is also aware that staff from
different cultures may have different needs in groups, which is why multicultural committees
should be the norm. In addition, because gender differences are increasingly being recognized
as playing a role in problem solving, communication, and power, efforts should be made to
include both men and women on committees.
When assigning members to committees, cultural and gender diversity should always be a goal.
The manager must not rely too heavily on committees or use them as a method to delay
decision making. Numerous committee assignments exhaust staff, and committees then
become poor tools for accomplishing work. An alternative that will decrease the time
commitment for committee work is to make individual assignments and gather the entire
committee only to report progress.
In the leadership role, an opportunity exists for important influence on committee and
group effectiveness. A dynamic leader inspires people to put spirit into working for a shared
goal. Leaders demonstrate their commitment to participatory management by how they work
with committees. Leaders keep the committee on course. Committees may be chaired by an
elected member of the group, appointed by the manager, or led by the department or unit
manager. Informal leaders may also emerge from the group process.
It is important for the manager to be aware of the possibility for groupthink to occur
in any group or committee structure. Groupthink occurs when group members fail to take
adequate risks by disagreeing, being challenged, or assessing discussion carefully. If the
manager is actively involved in the work group or on the committee, groupthink is less
likely to occur. The leadership role includes teaching members to avoid groupthink by
demonstrating critical thinking and being a role model who allows his or her own ideas to
be challenged.
ORGANIZATIONAL EFFECTIVENESS
There is no one “best” way to structure an organization. Variables such as the size of the
organization, the capability of its human resources, and the commitment level of its workers
should always be considered. Regardless of what type of organizational structure is used,
certain minimal requirements can be identified:
• The structure should be clearly defined so that employees know where they belong and
where to go for assistance.
• The goal should be to build the fewest possible management levels and have the shortest
possible chain of command. This eliminates friction, stress, and inertia.
• The unit staff need to be able to see where their tasks fit into common tasks of the
organization.
• The organizational structure should enhance, not impede communication.
• The organizational structure should facilitate decision making that results in the greatest
work performance.
• Staff should be organized in a manner that encourages informal groups to develop a
sense of community and belonging.
• Nursing services should be organized to facilitate the development of future leaders.
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282 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
Despite the known difficulties of bureaucracies, it has been difficult for some organizations
to move away from the bureaucratic model. However, perhaps as a result of magnet hospital
research demonstrating both improved patient outcomes and improved recruitment and
retention of staff, there has been an increasing effort to redesign and restructure organizations
to make them more flexible and decentralized. Still, progress toward these goals continues
to be slow.
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
ASSOCIATED WITH ORGANIZATIONAL STRUCTURE
Integrated leader-managers need to look at organizational structure as the road map that
tells them how organizations operate. Without organizational structure, people would work
in a chaotic environment. Structure becomes an important tool, then, to facilitate order and
enhance productivity.
Astute leader-managers understand both the structure of the organization in which they
work and external stakeholders. The integrated leader-manager, however, goes beyond
personal understanding of the larger organizational design. The leader-manager takes
responsibility for ensuring that subordinates also understand the overall organizational
structure and the structure at the unit level. This can be done by being a resource and a role
model to subordinates. The role modeling includes demonstrating accountability and the
appropriate use of authority.
The effective manager recognizes the difficulties inherent in advisory positions and
uses leadership skills to support staff in these positions. This is accomplished by granting
sufficient authority to enable advisory staff to carry out the functions of their role.
Leadership requires that problems are pursued through appropriate channels, that upward
communication is encouraged, and that unit structure is periodically evaluated to determine
if it can be redesigned to enable increased lower level decision making. The integrated
leader-manager also facilitates constructive informal group structure. It is important for the
manager to be knowledgeable about the organization’s culture and subcultures. It is just as
important for the leader to promote the development of a shared constructive culture with
subordinates.
It is a management role to evaluate the types of organizational structure and governance
and to implement those that will have the most positive impact in the department. It is
a leadership skill to role model the shared authority necessary to make newer models of
organizational structure and governance possible.
When serving on committees, the opportunity should be used to gain influence to
present the needs of patients and staff appropriately. The integrated leader-manager comes
to meetings well prepared and contributes thoughtful comments and ideas. The leader’s
critical thinking and role-modeling behavior discourages groupthink among work groups or
in committees.
Integrated leader-managers also refrain from judging and encourage all members of a
committee to participate and contribute. An important management function is to see that
appropriate work is accomplished in committees, that they remain productive, and that
they are not used to delay decision making. A leadership role is the involvement of staff
in organizational decision making, either informally or through more formal models of
organizational design, such as shared governance. The integrated leader-manager understands
the organization and recognizes what can be molded or shaped and what is constant. Thus,
the interaction between the manager and the organization is dynamic.

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Chapter 12 Organizational Structure 283
KEY CONCEPTS
● Many modern health-care organizations continue to be organized around a line or line-and-staff design
and have many attributes of a bureaucracy; however, there is a movement toward less bureaucratic
designs, such as ad hoc, matrix, and care-centered systems.
● a bureaucracy, as proposed by Max Weber, is characterized by a clear chain of command, rules and
regulations, specialization of work, division of labor, and impersonality of relationships.
● an organization chart depicts formal relationships, channels of communication, and authority through
line-and-staff positions, scalar chains, and span of control.
● Unity of command means that each person should have only one boss so that there is less confusion
and greater productivity.
● Centrality refers to the degree of communication of a particular management position.
● in centralized decision making, decisions are made by a few managers at the top of the hierarchy. in
decentralized decision making, decision making is diffused throughout the organization, and problems
are solved at the lowest practical managerial level.
● Organizational structure affects how people perceive their roles and the status given to them by other
people in the organization.
● Organizational structure is effective when the design is clearly communicated, there are as few
managers as possible to accomplish goals, communication is facilitated, decisions are made at the
lowest possible level, informal groups are encouraged, and future leaders are developed.
● the entities in an organization’s environment that play a role in the organization’s health and
performance, or which are affected by the organization, are called stakeholders.
● authority, responsibility, and accountability differ in terms of official sanctions, self-directedness, and
moral integration.
● Organizational culture is the total of an organization’s beliefs, history, taboos, formal and informal
relationships, and communication patterns.
● subunits of large organizations also have a culture. these subcultures may support or be in conflict with
other cultures in the organization.
● informal groups are present in every organization. they are often powerful, although they have no formal
authority. informal groups determine norms and assist members in the socialization process.
● shared governance refers to an organizational design that empowers staff nurses by making them an
integral part of patient care decision making and providing accountability and responsibility in nursing
practice.
● Magnet designation is conferred by the aNCC to health-care organizations exemplifying well-qualified
nurse executives in a decentralized environment, with organizational structures that emphasize open,
participatory management. Magnet-designated organizations demonstrate improved patient outcomes
and higher staff nurse satisfaction than organizations that do not have magnet status.
● the pathway to excellence designation, also conferred by the aNCC, recognizes health-care
organizations with foundational quality initiatives in creating a positive work environment, as defined by
nurses and supported by research.
● too many committees in an organization is a sign of a poorly designed organizational structure.
● Committees should have an appropriate number of members, prepared agendas, clearly outlined tasks,
and effective leadership if they are to be productive.
● Groupthink occurs when there is too much conformity to group norms.
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284 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
LEARNING EXERCISE 12.5
Restructuring—In Depth
You are the supervisor at a home health agency. there are 22 RNs in your span of control. in
a meeting today, John dao, the CNO, tells you that your span of control needs adjustment to
be effective. therefore, the CNO has decided to flatten the organization and decentralize the
department. to accomplish this, he plans to designate three of your staff as shift coordinators.
these shift coordinators will “schedule patient visits for all the staff on their shift and be accountable
for the staff that they supervise.” the CNO believes that this restructuring will give you more time
for implementing a continuous quality improvement program and promoting staff development.
although you are glad to have the opportunity to begin these new projects, you are somewhat
unclear about the role expectations of the new shift coordinators and how this will change your job
description. in fact, you worry that this is just a precursor to the elimination of your position. Will
these shift coordinators report to you? if so, will you have direct line authority or staff authority? Who
should be responsible for evaluating the performance of the staff nurses now? Who will handle
employee disciplinary problems? How involved should the shift coordinators be in strategic planning
or determining next year’s budget? What types of management training will be needed by the shift
coordinators to prepare for their new role? are you the most appropriate person to train them?
Assignment: there is great potential for conflict here. in small groups, make a list of 10
questions (not including the ones listed in the learning exercise) that you would want to ask the
CNO at your next meeting to clarify role expectations. discuss tools and skills that you have
learned in the preceding units that could make this role change less traumatic for all involved.
LEARNING EXERCISE 12.6
Problem Solving: Working Toward Shared governance
You are the supervisor of a surgical services department in a nonunion hospital. the staff on
your unit have become increasingly frustrated with hospital policies regarding staffing ratios,
on-call pay, and verbal medical orders but feel that they have limited opportunities for providing
feedback to change the current system. You would like to explore the possibility of moving
toward a shared governance model of decision making to resolve this issue and others like it
but are not quite sure where to start.
Assignment: assume that you are the supervisor in this case. answer the following questions.
1. Who do i need to involve in this discussion and at what point?
2. How might i determine if the overarching organizational structure supports shared
governance? How would i determine if external stakeholders would be impacted?
How would i determine if organizational culture and subculture would support a shared
governance model?
3. What types of nursing councils might be created to provide a framework for operation?
4. Who would be the members on these nursing councils?
5. What support mechanisms would need to be in place to ensure success of this project?
6. What would be my role as a supervisor in identifying and resolving employee concerns in a
shared governance model?

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Chapter 12 Organizational Structure 285
LEARNING EXERCISE 12.7
Finding Direction
You are a new graduate working in the 3 to 11 pm shift in a large, metropolitan hospital on the
pediatrics unit. You feel frustrated because you had many preceptors while you were being
oriented, and each told you slightly different variations of the unit routine. in addition, the regular
charge nurse has just been promoted and moved to another unit, and the charge nurse position
on your unit is being filled by two part-time nurses.
You feel inadequately prepared for the job and do not know where to turn or to whom you
should direct your questions. assuming that your organization chart resembles the one in
Figure 12.1, outline a plan of action that would be appropriate to take. share your plan with a
larger group.
LEARNING EXERCISE 12.8
Thinking About Committee Work
as a writing exercise, choose one of the following to examine in depth:
1. What has contributed to the productivity of the committees on which you have served?
2. Have you ever served on a committee that made recommendations on which higher
authority never acted? What was the effect on the group?
LEARNING EXERCISE 12.9
Participation and Productivity
You are a 3 to 11 pm charge nurse on a surgical unit. You have been selected to chair the unit’s
safety committee. each month, you have a short committee meeting with the other committee
members. Your committee’s main responsibility is to report upward any safety issues that have
been identified. Lately, you have found an increase in needle-stick incidents, and the committee
has been addressing this problem.
the committee is made up of two nursing assistants, one unit clerk, two staff RNs, and two
licensed professional nurses/licensed vocational nurses. all shifts and staff cultures are
represented. Lately, you have found that the meetings are not going well because one member
of the group, Mary, has begun to monopolize the meeting time. she is especially outspoken
about the danger of HiV and seems more interested in pointing blame regarding the needle
sticks than in finding a solution to the problem.
You have privately spoken to Mary about her frequent disruption of the committee business;
although she apologized, the behavior has continued. You feel that some members of the
committee are becoming bored and restless, and you believe that the committee is making
little progress.
Assignment: Using your knowledge of committee structure and effectiveness, outline steps
that you would take to facilitate more group participation and make the committee more
productive. Be specific and explain exactly what you would do at the next meeting to prevent
Mary from taking over the meeting.
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286 UNIT IV ROLES AnD FUnCtiOnS in ORGAniZinG
REFERENCES
LEARNING EXERCISE 12.10
Finding an Organizational Culture That Fits
Joanie smith is a 32-year-old single mother of two who will graduate in 3 months from a
local associate degree nursing program. Joanie has accrued some debts in completing her
nursing education. she has been offered two jobs upon graduation: one is at (Community
Center Hospital) a local medium-sized hospital and one is in a larger city some distance away
(Metropolitan City Hospital). Both job offers are in the obstetrical unit, which is Joanie’s desired
place of work as some day she hopes to return to school to become a nurse midwife.
Research on the two hospitals shows that both are accredited and have good medical staffs
and Joanie has received positive feedback on both from people whose judgment she trusts.
Assignment: pretend you are this nurse. Knowing what little you also know about Joanie and
the hospitals, what additional type of information should you gather to be able to decide which
of these organizations is a better fit? What particular assessment of organizational culture can
you do that would help you make a better decision?
American Nurses Credentialing Center. (2013a). ANCC
Magnet recognition program overview. Retrieved
May 29, 2013, from http://www.nursecredentialing
.org/Magnet/ProgramOverview.aspx
American Nurses Credentialing Center. (2013b). Growth of
the program. Retrieved May 28, 2013, from http://
www.nursecredentialing.org/MagnetGrowth.aspx
American Nurses Credentialing Center. (2013c). Pathway
program overview. Retrieved May 29, 2013,
from http://www.nursecredentialing.org/Pathway/
AboutPathway
Bennett, P. N., Ockerby, C., Begbie, J., Chalmers, C.,
G., & O’Connell, B. (2012). Professional nursing
governance in a large Australian health service.
Contemporary Nurse: A Journal for the Australian
Nursing Profession, 43(1), 99–106.
Budin, W. C. (2012). A commitment to excellence. Journal
of Perinatal Education, 21(1), 3–5.
BusinessDictionary.com (2013). Organizational culture.
Definition. Retrieved May 29, 2013, from
http://www.businessdictionary.com/definition/
organizational-culture.html
Education Portal (2003–2013). Characteristics of informal
organizations: The grapevine & informal groups.
Retrieved May 30, 2013, from http://education-portal
.com/academy/lesson/characteristics-of-informal
-organizations-the-grapevine-informal-groups.html
Fayol, H. (1949). General and industrial management
(C. Storrs, Trans.). London: Isaac Pittman and Sons.
Grover, S. (1999–2013). What are limitations to
using an organizational chart? eHow
money. Retrieved May 30, 2013, from http://www.
ehow.com/info_8484657_limitations-using
-organizaional-chart.html
Juneja, H. (2013). Span of control in an organization.
Selfgrowth.com. Retrieved May 30, 2013, from
http://www.selfgrowth.com/articles/Span_of
_Control_in_an_Organization.html
Pinkerton, S. (2008, September–October). The MAGNET
view: Pursuing ANCC magnet recognition as a
system or individual organization… American
Nurses Credentialing Center. Nursing Economics,
26 (5), 323–324.
Plath, D. (2013). Organizational processes supporting
evidence-based practice. Administration in Social
Work, 37(2), 171–188.
Rai, G. S. (2013). Job satisfaction among long-term care
staff: Bureaucracy iIsn’t always bad. Administration
in Social Work, 37(1), 90–99.
Schatz, T. (2013). Basic types of organizational structure:
Formal & informal. Chron. Retrieved May 30,
2013, from http://smallbusiness.chron.com/
basic-types-organizational-structure-formal
-informal-982.html

http://www.nursecredentialing.org/Magnet/ProgramOverview.aspx

http://www.nursecredentialing.org/MagnetGrowth.aspx

http://www.nursecredentialing.org/Pathway/AboutPathway

http://www.businessdictionary.com/definition/organizational-culture.html

http://education-portal.com/academy/lesson/characteristics-of-informal-organizations-the-grapevine-informal-groups.html

http://www.ehow.com/info_8484657_limitations-using-organizaional-chart.html

http://www.selfgrowth.com/articles/Span_of_Control_in_an_Organization.html

http://smallbusiness.chron.com/basic-types-organizational-structure-formal-informal-982.html

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287
13
Organizational, Political, and Personal Power
… nearly all men can stand adversity, but if you want to test a man’s character, give him power.
—Abraham Lincoln
… “Being powerful is like being a lady. If you have to tell people you are, you aren’t.”
—M. Thatcher
CROSSWALK This chApTer Addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential V: health-care policy, finance, and regulatory environments
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential VI: health policy and advocacy
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: Teamwork and collaboration
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency II: A knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: professionalism
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l assess how power dynamics in the family unit as a child, may affect an adult’s perception of
power, as well as the ability to use it appropriately
l explore the influence of gender in how an individual may view power and politics
l differentiate among legitimate, reward, coercive, expert, referent, charismatic, self, and
information power
l recognize the need to create and maintain a small authority–power gap
l identify and use appropriate strategies to increase his or her personal power base
l use power on behalf of other people rather than over them
l empower subordinates and followers by providing them with opportunities for success
l describe how to access and build political alliances and coalitions through networking
l use appropriate political strategies in resolving unit problems
l use cooperation rather than competition and avoid overt displays of power and authority
whenever possible
l explore factors that historically led to nursing’s limited power as a profession
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288 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
l identify driving forces in place as well as specific strategies to increase the nursing
profession’s power base
l identify political strategies the novice manager could use to negate the negative effects of
organizational politics
l serve as a role model of an empowered nurse
Chapter 12 reviewed organizational structure and introduced status, authority, and
responsibility at different levels of the organizational hierarchy. In this chapter, the organization
is examined further, with emphasis on the management functions and leadership roles
inherent in effective use of authority, establishment of a personal power base, empowerment
of staff, and the impact of organizational politics on power. In addition, factors that have
historically contributed to nursing’s limited power as a profession are presented as well as the
driving forces in place to change this phenomenon. Finally, this chapter introduces strategies
both the individual and the nursing profession could use to increase their power base.
The word power is derived from the Latin verb potere (to be able); thus, power may be
appropriately defined as that which enables one to accomplish goals. Power can also be
defined as the capacity to act or the strength and potency to accomplish something. Huston
(2008, p. 58) suggests that “it is almost impossible to achieve organizational or personal goals
without an adequate power base. It is even more difficult to help subordinates, patients, or
clients achieve their goals when powerless, since having access to and control over resources
is often related to the degree of power one holds.”
Having power gives one the potential to change the attitudes and behaviors of individual people
and groups.
Authority, or the right to command, accompanies any management position and is a source
of legitimate power, although components of management, authority, and power are also
necessary, to a degree, for successful leadership. The manager who is knowledgeable about
the wise use of authority, power, and political strategy is more effective at meeting personal,
unit, and organizational goals. Likewise, powerful leaders are able to raise morale because they
delegate more and build with a team effort. Thus, their followers become part of the growth
and excitement of the organization as their own status is enhanced. The leadership roles and
management functions inherent in the use of authority and power are shown in Display 13.1.
DISpLAy 13.1 Leadership Roles and Management Functions Associated with
Organizational, Political, and Personal Power
LEADERSHIP ROLES
1. creates a climate that promotes followership in response to authority.
2. recognizes the dual pyramid of power that exists between the organization and its employees.
3. Uses a powerful persona and referent power to increase respect and decrease fear in subordi-
nates
4. recognizes when it is appropriate to have authority questioned or to question authority.
5. is personally comfortable with power in the political arena.
6. empowers others whenever possible.
7. Assists others in using appropriate political strategies.
8. serves as a role model of the empowered nurse.
9. strives to eliminate a perception of powerlessness among others.
10. is vigilant in using power judiciously and mindfully.
11. role models political skill in developing consensus, inclusion, and follower involvement.
12. Builds alliances and coalitions inside and outside of nursing.

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Chapter 13 Organizational, Political, and Personal Power 289
UNDERSTANDING pOWER
Power may be feared, worshipped, or mistrusted. It is frequently misunderstood. Our first
experience with power usually occurs in the family unit. Because children’s roles are likened
to later subordinate roles and the parental power position is similar to management, adult
views of the management–subordinate relationship are often influenced by how power was
used in the family unit and the often unacknowledged impact of gender upon power in family
dynamics. A positive or negative familial power experience may greatly affect a person’s
ability to deal with power systems in adulthood.
Gender and Power
Successful leaders are attentive to the influence of gender on power. Knudson-Martin (2013)
suggests that an underlying assumption of couples therapy is that intimate relationships should
mutually support each partner, and while virtually no couples disagree with this assumption
at the time of counseling, few couples attain this ideal with most power imbalances being
related to gender. Knudson-Martin suggests that male power typically does not come from
outright acts of domination but from an unacknowledged preeminence of men’s priorities,
needs, and desires in ways that seem ordinary or natural. In addition, women often contribute
to this power imbalance by being far more accommodating and submissive than their male
partners.
Some of the reluctance of women to embrace power in relationships can be explained
by their socialization to the female role. Some women, in particular, may hold negative
connotations of power and never learn to use power constructively. Indeed, women
traditionally were expected to demonstrate, at best, ambivalence toward the concept of power,
and often times, to openly eschew the pursuit of power. This occurred because many women
were socialized to view power differently than men.
As a result, some women view power as dominance versus submission; associated with
personal qualities, not accomplishment; and dependent on personal or physical attributes, not
skill. Also, some women believe that they do not inherently possess power but instead must
rely on others to acquire it. Thus, rather than feeling capable of achieving and managing
power, some women feel that power manages them (Huston, 2014). The end result has been
that far too many women have remained unskilled in the art of the political process.
However, this historical view of women as less powerful than men is changing. In
contemporary society, people are finding new ways for leaders, regardless of gender, to
MANAGEMENT FUNCTIONS
1. Uses authority to ensure that organizational goals are met.
2. Uses political strategies that are complementary to the unit and organization’s functioning.
3. Builds a power base appropriate for the assigned management role.
4. creates and maintains a small authority–power gap.
5. is knowledgeable about the essence and appropriate use of power.
6. Maintains personal credibility with subordinates.
7. Avoids using power over others rather than on behalf of others whenever possible.
8. demonstrates reasoned risk taking in decision making with political implications.
9. Uses reward power, coercive power, legitimate power, and expert power when appropriate to
positively influence the achievement of organizational goals.
10. Avoids visible displays of legitimate power and overusing commands.
11. Understands the organizational structure in which he/she works, functions effectively within
that structure, and deals effectively with the institution’s inherent politics.
12. promotes subordinate identification and recognition.
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290 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
acquire and manage power. These changes are taking place within women, in women’s view
of other women holding power, in organizational hierarchies, and among male subordinates
and male colleagues (Huston, 2014). Indeed, skills that have often been linked to female
characteristics such as political skill in developing consensus, inclusion, and involvement are
now viewed as strengths in the corporate world. These attributes are certainly not limited to
women, but it is notable that the same attributes that once closed corporate doors and created
the barrier popularly called the glass ceiling are now generally welcomed in the boardroom.
Today, gender differences regarding power are fading, and the corporate world is beginning to
look at new ways for all leaders, regardless of gender, to obtain and handle power.
LEARNING EXERCISE 13.1
Is Power Different for Men and Women?
research studies differ on how men and women view power and how others view men and
women in positions of authority. do you think that there are gender differences in how people
are viewed as being powerful? Who did you feel was most powerful in your family while growing
up? Why do you think that person was powerful? if you are using group work, how many in your
group named powerful male figures; how many named powerful female figures? discuss this in
a group, and then go to the library or use internet sources to see if you can find recent studies
that support your views.
Power and Powerlessness
In determining whether power is desirable, it may be helpful to look at its opposite:
powerlessness. Most people agree that they dislike being powerless and there is growing
recognition that the consequences of powerless may even include poor health outcomes and
morbidity. For example, stress combined with little decision-making power is linked to heart
attack risk in older men (Stress Combined with Little Decision Making, 2013).
Everyone needs to have some control in their life and when that is not the case, the end
result is typically a bossy and rules-oriented individual, desperate to have some degree of
power or control. The leader-manager who feels powerless often creates an ineffective,
petty, dictatorial, and rule-minded management style. They may become oppressive leaders,
punitive and rigid in decision making, or withhold information from others, and they become
difficult to work with. This suggests that while the adage that power corrupts might be true
for some, it is also likely correct to say that powerlessness holds at least as much potential
for corruption.
Power is likely to bring more power in an ascending cycle, whereas powerlessness will only
generate more powerlessness.
In contrast, the truly powerful individual knows he/she is powerful and does not need to
display this overtly. Instead, their power is evident in the respect and cooperation of their
followers. Because the powerful have credibility to support their actions, they have greater
capacity to get things accomplished and can enhance their base.
Apparently, then, power has a negative and a positive face. The negative face of power
is the “I win, you lose” aspect of dominance versus submission. The positive face of
power occurs when someone exerts influence on behalf of—rather than over—someone or
something. Power, therefore, is not good or evil; it is how it is used and for what purpose
that matters.

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Chapter 13 Organizational, Political, and Personal Power 291
Types of Power
For leadership to be effective, some measure of power must often support it. This is true for
the informal social group and the formal work group. Mindtools (1996-2013), in their classic
work, postulate that several bases, or sources, exist for the exercise of power: reward power,
punishment or coercive power, legitimate power, expert power, and referent power.
Reward power is obtained by the ability to grant favors or reward others with whatever
they value. The arsenal of rewards that a manager can dispense to get employees to work
toward meeting organizational goals is very broad. Positive leadership through rewards tends
to develop a great deal of loyalty and devotion toward leaders.
Punishment or coercive power, the opposite of reward power, is based on fear of
punishment if the manager’s expectations are not met. The manager may obtain compliance
through threats (often implied) of transfer, layoff, demotion, or dismissal. The manager who
shuns or ignores an employee is exercising power through punishment, as is the manager who
berates or belittles an employee.
Legitimate power is position power. Authority is also called legitimate power. It is the
power gained by a title or official position within an organization. Legitimate power has
inherent in it the ability to create feelings of obligation or responsibility. The socialization and
culture of subordinate employees will influence to some degree how much power a manager
has due to his or her position.
Expert power is gained through knowledge, expertise, or experience. Having critical
knowledge allows a manager to gain power over others who need that knowledge. This type
of power is limited to a specialized area. For example, someone with vast expertise in music
would be powerful only in that area, not in another specialization. When Florence Nightingale
used research to quantify the need for nurses in the Crimea (by showing that when nurses
were present, fewer soldiers died), she was using her research to demonstrate expertise in the
health needs of the wounded.
Referent power is power that a person has because others identify with that leader or with what
that leader symbolizes. Referent power also occurs when one gives another person, feelings of
personal acceptance or approval. It may be obtained through association with the powerful. People
may also develop referent power because others perceive them as powerful. This perception
could be based on personal charisma, the way the leader talks or acts, the organizations to which
he or she belongs, or the people with whom he or she associates. People who others accept as role
models or leaders enjoy referent power. Physicians use referent power very effectively; society, as
a whole, views physicians as powerful, and physicians carefully maintain this image.
Although correlated with referent power, charismatic power is distinguished by some
from referent power. Referent power is gained only through association with powerful others,
whereas charisma is a more personal type of power.
Another type of power, which is often added to the French and Raven power source is
informational power. This source of power is obtained when people have information that others
must have to accomplish their goals. The various sources of power are summarized in Table 13.1.
TABLE 13.1 Sources of Power
Type Source
referent Association with others
Legitimate position
coercive Fear
reward Ability to grant favors
expert Knowledge and skill
charismatic personal
informational The need for information
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292 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
THE AUTHORITy–pOWER GAp
If authority is the right to command, then a logical question is, “Why do workers sometimes
not follow orders?” Galinski, Magee, Ena Inesi, and Gruenfeld (2009) suggest that this may
occur because people in power are prone to dismiss or, at the very least, misunderstand
the viewpoints of those who lack authority. For example, “dictators often exhibit extreme
behavior in ways patently detrimental to their nations; managers are often accused of not
understanding their subordinates’ points of view; and the dominant partner in a relationship
is often accused of being insensitive to the other’s needs” (Galinski et al., 2009, para 1).
When followers feel that their needs and wants are immaterial and that the person in charge
focuses only on his or her own perspective, their innate motivation to be a good follower
declines.
Clearly then, the right to command does not ensure that employees will follow orders. The
gap that sometimes exists between a position of authority and subordinate response is called
the authority–power gap. The term manager power may explain subordinates’ response to the
manager’s authority. The more power subordinates perceive a manager to have, the smaller
the gap between the right to expect certain things and the resulting fulfillment of those
expectations by others.
The negative effect of a wide authority–power gap is that organizational chaos may
develop. There would be little productivity if every order were questioned. The organization
should rightfully expect that its goals would be accomplished. One of the core dynamics of
civilization is that there will always be a few authority figures pushing the many for a certain
standard of performance.
People in the United States are socialized very early to respond to authority figures. In
many cases, children are conditioned to accept the directives of their parents, teachers, and
community leaders. The traditional nurse-educator has been portrayed as an authoritarian
who demands unconditional obedience. Educators who maintain a very narrow authority–
power gap reinforce dependency and obedience by emphasizing the ultimate calamity—the
death of the patient. Thus, nursing students may be socialized to be overly cautious and to
hesitate when making independent nursing judgments.
Because of these types of early socialization, the gap between the manager’s authority and
the worker’s response to that authority tends to be relatively small. In other countries, it may
be larger or smaller, depending on how people are socialized to respond to authority. This
authority dependence that begins with our parents and is later transferred to our employers
may be an important resource to managers.
Although the authority–power gap continues to be narrow, it has grown in the last 30
years. Both the women’s movement and the student unrest of the 1960s have contributed
to the widening of the authority–power gap. This widening gap was evident when a 1970s
college student asked her mother why she did not protest as a college student; the mother
replied, “I didn’t know I could.”
At times, however, authority should be questioned by either the leader or the subordinates.
This is demonstrated in health care by the increased questioning of the authority of
physicians—many of whom feel they have the authority to command—by nurses and
consumers. Figure 13.1 shows the dynamics of the relationships in the organizational
authority–power response.
Bridging the Authority–Power Gap
Sometimes subordinates feel badgered by very visible exercises of authority (which should
be used sparingly). Because overusing commands can stifle cooperation, outright naked
commands should be used only infrequently.

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Chapter 13 Organizational, Political, and Personal Power 293
Overt displays of authority should be used as a last resort.
One way for the leader to bridge the gap is to make a genuine effort to know and care about
each subordinate as a unique individual. This is especially important because each person has
a limited tolerance of authority, and subordinates are better able to tolerate authority if they
believe that the leader cares about them as individuals.
In addition, the manager needs to provide enough information about organizational and
unit goals to subordinates so that they understand how their efforts and those of their manager
are contributing to goal attainment. The manager will have bridged the authority–power gap
if followers (a) perceive that the manager is doing a good job, (b) believe that the organization
has their best interests in mind, and (c) do not feel controlled by authority.
Finally, the manager must be seen as credible for the authority–power gap not to widen.
All managers begin their appointment with subordinates ready to believe them. This, again,
is due to the socialization process that causes people to believe that those in power say
what is true. However, the deference to authority will erode if managers handle employees
carelessly, are dishonest, or seem incapable of carrying out their duties. When a manager
loses credibility, the power inherent in his or her authority decreases.
Fry (2013) agrees, suggesting that truth telling is critical for the leader. “When trust in the
organization is low, staff turn to their managers to find out what is happening. If you do not know
the answer, tell them so. If you do know, share as much information as you can” (Fry, p. 33).
LEARNING EXERCISE 13.2
Power and Authority
Think back to your childhood. did you grow up with a very narrow authority–power gap? have
your views regarding authority and power changed since you were a child? do you believe that
children today have an authority–power gap similar to what you had as a child? support your
answers with examples.
++
Socialization
of individuals
to power/
authority figures
Perceived
power
of the
manager
Legitimate
authority
of the
position
++
Response
to
authority==
FIGURE 13.1 • interdependency of response to authority. copyright ® 2006 Lippincott
Williams & Wilkins. instructor’s resource cd-rOM to Accompany Leadership roles and
Management Functions in Nursing, by Bessie L. Marquis and carol J. huston.
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294 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
Another dimension of credibility that influences the authority–power relationship is future
promising. It is best to underpromise if promises must be made. Managers should never
guarantee future rewards unless they have control of all possible variables. If managers
revoke future rewards, they lose credibility in the eyes of their subordinates. However,
managers should dispense present rewards to buy patronage, making the manager more
believable and building greater power into his or her legitimate authority. A scenario that
illustrates the difference in dispensing future and present awards follows.
A registered nurse (RN) requests a day off to attend a wedding, and you are able to replace
her. You use the power of your position to reward her and give her the day off. The RN is
grateful to you, and this increases your power. Another RN requests 3 months in advance to
have every Thursday off in the summer to take a class. Although you promise this to her, on
the first day of June, three nurses resign, rendering you unable to fulfill your promise. This
nurse is very upset, and you have lost much credibility and, therefore, power. It would have
been wiser for you to say that you could not grant her original request (underpromising) or to
make it contingent on several factors. If the situation had remained the same and the nurses
had not resigned, you could have granted the request. Less trust is lost between the manager
and the subordinate when underpromising occurs than when a granted request is rescinded,
as long as the subordinate believes that the manager will make a genuine effort to meet his
or her request.
LEARNING EXERCISE 13.3
Authority–Power Gap in the Student Role
You are a senior nursing student completing your final leadership practicum. Your assignment
today is to assume leadership of a small team composed of the rN, one licensed vocational
nurse (LVN/LpN), and one certified nursing assistant (cNA). The rN preceptor has agreed
to let you take on this leadership role in her place, although she will shadow your efforts and
provide support throughout the day.
Almost immediately after handoff report, a patient puts on the call light and tells you that she
needs to have her sheets changed as she was incontinent in the bed. Because you are just
beginning your 0800 med pass and are already behind, you ask the cNA if she has time to do
this task. she immediately responds, “i’m busy and you’re the student…. do it yourself. it would
be a good learning experience for you.” When you try to explain your leadership role for the day,
she walks away, saying that she does not have time anyway.
A few minutes after that, a physician enters the unit. he wants to talk to the nurse about his
patient. When you inform him that you are the student nurse caring for his patient that day, he
responds… “no—i want to talk to the real nurse.”
You feel frustrated with this emerging authority–power gap and seek out the rN to formulate a
plan to make this gap smaller.
Assignment: identify at least four strategies you might use to reduce the size of this authority–
power. Would you involve the rN in your plan? do you anticipate having similar authority–power
gaps in the new graduate role?
Empowering Subordinates
The empowerment of staff is a hallmark of transformational leadership. To empower means
to enable, develop, or allow. Empowerment, as discussed in Chapter 2, can be defined as
decentralization of power. Empowerment occurs when leaders communicate their vision;

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Chapter 13 Organizational, Political, and Personal Power 295
employees are given the opportunity to make the most of their talents; and learning, creativity,
and exploration are encouraged. Empowerment plants seeds of leadership, collegiality, self-
respect, and professionalism.
Individuals may be born average, but staying average is a choice.
Empowerment can also be as simple as assuring that all individuals in the organization
are treated with dignity. Fry (2013, p. 33) suggests that leader-managers should “never
turn a blind eye to free-range bullying, negativity, gossip, tardiness and failure to share the
workload in the workplace. Instead, they should point staff to the standards of practice, the
code of ethics and the mission, vision and values (the organization’s and the leader-manager’s
practice setting’s).”
Empowerment, however, is not an easy one-step process. Instead, it is a complex process
that consists of responsibility for the individual desiring empowerment as well as the
organization and its leadership. Individually, all practitioners must have professional traits,
including responsibility for continuing education, participation in professional organizations,
political activism, and most importantly, a sense of value about their work. In addition, the
nurse must work in an environment that encourages empowerment, and the empowerment
process must include an effective leadership style.
Rao (2012) agrees, noting that while the language of empowerment is commonly
referenced, it is much more difficult to achieve in real life. He argues that most of nursing’s
efforts to enhance professional practice occur through structural empowerment, instead of the
equally important psychological and critical social empowerment. Rao suggests for nurses to
practice as professionals, they must be empowered to take action and respond to challenges
using professional skill and knowledge. Unless nurses feel empowered to act, they will rely
too heavily on rigid bureaucratic structures rather than their own professional power to guide
practice (Examining the Evidence 13.1).
Source: Rao, A. (2012). The contemporary construction of nurse empowerment. Journal of Nursing scholarship,
44(4), 396–402.
The purpose of this article was to describe how nursing’s construction of empowerment has
selectively shaped the manner in which the concept is applied to nursing practice and to highlight
the complex interactions that shape nurse empowerment. The literature reviewed was selected
from works published in the English language in the fields of nursing, management, and women’s
studies from 1960 to 2010.
The research findings suggest that nurse empowerment is critically important to nursing prac-
tice and that nurses working within health-care organizations must feel empowered to act, or they
will rely too heavily on rigid bureaucratic structures rather than their own professional power to
guide practice. Limiting nurses in this way denies the professional power their role affords them
and constrains their ability to achieve extraordinary outcomes through positive deviance.
Rao notes, however, that this does not imply that nurses are powerless until they become
empowered by someone else. When nurse empowerment is tied to images of nurse oppression,
Rao argues that it validates the construction of nursing as a powerless profession and diminishes
nurses’ existent professional power. Instead, Rao suggests that nursing’s efforts to enhance pro-
fessional practice through empowerment must extend beyond structural empowerment and con-
sider psychological and critical social empowerment as well. For example, nurse-leaders should
focus on mobilizing power to promote nurses’ professional practice and highlight the essential
contribution nurses make to their organizations and communities.
Examining the Evidence 13.1
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296 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
One way that leaders empower subordinates is when they delegate assignments to
provide learning opportunities and allow employees to share in the satisfaction derived from
achievement. Empowerment is not the relinquishing of rightful power inherent in a position,
nor is it a delegation of authority or its commensurate responsibility and accountability.
Instead, the actions of empowered staff are freely chosen, owned, and committed to on behalf
of the organization without any requests or requirements to do so.
Empowerment creates and sustains a work environment that speaks to values, such as
facilitating the employee’s choice to invest in and own personal actions and behaviors that
result in positive contributions to the organization’s mission.
Not having a commitment to empowerment is a barrier to creating an environment for
empowerment in an organization. Other barriers would include a rigid organizational belief
about authority and status. A manager’s personal feelings regarding empowerment’s potential
effect on the manager’s own power can also impede the empowering process.
Once organizational barriers have been minimized or eliminated, the leader should develop
strategies at the unit level to empower staff. The easiest strategy is to be a role model of an
empowered nurse. Another strategy would be to assist staff in building their own personal power
base. This can be accomplished by showing subordinates how their personal, expert, and referent
power can be expanded. Empowerment also occurs when workers are involved in planning and
implementing change and when workers believe that they have some input in what is about to
happen to them and some control over the environment in which they will work in the future.
LEARNING EXERCISE 13.4
Cultural Diversity
do you think that cultural diversity might be a challenge when empowering nurses? Think of
ways that various cultures may view power and empowerment differently. if you know people
from other cultures, ask them how powerful people or those in authority positions are viewed in
their culture and compare that with your own culture.
MOBILIZING THE pOWER OF NURSING
Until the nursing profession has a seat at the health-care policy-making table, individual nurses
and leader-managers will be limited in how much personal power they will hold. Huston (2014)
suggests that nursing has not been the force it could be in the policy arena, stating that nurses
have often been reactive rather than proactive in addressing policy decisions and legislation
after the fact rather than taking part in drafting and sponsoring legislation. However, she cites
several driving forces that should increase nursing’s power base (Display 13.2).
DISpLAy 13.2 Six Driving Forces to Increase Nursing’s Power Base
1. The timing is right
2. The size of the nursing profession
3. Nursing’s referent power
4. increasing knowledge base and education for nurses
5. Nursing’s unique perspective
6. desire of consumers and providers for change
Source: Huston, C. (2014). The nursing profession’s historic struggle to increase its power base. In C. Huston (Ed.),
professional issues in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Used with permission 310–326.

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Chapter 13 Organizational, Political, and Personal Power 297
• Right timing. The errors reported in our medical system, the numbers of uninsured, and
the shortcomings of our current health-care system are all reasons that consumers and
legislators are willing to listen to nurses as an attempt is made to fix the health-care
crisis. “Clearly the public wants a better health care system and nurses want to be able
to provide high quality nursing care. Both are powerful elements for change and new
nurses are entering the profession at a time when their energy and expertise will be more
valued than ever” (Huston, 2014, p. 317).
• Size of the nursing profession. Numbers are very important in politics, and the nursing
profession’s size is its greatest asset. The United States has approximately 3 million
RNs, which represents an impressive voting block.
• Nursing’s referent power. The nursing profession has a great deal of referent power as
a result of the high degree of trust and credibility the public places in them. Indeed,
nurses have placed #1 almost every year in the Gallup Organization’s annual poll on
professional honesty and ethical standards since nurses were first included in the survey
in 1999.
• Increasing knowledge base and education for nurses. There are more nurses being awarded
master’s and doctoral degrees than ever before. In addition, more nurses are stepping into
advanced practice roles as nurse practitioners, clinical nurse specialists, certified nurse
midwives, RN anesthetists, or clinical nurse-leaders. If knowledge is power, then those
having knowledge can influence others, gain credibility, and gain power.
“Furthermore, leadership, management and political theory are increasingly a part
of baccalaureate nursing education, although the majority of nurses still do not hold
baccalaureate degrees. These are learned skills and collectively, the nursing profession’s
knowledge of leadership, politics, negotiation, and finance is increasing. This can only
increase the nursing profession’s influence outside the field” (Huston, 2014, p. 318).
• Nursing’s unique perspective. Nursing has long been recognized as having a strong
caring component. Combine that with nursing’s recent surge in scientific knowledge and
critical thinking, and there is a blend of art and science that brings a unique perspective
to the health-care arena.
• Desire of consumers and providers for change. Health-care restructuring and downsizing
have sparked increasing concern among consumers. The public cares about who is
taking care of them. The public wants quality care.
Huston (2014) also developed an action plan for the nursing profession to build its
power base (Display 13.3 shows a summary of these actions). This action plan includes the
following strategies:
DISpLAy 13.3 Action Plan for Increasing the Power of the Nursing Profession
1. place more nurses in positions that influence public policy.
2. stop nurses from acting like victims.
3. increase level of nurses’ understanding regarding all health-care policy efforts.
4. Build coalitions within and outside of nursing.
5. promote greater research to strengthen evidence-based practice.
6. support nursing leaders.
7. pay attention to mentoring future nurse-leaders and leadership succession.
Source: Huston, C. (2014). The nursing profession’s historic struggle to increase its power base. In C. Huston (Ed.),
professional issues in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Used with permission 310–326.
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298 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
• Place more nurses in positions that influence public policy. Holding office is the
ultimate in political activism. Huston (2014, p. 319) argues that “nurses are uniquely
qualified to hold public office because they have the greatest firsthand experience of
problems faced by patients in today’s healthcare system as well as an uncanny ability to
translate the healthcare experience to the general public. As a result, more nurses need to
seek out this role. In addition, because the public respects and trusts nurses, nurses who
choose to run for public office are often elected. The problem then is not that nurses are
not elected … the problem is that not enough nurses are running for office.”
• Stop acting like victims. Unhappy nurses tend to look like victims. That is not to say
that nurses have not been victimized in the past, but nurses need to address the cause
of their unhappiness and attempt to alleviate the problem. They can confront situations,
change jobs, or move into a different career path. Motivated people who care about their
profession will help bring power to nursing.
• Become better informed about all health-care policy efforts. This means becoming
involved with grassroots knowledge building and becoming better-informed consumers
and providers of health care with a commitment to collective strength. Breslin (2012)
agrees, noting that being politically active is part of our responsibility as nurses.
Changing nurse’s view of both power and politics is perhaps the most significant key to
proactive rather than reactive participation in policy setting.
• Build coalitions inside and outside of nursing. Health policy takes place in a
virtual network of participants, professions, and organizations, both locally and
nationally. Nurses have not always done well in building political coalitions with other
interdisciplinary professionals with similar challenges. In addition to belonging to
nursing professional organizations, nurses need to reach out to other non-nursing groups
with the same concerns and goals. This interdependence and strength in numbers is what
will ultimately help the profession achieve its goals.
Success comes not only with whom you know, but also, with who knows you! (Collins, 2012)
• Conduct more research to strengthen evidence-based practice. Great strides have been
made in researching what it is that nurses do that makes a difference in patient outcomes
(research on nursing sensitivity), but more needs to be done. Nurses must use research
to present the case that nursing skills are vital to competent health care. In addition,
“building and sustaining evidence-based practice in nursing will require far greater
numbers of master’s and doctorally prepared nurses, as well as entry into practice at an
educational level similar to other professions” (Huston, 2014, p. 323).
• Support nursing leaders. Rather than supporting their leaders’ efforts to lead, nurses
have often viewed their leaders as deviants and this has occurred at a high personal cost
to the innovator. In addition, nurses often resist change from their leaders and instead
look to leaders in medicine or other health-related disciplines. Thus, the division in
nursing often comes from within the profession itself (Huston, 2014).
• Mentor future nurse-leaders and plan for leadership succession. Female-dominated
professions such as nursing often exemplify the queen bee syndrome. The queen bee is
a woman who has struggled to become successful, but once successful, she refuses to
help other women reach the same success. This leads to inadequate empowering of new
leaders by the older, more established leaders. Increased and adequate empowering of
others, mentoring the young, and ensuring leadership succession is clearly needed to
advance nursing leadership. Remember that “it is the young who hold, not only the keys

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Chapter 13 Organizational, Political, and Personal Power 299
to the present, but also the hope for the future. The nursing profession is responsible for
ensuring leadership succession and is morally bound to do it with the brightest, most
highly qualified individuals ” (Huston, 2014, p. 323).
STRATEGIES FOR BUILDING A pERSONAL pOWER BASE
In addition to assisting with empowering the profession, nurse-leaders and nurse-managers
must build a personal power base to further organizational goals, fulfill the leadership role,
carry out management functions, and meet personal goals. Even a novice manager or newly
graduated nurse can begin to build a power base in many ways. Habitual behaviors resulting
from early lessons, passivity, and focusing on wrong targets can be replaced with new power-
gaining behaviors. The following are suggested strategies for enhancing power.
Maintain Personal Energy
Power and energy go hand in hand. “To take care of others you must first take care of you.
Self-care is probably one of the most important practices a nurse must cultivate to stay
grounded, avoid burnout, and cope with the stress of nursing” (Creative RN, 2013, para 1).
Effective leaders take sufficient time to unwind, reflect, rest, and have fun when they feel tired.
Leader-managers who do not take care of themselves begin to make mistakes in judgment
that may result in terrible political consequences. Taking time for significant relationships and
developing outside interests are important so that other resources are available for sustenance
when political forces in the organization drain energy.
You must take care of yourself before you can take care of others.
Present a Powerful Picture to Others
How people look, act, and talk influence whether others view them as powerful or powerless.
Fry (2013) suggests that leader-managers choose their attitude and behaviors wisely since
staff are always listening and watching their every move. The nurse who stands tall and is
poised, assertive, articulate, and well groomed presents a picture of personal control and
power. The manager who looks like a victim will undoubtedly become one. When individuals
take the time for self-care, they exude confidence. This is apparent in not only how they dress
and act but also in how they interact with others (Huston, 2008).
Pay the Entry Fee
Newcomers who stand out and appear powerful are those who do more, work harder, and
contribute to the organization. They are not clock watchers or “nine-to-fivers.” They attend
meetings and in-service opportunities; they do committee work and take their share of
night shifts and weekend and holiday assignments without complaining. A power base is
not achieved by slick, easy, or quick maneuvers but through hard work. In addition, Huston
(2008) suggests that it is important to be a team player. “Showing a genuine interest in others,
being considerate of other people’s needs and wants, and offering others support whenever
possible, are all a part of successful team building. These interpersonal skills are part of
emotional intelligence” (p. 61).
Determine the Powerful in the Organization
Understanding and working successfully within both formal and informal power structures
are important strategies for building a personal power base. Individuals must be cognizant
of their limitations and seek counsel appropriately. One should know the names and faces
of those with both formal power and informal power. The powerful people in the informal
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300 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
structure are often more difficult to identify than those in the formal structure. When
working with powerful people, look for similarities and shared values and avoid focusing on
differences.
Learn the Language and Symbols of the Organization
Each organization has its own culture and value system. Watkins (2013) notes that
organizational culture is “the story” in which people in the organization are embedded, and
the values and rituals that reinforce that narrative. It also focuses attention on the importance
of symbols and the need to understand them—including the idiosyncratic languages used
in organizations. New members must understand this culture and be socialized into the
organization if they are to build a power base. Being unaware of institutional taboos often
results in embarrassment for the newcomer.
Learn How to Use the Organization’s Priorities
Every group has its own goals and priorities for achieving those goals. Those seeking to build
a power base must be cognizant of organizational goals and use those priorities and goals
to meet management needs. For example, a need for a new manager in a community health
service might be to develop educational programs on chemotherapy because some of the
new patient caseload includes this nursing function. If fiscal management is a high priority,
the manager needs to show superiors how the cost of these educational programs will be
offset by additional revenues. If public relations with physicians and patients are a priority,
the manager would justify the same request in terms of additional services to patients and
physicians.
Increase Professional Skills and Knowledge
Because employees are expected to perform their jobs well, one’s performance must be
extraordinary to enhance power. One method of being extraordinary is to increase professional
skills and knowledge to an expert level. Having knowledge and skill that others lack greatly
augments a person’s power base. Excellence that reflects knowledge and demonstrates skill
enhances a nurse’s credibility and determines how others view him or her.
Maintain a Broad Vision
Vision is one of the most powerful tools that a leader has in his/her toolbox. When
communicated effectively, it serves as the driving force for goal attainment (The Importance
of Vision, 2013). Because workers are assigned to a unit or department, they often develop a
narrow view of the total organization. Power builders always look upward and outward. The
successful leader recognizes not only how the individual unit fits within the larger organization
but also how the institution as a whole fits into the scheme of the total community. People
without vision rarely become very powerful.
Use Experts and Seek Counsel
Newcomers should seek out role models. Role models are experienced, competent
individuals an individual wishes to emulate (Huston, 2008). Even though there may be no
significant interpersonal relationship, one can learn a great deal about successful leadership,
management, and decision making by observing and imitating positive role models. By
looking to others for advice and counsel, people demonstrate that they are willing to be team
players, that they are cautious and want expert opinion before proceeding, and that they are
not rash newcomers who think they have all the answers. Aligning oneself with appropriate
veterans in the organization is excellent for building power.

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Chapter 13 Organizational, Political, and Personal Power 301
Be Flexible
Bossong (2013) suggests that one of the greatest assets a football quarterback has is his ability
to determine at the line of scrimmage, an instant backup plan based on immediate feedback
he sees or feels. The same is true for leadership. Great leaders understand the power of
flexibility. Anyone wishing to acquire power should develop a reputation as someone who
can compromise. The rigid, uncompromising newcomer is viewed as being insensitive to the
organization’s needs.
Develop Visibility and a Voice in the Organization
Newcomers to an organization must become active in committees or groups that are
recognized by the organization as having clout. When working in groups, the newcomer
must not monopolize committee time. In addition, novice leaders and managers must develop
observational, listening, and verbal skills. Their spoken contributions to the committee should
be valuable and articulated well.
Experienced leader-managers must strive for visibility and voice as well. Bossong
(2013) suggests that managers should spend time with all of the staff, not just direct reports.
Managers who are too far removed from workers in the organization hierarchy can have a
view that is cloudy or distorted. Bossong suggests that managers at all levels of the hierarchy
should get out of their offices and attempt to interact with everyone in the organization. If
workers do not know their managers, they will not trust them.
Learn to Toot Your Own Horn
Accepting compliments is an art. One should be gracious but certainly not passive when
praised for extraordinary effort. In addition, people should let others know when some special
professional recognition has been achieved. This should be done in a manner that is not
bragging but reflects the self-respect of one who is talented and unique.
Maintain a Sense of Humor
Appropriate humor is very effective. The ability to laugh at oneself and not take oneself too
seriously is a most important power builder. Brody (2011) notes that humor often relieves
stress or tension, especially the inherent stress that accompanies leadership. Humor allows the
leader to relax so that he/she can step away from the challenge, and look at the circumstance
in a different perspective.
Empower Others
Leaders need to empower others, and followers must empower their leaders. When nurses
empower each other, they gain referent power. Individual nurses and the profession as a
whole do not gain their share of power because they allow others to divide them and weaken
them. Nurses can empower other nurses by sharing knowledge, maintaining cohesiveness,
valuing the profession, and supporting each other.
Power-building and political strategies are summarized in Display 13.4.
DISpLAy 13.4 Leadership Strategies: Developing Power and Political Savvy
Power-Building Strategies Political Strategies
Maintain personal energy develop information acquisition skills
present a powerful persona communicate astutely
pay the entry fee Become proactive
determine the powerful Assume authority
Learn the organizational culture Network
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302 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
THE pOLITICS OF pOWER
Politics is the art of using legitimate power wisely. It requires clear decision making,
assertiveness, accountability, and the willingness to express one’s own views. It also requires
being proactive rather than reactive and demands decisiveness. Leader-managers in power
positions in today’s health-care settings are more likely to recognize their innate abilities that
support the effective use of power.
It is important for managers to understand politics within the context of their employing
organization. After the employee has built a power base through hard work, increased
personal power, and knowledge of the organization, developing skills in the politics of power
is necessary. After all, power may not be gained indefinitely; it may be fleeting. For example,
people often lose hard-earned power in an organization because they make political mistakes.
Even seasoned leaders occasionally blunder in this arena.
Although power is a universally available resource, it does not have a finite quality and can be
lost as well as gained.
It is useless to argue the ethics or value of politics in an organization, because politics exists
in every organization. Thus, nurses waste energy and remain powerless when they refuse to
learn the art and skill of political maneuvers. Politics becomes divisive only whenever gossip,
rumor, or unethical strategies occur.
Use organizational priorities expand personal resources
increase skills and knowledge Maintain maneuverability
have a broad vision remain sensitive to people, timing, and situations
Use experts and seek counsel
Be flexible promote subordinates’ identities
Be visible and have a voice Meet organizational needs
Toot your own horn
Maintain a sense of humor
empower others
LEARNING EXERCISE 13.5
Building Power as the New Nurse
You have been an rN for 3 years. six months ago, you left your position as a day charge nurse
at one of the local hospitals to accept a position at the public health agency. You really miss your
friends at the hospital and find most of the public health nurses older and aloof. however, you
love working with your patients and have decided that this is where you want to build a lifetime
career. Although you believe that you have some good ideas, you are aware that because you
are new, you will probably not be able to act as change agent yet. eventually, you would like
to be promoted to agency supervisor and become a powerful force for stimulating growth
within the agency. You decide that you can do a few things to build a power base. You spend a
weekend designing a personal power-building plan.
Assignment: Make a power-building plan. Give six to ten specific examples of things you would
do to build a power base in the new organization. provide rationale for each selection. (do not
merely select from the general lists in the text. Outline specific actions that you would take.)
it might be helpful to consider your own community and personal strengths when solving this
learning exercise.

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Chapter 13 Organizational, Political, and Personal Power 303
Much attention is given to improving competence, but little time is spent in learning
the intricacies of political behavior. The most important strategy is to learn to “read the
environment” (e.g., understand relationships within the organization) through observation,
listening, reading, detachment, and analysis.
Because power implies interdependence, nurses must not only understand the
organizational structure in which they work but also be able to function effectively
within that structure, including dealing effectively with the institution’s inherent politics.
Only when managers understand power and politics will they be capable of recognizing
limitations and potential for change.
Understanding one’s own power can be frightening, especially when one considers that
“attacks” (or opposition) from various fronts may reduce that power. When these attacks
occur, people who hold powerful positions may undermine themselves by regressing rather
than progressing and by being reactive rather than proactive. The following political strategies
will help the novice manager to negate the negative effects of organizational politics:
• Become an expert handler of information and communication. Beware that facts can be
presented seductively and out of context. Be cautious in accepting facts as presented,
because information is often changed to fit others’ needs. Managers must become
artful at acquiring information and questioning others. Delay decisions until adequate
and accurate information has been gathered and reviewed. Failing to do the necessary
homework may lead to decisions with damaging political consequences.
Managers must not trap themselves by discussing something about which they know very
little. Political astuteness in communication is a skill to be mastered, and the politically
astute manager says, “I don’t know” when adequate information is unavailable. Grave
consequences can result from sharing the wrong information with the wrong people at
the wrong time. Determining who should know, how much they should know, and when
they should know requires great finesse.
One of the most politically serious errors that one can make is lying to others within the
organization. Unlike withholding and refusing to divulge information, which may be
good political strategies, lying destroys trust, and leaders must never underestimate the
power of trust.
• Be a proactive decision maker. Nurses have had such a long history of being reactive
that they have had little time to learn how to be proactive. Although being reactive is
better than being passive, being proactive means getting the job done better, faster, and
more efficiently. Proactive leaders prepare for the future instead of waiting for it. Seeing
changes approaching in the health-care system, they prepare to meet them, not fight them.
Assuming authority is one way that nurses can become proactive. Part of power is the image
of power; a powerful political strategy also involves image. Instead of asking, “May I?”
leaders assume that they may. When people ask permission, they are really asking someone
to take responsibility for them. If something is not expressly prohibited in an organization or
a job description, the powerful leader assumes that it may be done. Politically astute nurses
have been known to create new positions or new roles within a position simply by gradually
assuming that they could do things that no one else was doing. In other words, they saw a
need in the organization and started meeting it. The organization, through default, allowed
expansion of the role. People need to be aware, however, that if they assume authority and
something goes wrong, they will be held accountable; so this strategy is not without risk.
• Expand personal resources. Because organizations are dynamic and the future is
impossible to predict, the proactive nurse prepares for the future by expanding personal
resources. Personal resources include economic stability, higher education, and a
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304 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
broadened skill base. Some call this the political strategy of “having maneuverability,”
that is, the person avoids having limited options. People with “money in the bank and
gas in the tank” have a political freedom of maneuverability that others do not. People
lose power if others within the organization know that they cannot afford to make a job
change or lack the necessary skills to do so. Those who become economically dependent
on a position lose political clout. Likewise, the nurse who has not developed additional
skills or sought further education loses the political strength that comes from being able
to find quality employment elsewhere.
• Develop political alliances and coalitions. Nurses often can increase their power and
influence by forming coalitions and alliances (networking) with other groups, be they
peers, sponsors, or subordinates, especially when these alliances are with peers outside the
organization. In this manner, the manager keeps abreast of current happenings and consults
others for advice and counsel. Although networking works among many groups, for the
nurse-manager, few groups are as valuable as local and state nursing associations. More
power and political clout result from working together rather than alone. When a person
faces political opposition from others in the organization, group power is very useful.
Nurses must be represented in mass, in some way, before they will be able to significantly
impact the decisions that directly influence their own profession.
• Be sensitive to timing. Successful leaders are sensitive to the appropriateness and timing of
their actions. The person who presents a request to attend an expensive nursing conference
on the same afternoon that his or her supervisor just had extensive dental work typifies
someone who is insensitive to timing. Besides being able to choose the right moment, the
effective manager should develop skill in other areas of timing, such as knowing when
it is appropriate to do nothing. For example, in the case of a problem employee who is
3 months from retirement, time itself will resolve the situation. The sensitive manager
also learns when to stop requesting something. That time is before a superior issues a firm
“no,” at which point continuing to press the issue is politically unwise.
• Promote subordinate identification. A manager can promote the identification of
subordinates in many ways. A simple “thank you” for a job well done works well when
spoken in front of someone else. Calling attention to the extra efforts of subordinates
says in effect, “Look what a good job we are capable of doing.” Sending subordinates
sincere notes of appreciation is another way of praising and promoting. Rewarding
excellence is an effective political strategy.
• View personal and unit goals in terms of the organization. Even extraordinary and
visible activities will not result in desired power unless those activities are used to meet
organizational goals. Hard work purely for personal gain will become a political liability.
Frequently, novice managers think only in terms of their needs and their problems
rather than seeing the large picture. Moreover, people often look upward for solutions
rather than attempting to find answers themselves. When problems are identified, it is
more politically astute to take the problem and a proposed solution upward rather than
just presenting the problem to the superior. Although the superior may not accept the
solution, the effort to problem solve will be appreciated.
• “Leave your ego at home in a jar.” Although political actions can be negative, you should
make an effort not to take political muggings personally, because you may well be a
bystander hit in a crossfire. Likewise, be careful about accepting credit for all political
successes, because you may just have been in the right place at the right time. Be prepared
as a manager to make political errors. The key to success is how quickly you rebound.

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Chapter 13 Organizational, Political, and Personal Power 305
INTEGRATING LEADERSHIp ROLES AND MANAGEMENT FUNCTIONS WHEN
USING AUTHORITy AND pOWER IN ORGANIZATIONS
A manager’s ability to gain and wisely use power is critical to his or her success. Nurses
will never be assured of adequate resources until they gain the power to manipulate the
needed resources legitimately. To do this, managers must be able to bridge the authority–
power gap, build a personal power base, and minimize the negative politics of the
organization.
One of the most critical leadership roles in the use of power and authority is the
empowerment of subordinates. The leader recognizes the dual pyramid of power and
acknowledges the power of others, including that of subordinates, peers, and higher
administrators.
The key then to establishing and keeping authority and power in an organization is for the
leader-manager to be able to accomplish four separate tasks:
• Maintain a small authority–power gap.
• Empower subordinates whenever possible.
• Use authority in such a manner that subordinates view what happens in the organization
as necessary.
• When needed, implement political strategies to maintain power and authority.
LEARNING EXERCISE 13.6
Turning Lemons into Lemonade
The following is based on a real event. The cast includes sally Jones, the chief Nursing
Officer; Jane smith, the hospital administrator and ceO; and Bob Black, the assistant hospital
administrator. sally has been in her position at Memorial hospital for 2 years. she has made
many improvements in the nursing department and is generally respected by the hospital
administrator, the nursing staff, and the physicians.
The present situation involves the newly hired Bob Black. previously too small to have an
assistant administrator, the hospital has grown, and this position was created. One of the
departments assigned to Bob is the personnel and payroll department. Until now, nursing,
which comprises 45% of all personnel, has done its own recruiting, interviewing, and selecting.
since Bob has been hired, he has shown obvious signs that he would like to increase his power
and authority. Now Bob has proposed that he hire an additional clerk who will do much of the
personnel work for the nursing department, although nursing administration will be able to make
the final selections in hiring. Bob proposes that his department should do the initial screening
of applicants, seeking references, and so on. sally has grown increasingly frustrated in dealing
with the encroachment of Bob. having just received Bob’s latest proposal, she has requested
to meet with Jane smith and Bob to discuss the plan.
Assignment: What danger, if any, is there for sally Jones in Bob Black’s proposal? explain two
political strategies that you believe sally could use in the upcoming meeting. is it possible to
facilitate a win–win solution to this conflict? if so, how? if there is not a win–win solution, how
much can sally win?
Note: Attempt to solve this case before reading the solution presented in the Appendix.
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306 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
Integrating the leadership role and the functions of management reduces the risk that
power will be misused. Power and authority will be used to increase respect for the position
and for nursing as a whole. The leader comfortable with power ensures that the goal of
political maneuvers is cooperation, not personal gain. The successful manager who has
integrated the role of leadership will not seek to have power over others but instead will
empower others. It is imperative for leader-managers to become skillful in the art of politics
and the use of political strategy if they are to survive in the corporate world of the health-care
industry. It is with the use of such strategies that organizational resources are obtained and
goals are achieved.
KEY CONCEPTS
l power and authority are necessary components of leadership and management.
l A person’s response to authority is conditioned early through authority figures, experiences in the family
unit, and gender role identification.
l The gap that sometimes exists between a position of authority and subordinate response is called the
authority–power gap.
l The empowerment of staff is a hallmark of transformational leadership. empowerment means to enable,
develop, or allow.
l power has both a positive and a negative face.
l Traditionally, women have been socialized to view power differently than men do. however, recent
studies show that gender differences regarding power are slowly changing.
l reward power is obtained by the ability to grant rewards to others.
l coercive power is based on fear and punishment.
l Legitimate power is the power inherent in one’s position.
l expert power is gained through knowledge or skill.
l referent power is obtained through association with others.
l charismatic power results from a dynamic and powerful persona.
l information power is gained when someone has information that another needs.
l Female-dominated professions such as nursing often exemplify the queen bee syndrome. The queen
bee is a woman who has struggled to become successful, but once successful, refuses to help other
women reach the same success.
l even a novice manager or newly graduated nurse can begin to build a power base by using appropriate
power-building tactics.
l power gained may be lost because one is politically naive or fails to use appropriate political strategies.
l politics exist in every organization, and leader-managers must learn the art and skills of politics.
l The nursing profession has not been the political force it could be since historically, it has been more
reactive than proactive in addressing needed policy decisions and legislation.
l Numerous driving forces are in place to increase the nursing profession’s power base, including timing,
the size of the profession, nursing’s referent power, the increasing educational levels of nurses, nursing’s
unique perspective, and the desire of consumers and providers for change.

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Chapter 13 Organizational, Political, and Personal Power 307
ADDITIONAL LEARNING EXERCISES AND AppLICATIONS
LEARNING EXERCISE 13.7
Empowering Your Staff
After 5 years as a public health nurse, you have just been appointed as supervisor of the
western region of the county health department. There is one supervisor for each region, a
nursing director, and an assistant director. You have eight nurses who report directly to you.
Your organization seems to have few barriers to prevent staff empowerment, but in talking with
the staff that report to you, they frequently express feelings of powerlessness in their ability to
effect lasting change in their patients or in changing policies within the organization. Your first
planned change, therefore, is to develop strategies to empower them.
Assignment: devise a political strategy for successfully empowering the staff that report directly
to you. consider the three elements necessary in the empowerment process: professional traits
of the staff, a supportive environment, and effective leadership. Of these things, what is in your
sphere of control? Where is the danger of your plan being sabotaged? What change tactics
can you use to increase the likelihood of success?
LEARNING EXERCISE 13.8
Friendships and Truth
You are a middle-level manager in a public health department. One of your closest friends,
Janie, is an rN under your span of control. Today, Janie calls and tells you that she injured her
back yesterday during a home visit after she slipped on a wet front porch. she said that the
home owners were unaware that she fell and that no one witnessed the accident. she has just
returned from visiting her doctor, who advises 6 weeks of bed rest. she requests that you initiate
the paperwork for workers compensation and disability, because she has no sick days left.
shortly after your telephone conversation with Janie, you take a brief coffee break in the lounge.
You overhear a conversation between Jon and Lacey, two additional staff members in your
department. Jon says that he and Janie were water skiing last night, and she took a terrible fall
and hurt her back. he planned to call her to see how she was feeling.
You initially feel hurt and betrayed by Janie because you believe that she has lied to you. You
want to call Janie and confront her. You plan to deny her request for workers’ compensation and
disability. You are angry that she has placed you in this position. You are also aware that proving
Janie’s injury is not work related may be difficult.
Assignment: how should you proceed? What are the political ramifications if this incident is not
handled properly? how should you use your power and authority when dealing with this problem?
LEARNING EXERCISE 13.9
Decision Making: Conflict and Dilemma
You are the director of a small Native American health clinic. Other than yourself and a part-time
physician, your only professional staff members are two rNs. The remaining staff members are
Native Americans and have been trained by you.
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308 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
Because nurse Bennett, a 26-year-old female BsN graduate, has had several years of
experience working at a large southwestern community health agency, she is familiar with many
of the patients’ problems. she is hard working and extremely knowledgeable. Occasionally,
her assertiveness is mistaken for bossiness among the Native American workers. however,
everyone respects her judgment.
The other rN, Nurse Mikiou, is a 34-year-old male Native American. he started as a medic in the
persian Gulf War and attended several career-ladder external degree programs until he was able
to take the rN examination. he does not have a baccalaureate degree. his nursing knowledge
is occasionally limited, and he tends to be very casual about performing his duties. however, he
is competent and has never shown unsafe judgment. his humor and good nature often reduce
tension in the clinic. The Native American population is very proud of him, and he has a special
relationship with them. however, he is not a particularly good role model because his health
habits leave much to be desired, and he is frequently absent from work.
Nurse Bennett has come to find Nurse Mikiou intolerable. she believes that she has tried
working with him, but this is difficult because she does not respect him. As the director of the
clinic, you have tried many ways to solve this problem. You feel especially fortunate to have nurse
Bennett on your staff. it is difficult to find many nurses of her quality willing to come and live on
a Native American reservation. On the other hand, if the care is to be as culturally relevant as
possible, the Native Americans themselves must be educated and placed in the agencies so
that one day they can run their own clinics. it is very difficult to find educated Native Americans
who want to return to this reservation. Now, you are faced with a management dilemma. Nurse
Bennett has said that either Nurse Mikiou must go, or she will go. she has asked you to decide.
Assignment: List the factors bearing on this decision. What (if any) power issues are involved?
Which choice will be the least damaging? Justify your decision.
LEARNING EXERCISE 13.10
Power Struggle
You are team leader on a medical unit of a small community hospital. Your shift is 3 to 11 pm.
When leaving the report room, John, the day-shift team leader, tells you that Mrs. Jackson,
a patient who is terminally ill with cancer, has decided to check herself out of the hospital
“against medical advice.” John states that he has already contacted Mrs. Jackson’s doctor,
who expressed his concern that the patient would have inadequate pain control at home and
undependable family support. he believes that she will die within a few days if she leaves the
hospital. he did, however, leave orders for home prescriptions and a follow-up appointment.
You immediately go into Mrs. Jackson’s room to assess the situation. she tells you that the
doctor has told her she will probably die within 6 weeks and that she wants to spend what
time she has left at home with her little dog, who has been her constant companion for many
years. in addition, she has many things “to put in order.” she states that she is fully aware of
her doctor’s concerns and that she was already informed by the day-shift nurse that leaving
“against medical advice” may result in the insurance company refusing to pay for her current
hospitalization. she states that she will be leaving in 15 minutes when her ride home arrives.
When you go to the nurse’s station to get a copy of the home prescriptions and follow-up
doctor’s appointment for the patient, the unit clerk states, “The hospital policy says that patients
who leave against medical advice have to contact the physician directly for prescriptions and
an appointment, because they are not legally discharged. The hospital has no obligation to

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Chapter 13 Organizational, Political, and Personal Power 309
REFERENCES
provide this service. she made the choice—now let her live with it.” she refuses to give a copy
of the orders to you and places the patient’s chart in her lap. short of physically removing the
chart from the clerk’s lap, you clearly have no immediate access to the orders.
You confront the charge nurse, who is unsure what to do and who states that the hospital policy
does give that responsibility to the patient. The unit director, who has been paged, appears to
be out of the hospital temporarily.
You are outraged. You believe that the patient has the “right” to her prescriptions because the
doctor ordered them, assuming she would receive them before she left. You also know that if
the medications are not dispensed by the hospital, there is little likelihood that Mrs. Jackson will
have the resources to have the prescriptions filled. Five minutes later, Mrs. Jackson appears at
the nurse’s station, accompanied by her friend. she states that she is leaving and would like her
discharge prescriptions.
Assignment: The power struggle in this scenario involves you, the unit clerk, the charge nurse,
and organizational politics. does the unit clerk in this scenario have informal or formal power?
What alternatives for action do you have? What are the costs or consequences of each possible
alternative? What action would you take?
LEARNING EXERCISE 13.11
Ego and the Chain of Command
You are the day-shift charge nurse for the intensive care unit. One of your nurses, carol, has just
requested a week off to attend a conference. she is willing to use her accrued vacation time for
this and to pay the expenses herself. The conference is in 1 month, and you are a little irritated
with her for not coming to you sooner. carol’s request conflicts with a vacation that you have
given another nurse. This nurse requested her vacation 3 months ago.
You deny carol’s request, explaining that you will need her to work that week. carol protests,
stating that the educational conference will benefit the intensive care unit and repeating that
she will bear the cost. You are firm but polite in your refusal. Later, carol goes to the supervisor
of the unit to request the time. Although the supervisor upholds your decision, you are upset
because you believe that carol has gone over your head inappropriately in handling this matter.
Assignment: Were carol’s actions appropriate in going over your head in addressing her
concerns? does ego impact your response? how are you going to deal with carol? decide on
your approach and support it with political rationale.
Bossong, J. (2013, May 19). 6 keys to leadership flexibility.
Wordpress. Retrieved May 31, 2013, from http://
johnbossong.com/2013/05/19/6-keys-to-leadership
-flexibility/
Breslin, J. (2012). Democrat? Republican? I’m a nurse first.
Michigan Nurse, 85(5), 4.
Brody, R. (2011, April 12). Leaders need sense of humor.
EzineArticles.com. Retrieved June 1, 2013, from
http://ezinearticles.com/?Leaders-Need-Sense-Of
-Humor&id=6171144
Collins, B. (2012). Networking and the power of being
connected. Journal of Environmental Health,
75(3), 4–5.
Creative RN (2013, March 27). 3 Easy self-care practices
for nurses. Retrieved June 1, 2013, from http://www
.creativern.com/2013/03/27/3-easy-self-care
-practices/
Fry, B. (2013). Power up your leadership: Straight talk
for nurse managers. Canadian Nurse, 109(5),
32–33.
www.ebook777.com

http://www.creativern.com/2013/03/27/3-easy-self-care-practices/

http://johnbossong.com/2013/05/19/6-keys-to-leadership-flexibility/

http://ezinearticles.com/?Leaders-Need-Sense-Of-Humor&id=6171144

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310 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
Galinski, A. D., Magee, J. C., Ena Inesi, M., & Gruenfeld, D. H.
(2009). Losing touch. Power diminishes perception and
perspective. Kellogg insight: focus on research. Retrieved
December 19, 2009, from http://insight.kellogg.
northwestern.edu/index.php/Kellogg/article/losing_touch
Huston, C. (2008, April). Eleven strategies for building a personal
power base. Nursing Management, 39(4), 58–61.
Huston, C. (2014). The nursing profession’s historic struggle
to increase its power base. In C. Huston (Ed.),
Professional issues in nursing (3rd ed.). Philadelphia,
PA: Lippincott Williams & Wilkins 310–326.
Knudson-Martin, C. (2013). Why power matters: Creating a
foundation of mutual support in couple relationships.
Family Process, 52(1), 5–18.
Mindtools (1996-2013). French and Raven’s Five Forms
of Power. Understanding Where Power Comes
From in the Workplace. Retrieved Oct. 27, 2013
from http://www.mindtools.com/pages/article/
newLDR_56.htm
Rao, A. (2012). The contemporary construction of nurse
empowerment. Journal of Nursing Scholarship,
44(4), 396–402.
Stress Combined with Little Decision-Making Power Linked
to Heart Attack Risk in Men (2013). Occupational
Health, 65(1), 4.
The Importance of Vision. (2013, January 13). Retrieved
June 1, 2013, from http://winningleadership
.wordpress.com/2013/01/13/the-importance-of-vision/
Watkins, M. (2013, May 15). What is organizational culture?
And why should we care? Retrieved June 1, 2013,
from http://blogs.hbr.org/cs/2013/05/what_is
_organizational_culture.html

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http://insight.kellogg.northwestern.edu/index.php/Kellogg/article/losing_touch

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311
14
Organizing Patient Care
… patients now more than ever need reassurance that they are indeed the focus of the healthcare
team.
—Joan Shinkus Clark
… nurses have gone beyond the role of caregivers to become key integrators, care coordinators and
efficiency experts who are redesigning the patient experience through new, innovative healthcare
delivery models
—Linda Beattle
CROSSWALK thiS Chapter addreSSeS:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential V: health-care policy, finance, and regulatory environments
MSN Essential II: Organizational and systems leadership
MSN Essential III: Quality improvement and safety
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: teamwork and collaboration
QSEN Competency: patient-centered care
QSEN Competency: Quality improvement
QSEN Competency: Safety
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
LEARNING OBJECTIVES The learner will:
l differentiate among various types of patient care delivery systems, including total patient care,
functional nursing, team nursing, modular nursing, primary nursing, and case management
l discuss the historical events that led to the evolution of different types of patient care
delivery models
l debate the driving and restraining forces for reserving the primary nurse role for the
registered nurse
l differentiate between managed care and population-based health-care management
l identify desired outcomes in disease management programs and the role the case manager
plays in achieving those outcomes
l differentiate between nurse case managers and nurse navigators
l discuss how work redesign may affect social relationships on a unit
l explain what effect staff mix has on work design and patient care organization
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312 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
l identify factors that must be evaluated before initiating a change in a patient care delivery
system
l delineate new roles that are expanding the role of nurses beyond caregivers to key integrators,
care coordinators and efficiency experts such as case managers, nurse navigators, and clinical
nurse-leaders
l describe the core concepts of patient- and family-centered care
l describe the role competencies expected of the clinical nurse-leader, as described by the
american association of Colleges of Nursing
Top-level managers are most likely to influence the philosophy and resources necessary for
any selected care delivery system to be effective, since without a supporting philosophy and
adequate resources, the most well-intentioned delivery system will fail. It is the first- and
middle-level managers, however, who generally have the greatest influence on the organizing
phase of the management process at the unit or department level. It is here that leader-
managers organize how work is to be done, shape the organizational climate, and determine
how patient care delivery is organized.
In addition, the unit leader-manager determines how best to plan work activities so that
organizational goals are met effectively and efficiently. This involves using resources wisely
and coordinating activities with other departments, since how activities are organized can
impede or facilitate communication, flexibility, and job satisfaction.
For organizing functions to be productive and facilitate meeting the organization’s
needs, the leader must also know the organization and its members well. Activities will be
unsuccessful if their design does not meet group needs and capabilities. The roles and functions
of the leader-manager in organizing groups for patient care are shown in Display 14.1.
LEADERSHIP ROLES
1. periodically evaluates the effectiveness of the organizational structure for the delivery of patient care.
2. determines if adequate resources and support exist before making any changes in the organiza-
tion of patient care.
3. examines the human element in work redesign and supports personnel during adjustment to
change.
4. inspires the work group toward a team effort.
5. inspires subordinates to achieve higher levels of education, clinical expertise, competency, and
experience in differentiated practice.
6. ensures that chosen nursing care delivery models advance the practice of professional nursing.
7. encourages and supports the use of nursing care delivery models that maximize the abilities of
each member on the health-care team.
8. assures congruence between the organizational mission and philosophy and the patient care
delivery system selected for use.
9. assures that the patient and family are the focus of patient care delivery, regardless of which
patient care delivery system is used.
MANAGEMENT FUNCTIONS
1. Makes changes in work design to facilitate meeting organizational goals.
2. Selects a patient care delivery system that is most appropriate to the needs of the patients being
served as well as the expertise of the staffing mix.
3. Uses scientific research and current literature to analyze proposed changes in nursing care
delivery models.
4. Uses a patient care delivery system that maximizes human and physical resources as well as time.
5. ensures that nonprofessional staff are appropriately trained and supervised in the provision of care.
DISPLAY 14.1 Leadership Roles and Management Functions Associated with Organizing
Patient Care

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Chapter 14 Organizing Patient Care 313
TRADITIONAL MODES OF ORGANIZING PATIENT CARE
The five most well-known means of organizing nursing care for patient care delivery are
total patient care, functional nursing, team and modular nursing, primary nursing, and case
management (Display 14.2). Each of these basic types has undergone many modifications,
often resulting in new terminology. For example, primary nursing was once called case
method nursing and is now frequently referred to as a professional practice model. Team
nursing is sometimes called partners in care or patient service partners, and case managers
assume different titles depending on the setting in which they provide care.
6. Organizes work activities to attain organizational goals.
7. Groups activities in a manner that facilitates communication and coordination within and
between departments.
8. Organizes work so that it is as time and cost-effective as possible.
9. appropriately identifies cost drivers in high-cost, high-resource utilization diseases and organizes
patient care to address these with efficiency across care settings.
10. explores opportunities to use case managers, nurse navigators, and clinical nurse-leaders
(CNLs) to better integrate and coordinate care.
When closely examined, many of the newer models of patient care delivery systems
are merely recycled, modified, or retitled versions of older models. Indeed, it is sometimes
difficult to find a delivery system true to its original version or one that does not have parts of
others in its design. Although some of these care delivery systems were developed to organize
care in hospitals, most can be adapted to other settings. The choice of an organization model
involves staff skills, availability of resources, patient acuity, and the nature of the work to be
performed.
Many of the newer models of patient care delivery systems are merely recycled, modified, or
retitled versions of older models.
Total Patient Care Nursing or Case Method Nursing
Total patient care is the oldest mode of organizing patient care. With total patient care, nurses
assume total responsibility during their time on duty for meeting all the needs of assigned
patients. Total patient care nursing is sometimes referred to as the case method of assignment
because patients may be assigned as cases, much like private-duty nursing was historically
carried out.
Indeed, at the turn of the 19th century, total patient care was the predominant nursing
care delivery model. Care was generally provided in the patient’s home, and the nurse was
responsible for cooking, house cleaning, and other activities specific to the patient and family
in addition to traditional nursing care. During the Great Depression of the 1930s, however,
people could no longer afford home care and began using hospitals for care that had been
performed by private-duty nurses in the home. During that time, nurses and students were
total patient care
Functional nursing
team and modular nursing
primary nursing
Case management
DISPLAY 14.2 Traditional Patient Care Delivery Methods
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314 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
the caregivers in hospitals and in public health agencies. As hospitals grew during the 1930s
and 1940s, providing total care continued to be the primary means of organizing patient care.
This method of assignment is still widely used in hospitals and home health agencies.
This organizational structure provides nurses with high autonomy and responsibility.
Assigning patients is simple and direct and does not require the planning that other
methods of patient care delivery require. The lines of responsibility and accountability are
clear. The patient theoretically receives holistic and unfragmented care during the nurse’s
time on duty.
Each nurse caring for the patient can, however, modify the care regimen. Therefore, if there
are three shifts, the patient could receive three different approaches to care, often resulting
in confusion for the patient. To maintain quality care, this method requires highly skilled
personnel and thus may cost more than some other forms of patient care. This method’s
opponents argue that some tasks performed by the primary caregiver could be accomplished
by someone with less training and therefore at a lower cost. A structural diagram of total
patient care is shown in Figure 14.1.
The greatest disadvantage of total patient care delivery occurs when the nurse is
inadequately prepared or too inexperienced to provide total care to the patient. In the early
days of nursing, only registered nurses (RNs) provided care; now, many hospitals assign
LVNs/LPNs as well as unlicensed health-care workers to provide much of the nursing care.
Because the coassigned RN may have a heavy patient load, little opportunity for supervision
may exist and this could result in unsafe care.
Functional Method
The functional method of delivering nursing care evolved primarily as a result of World War
II and the rapid construction of hospitals as a result of the Hill Burton Act. Because nurses
were in great demand overseas and at home, a nursing shortage developed and ancillary
Nursing Staff
Charge Nurse
Patients
Patients
Patients
Nursing Staff
Nursing Staff
FIGURE 14.1 • Case method or total patient care structure.

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Chapter 14 Organizing Patient Care 315
personnel were needed to assist in patient care. These relatively unskilled workers were
trained to do simple tasks and gained proficiency by repetition. Personnel were assigned to
complete certain tasks rather than care for specific patients. Examples of functional nursing
tasks were checking blood pressures, administering medication, changing linens, and bathing
patients. RNs became managers of care rather than direct care providers, and “care through
others” became the phrase used to refer to this method of nursing care. Functional nursing
structure is shown in Figure 14.2.
The functional form of organizing patient care was thought to be temporary, as it was
assumed that when the war ended, hospitals would not need ancillary workers. However,
the baby boom and resulting population growth immediately following World War II left
the country short of nurses. Thus, employment of personnel with various levels of skill and
education proliferated as new categories of health-care workers were created. Currently,
most health-care organizations continue to employ health-care workers of many educational
backgrounds and skill levels.
Most administrators consider functional nursing to be an economical and efficient means
of providing care. This is true if quality care and holistic care are not regarded as essential.
A major advantage of functional nursing is its efficiency; tasks are completed quickly, with
little confusion regarding responsibilities. Functional nursing does allow care to be provided
with a minimal number of RNs, and in many areas, such as the operating room, the functional
structure works well and is still very much in evidence. Long-term care facilities also
frequently use a functional approach to nursing care.
During the past decade, however, the use of unlicensed assistive personnel (UAP), also
known as nursing assistive personnel, in health-care organizations has increased. Many nurse
administrators believe that assigning low-skill tasks to UAP frees the professional nurse to
perform more highly skilled duties and is therefore more economical; however, others argue
that the time needed to supervise the UAP negates any time savings that may have occurred.
Most modern administrators would undoubtedly deny that they are using functional nursing,
yet the trend of assigning tasks to workers, rather than assigning workers to the professional
nurse, resembles, at least in part, functional nursing.
RN Medication
Nurse
RN Treatment
Nurse
Nursing Assistants/
Hygienic Care
Clerical/
Housekeeping
Patients
Charge Nurse
FIGURE 14.2 • Functional nursing organization structure. Copyright ® 2006 Lippincott
Williams & Wilkins. instructor’s resource Cd-rOM to accompany Leadership roles and
Management Functions in Nursing, by Bessie L. Marquis and Carol J. huston.
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316 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
Functional nursing may lead to fragmented care and the possibility of overlooking patient
priority needs. In addition, because some workers feel unchallenged and understimulated in
their roles, functional nursing may result in low job satisfaction. Functional nursing may also
not be cost-effective due to the need for many coordinators. Employees often focus only on
their own efforts, with less interest in overall results.
LEARNING EXERCISE 14.1
Transitioning to Total Patient Care
Most nursing students begin their clinical training by doing some form of functional nursing care
and then advancing to total patient care for a small number of patients. reflect back to your
earliest clinical experiences as a student nurse. Which tasks were easiest for you to learn? how
did you gain mastery of those tasks? Was task mastery a time-consuming process for you? Was
it difficult to make the transition to total patient care? if so, why? What skills were most difficult
for you to learn in providing total patient care? do you anticipate having to learn additional skills
to feel comfortable in the role of total care provider as an rN? What higher level (nonfunctional)
skills do you think will be the hardest to learn and be confident with?
Team Nursing
Despite a continued shortage of professional nursing staff in the 1950s, many believed that a
patient care system had to be developed that reduced the fragmented care that accompanied
functional nursing. Team nursing was the result. In team nursing, ancillary personnel
collaborate in providing care to a group of patients under the direction of a professional nurse.
As the team leader, the nurse is responsible for knowing the condition and needs of all the
patients assigned to the team and for planning individual care. The team leader’s duties vary
depending on the patient’s needs and the workload. These duties may include assisting team
members, giving direct personal care to patients, teaching, and coordinating patient activities.
Team nursing structure is illustrated in Figure 14.3.
Through extensive team communication, comprehensive care can be provided for patients
despite a relatively high proportion of ancillary staff. This communication occurs informally
between the team leader and the individual team members and formally through regular team
planning conferences. A team should consist of not more than five people, or it will revert to
more functional lines of organization.
Team nursing is also usually associated with democratic leadership. Group members are
given as much autonomy as possible when performing assigned tasks, although the team
shares responsibility and accountability collectively. The need for excellent communication
and coordination skills makes implementing team nursing difficult and requires great self-
discipline on the part of team members.
Team nursing also allows members to contribute their own special expertise or skills.
Nagi, Davies, Williams, Roberts, and Lewis (2012, p. 56) note that “overall, the team
model encompasses all levels of skills and is characterized by a sharing of workload and
the supervisory/evaluative role of the team leader.” Team leaders, then, should use their
knowledge about each member’s abilities when making patient assignments. Recognizing
the individual worth of all employees and giving team members autonomy results in high
job satisfaction.
Disadvantages to team nursing are associated primarily with improper implementation
rather than with the philosophy itself. Frequently, insufficient time is allowed for team care
planning and communication. This can lead to blurred lines of responsibility, errors, and

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Chapter 14 Organizing Patient Care 317
fragmented patient care. For team nursing to be effective then, the team leader must be
an excellent practitioner and have good communication, organizational, management, and
leadership skills.
The Multidisciplinary Team Leader Role
One of the recommendations of the 2010 Institute of Medicine Report, The Future of
Nursing, was to expand the opportunities for nurses to lead and diffuse collaborative
improvement efforts with physicians and other members of the health-care team to
improve practice environments (Robert Wood Johnson Foundation, 2011). Some health-care
organizations currently incorporate pharmacists, social workers, occupational therapists,
speech therapists, and other health-care workers as part of the multidisciplinary team to
assure that comprehensive and holistic health care can be provided to each patient, although
the responsibility for team leadership still typically falls to the RN.
Nagi et al. (2012) note, however, that implementation problems are common in
multidisciplinary or multiprofessional teams since; mutual respect and collaboration is not a
given; not all workers like working in teams; and role clarification issues surrounding clinical
accountability, leadership, and understanding between professionals are common. Carlyle,
Crowe, and Deering (2012) concur, noting that in both the inpatient and outpatient mental
health setting, nursing is usually delivered by multidisciplinary teams with an assumption
that all disciplines are working within a common model of care. Carlyle et al. (2012) suggest,
however, that this often is not the case.
Nursing Staff
Charge Nurse
Patients
Patients
Patients
Team Leader
Team Leader
Team Leader
Nursing Staff
Nursing Staff
FIGURE 14.3 • team nursing organization structure. Copyright ® 2006 Lippincott
Williams & Wilkins. instructor’s resource Cd-rOM to accompany Leadership roles
and Management Functions in Nursing, by Bessie L. Marquis and Carol J. huston.
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318 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
In addition, like traditional team nursing, multidisciplinary teams require an efficient
means of communication about patient goals, progress, and problems. It is not often easy to
find opportunities for the whole team to meet because of work shift patterns or other work
commitments.
In addition, sometimes, there are challenges in determining who the members of the
team should be. For example, teamwork has long been considered an expectation in the
field of trauma care since the initial assessment and resuscitation of trauma victims is most
successfully carried out by an organized trauma team (Speck, Jones, Barg, & McCunn, 2012).
Yet, as detailed in Examining the Evidence 14.1, general agreement about who holds critical
positions on this team and what roles they hold varies between team members; in particular,
the relative value of the RN as a member of the team may not be recognized.
Modular Nursing
Team nursing, as originally designed, has undergone much modification in the last 30 years.
Most team nursing was never practiced in its purest form but was instead a combination of
team and functional structure. More recent attempts to refine and improve team nursing have
resulted in many models including modular nursing.
Most team nursing was never practiced in its purest form but was instead a combination of team
and functional structure.
Modular nursing uses a mini-team (two or three members with at least one member being
an RN), with members of the modular nursing team sometimes being called care pairs.
In modular nursing, patient care units are typically divided into modules or districts and
assignments are based on the geographical location of patients.
Keeping the team small in modular nursing and attempting to assign personnel to the same
team as often as possible should allow the professional nurse more time for planning and
coordinating team members. In addition, a small team requires less communication, allowing
members better use of their time for direct patient care activities.
Source: Speck, R. M., Jones, G., Barg, F. K., & McCunn, M. (2012). Team composition and perceived roles of team
members in the trauma bay. Journal of trauma Nursing, 19(3), 133–138.
The researchers used two qualitative data collection strategies in this study: participant observa-
tion and semistructured interviews. Trauma team members were observed in the trauma bay of
an academic level 1 trauma center for more than 300 hours. In addition, 32 semistructured inter-
views were conducted with practitioners on trauma teams (attending physicians, nurses, fellows,
residents, and medical students).
The researchers found that team leaders (attending physicians and fellows) viewed nurses
as vital, irreplaceable members of the team. Yet, medical students and junior residents did not
even consider nurses to be part of the team. This finding was further complicated by the nurses’
descriptions of how they often instructed or guided junior trauma team members during cases.
These researchers suggested this disconnect may be attributable to a system where medical
students and residents are constantly rotating from specialties and are without a consistent
model of how team leaders view nurses. Another explanation may relate to the long-standing
inconsistency between nurses and physicians with regard to status, authority, gender, training,
and patient care responsibilities, and discrepant attitudes regarding collaboration between phy-
sicians and nurses.
Examining the Evidence 14.1

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Chapter 14 Organizing Patient Care 319
Primary Nursing and Interprofessional Primary Health-Care Teams
Primary Nursing
Primary nursing, also known as relationship-based nursing, was developed in the late 1960s,
uses some of the concepts of total patient care and brings the RN back to the bedside to provide
clinical care. According to Manthey (2009), “the foundational principles of primary nursing
were revolutionary: For the first time in hospital nursing, explicit responsibility and authority
for specific patients were clearly allocated to a specific registered nurse (whose license by law
permits independent decision making about nursing care). At no time in the history of hospital
nursing, had that degree of professional control over nursing practice been organizationally
sanctioned at the staff nurse level” (p. 36). This required a major redesign of unit organizations,
administrative structures, and managerial philosophy, as well as a challenging transformation
of roles and relationships at the point of patient care (Manthey, 2009).
In primary nursing, the primary nurse assumes 24-hour responsibility for planning the care
of one or more patients from admission or the start of treatment to discharge or the treatment’s
end. During work hours, the primary nurse provides total direct care for that patient. When
the primary nurse is not on duty, associate nurses, who follow the care plan established by the
primary nurse, provide care. Many experts have suggested that the role of the primary nurse
should be limited to RNs; however, Manthey (2009) argues that primary nursing can succeed
with a diverse skill mix just as team nursing or any other model can succeed with an all-RN
staff. Primary nursing structure is shown in Figure 14.4.
Primary nursing can succeed with a diverse skill mix just as team nursing or any other model
can succeed with an all-RN staff.
Although originally designed for use in hospitals, primary nursing lends itself well to
home health nursing, hospice nursing, and other health-care delivery enterprises as well.
Associate Nurse
(as needed)
(days)
Associate Nurse
(evenings)
Associate Nurse
(nights)
Health-Care
Organizations
Resources
Physician
Charge
Nurse
Primary Nurse
Patient
FIGURE 14.4 • primary nursing structure. Copyright ® 2006 Lippincott Williams &
Wilkins. instructor’s resource Cd-rOM to accompany Leadership roles and
Management Functions in Nursing, by Bessie L. Marquis and Carol J. huston.
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320 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
An integral responsibility of the primary nurse is to establish clear communication among
the patient, the physician, the associate nurses, and other team members. Although the
primary nurse establishes the care plan, feedback is sought from others in coordinating
the patient’s care. The combination of clear interdisciplinary group communication and
consistent, direct patient care by relatively few nursing staff allows for holistic, high-
quality patient care.
Although job satisfaction is high in primary nursing, this method is difficult to implement
because of the degree of responsibility and autonomy required of the primary nurse. However,
for these same reasons, once nurses develop skill in primary nursing care delivery, they often
feel challenged and rewarded.
Disadvantages to this method, as in team nursing, lie primarily in improper implementation.
An inadequately prepared or incompetent primary nurse may be incapable of coordinating
a multidisciplinary team or identifying complex patient needs and condition changes. Many
nurses may be uncomfortable in this role or initially lack the experience and skills necessary
for the role. In addition, although an all-RN nursing staff has not been proved to be more
costly than other modes of nursing, it sometimes has been difficult to recruit and retain
enough RNs to be primary nurses, especially in times of nursing shortages. Other challenges
in implementing primary nursing include “shorter lengths of stay, increasing numbers of
part-time positions, and variable shift lengths, combined with the ongoing pragmatic need to
provide holistic, coordinated care to human beings” (Manthey, 2009, p. 37). These logistical
issues can best be managed by unit-based decisions arrived at through the consensus of a
unified and cohesive staff (Manthey, 2009).
LEARNING EXERCISE 14.2
Reorganizing to Accommodate a Change in Staffing Mix
You are the head nurse of an oncology unit. at present, the patient care delivery method on
the unit is total patient care. You have a staff composed of 60% rNs, 35% practical nurses
(licensed professional nurses [LpNs]/licensed vocational nurses [LVNs]), and 5% clerical staff.
Your bed capacity is 28, but your average daily census is 24. an example of day-shift staffing
follows:
● One charge nurse who notes orders, talks with physicians, organizes care, makes
assignments, and acts as a resource person and problem solver
● three rNs who provide total patient care, including administering all treatments and
medications to their assigned patients, giving iV medications to the LVN/LpNs’ assigned
patients, and acting as a clinical resource person for the LVN/LpNs
● two LVN/LpNs assigned to provide total patient care except for administering iV medications
Your supervisor has just told all head nurses that because the hospital is experiencing financial
difficulties, it has decided to increase the number of nursing assistants in the staffing mix. the
nurses on your unit will have to assume more supervisory responsibilities and focus less on
direct care. Your supervisor has asked you to reorganize the patient care management on your
unit to best use the following day-shift staffing: three rNs, which will include the present charge
nurse position; two LVN/LpNs and two nursing assistants. You may delete the past charge
nurse position and divide charge responsibility among all three nurses or divide up the work any
way you choose.
Assignment: draw a new patient care organization diagram. Who would be most affected
by the reorganization? evaluate your rationale, for both the selection of your choice and the
rejection of others. explain how you would go about implementing this planned change.

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Chapter 14 Organizing Patient Care 321
Interprofessional Primary Health-Care Teams
Like team nursing, primary care has expanded to interdisciplinary teams. Sibbald, Wathen,
Kothari, and Day (2013) note primary health-care teams (PHCTs) are interprofessional
teams that include, but are not limited to, physicians, nurse practitioners, nurses, physical
therapists, occupational therapists, and social workers, who work collaboratively to deliver
coordinated patient care. “Team-based models of PHCT delivery have been created to achieve
(or work toward) several benefits to the health system, health care providers, and patients,
including better coordination of care, increased focus on collaborative problem solving and
decision making, and a commitment to patient-centered care” (Sibbald et al., p. 129). The
desired outcomes for PHCTs are reduced mortality and improved quality of life for patients,
a reduction in health-care costs, and a more rewarding professional experience for the health-
care worker.
The challenges to implementing primary health care on the PHCT mirror many of the
challenges seen in more traditional primary care, including hurdles in their formation;
overcoming the traditional physician-dominated hierarchy in determining who should lead
the team; role confusion; and determination of structure and function of the team. In addition,
because the interprofessional team brings together differing viewpoints, life experiences,
and knowledge of evidence-based practices, determining what knowledge is most important
in caring for the patient can be confusing. Research by Sibbald et al. (2013) found that in
most PHCTs, only a few individuals (residents, senior physicians, and nurse practitioners)
actively brought research findings and knowledge to the team and allied health professionals.
Sibbald et al. suggested that those with cross-team responsibilities might be better utilized as
information resources.
Case Management
Case management is another work design proposed to meet patient needs. Case management
is defined by the Case Management Society of America (CMSA) as “a collaborative process
of assessment, planning, facilitation and advocacy for options and services to meet an
individual’s health needs through communication and available resources to promote quality
cost-effective outcomes” (CMSA, 2008–2012, para 58).
In case management, nurses address each patient individually, identifying the most cost-
effective providers, treatments, and care settings possible. This requires the case manager
to drill down and identify any barriers to adherence that other providers may miss (Primary
Care—the New Frontier for Case Managers, 2013). In addition, the case manager helps
patients access community resources, learn about their medication regimen and treatment
plan, and ensures that they have recommended tests and procedures.
While case management referrals often begin in the hospital inpatient setting, with
length of stay (LOS) and profit margin per confinement used as measures of efficiency, case
management now frequently extends to outpatient settings as well. Indeed, the new medical
homes suggested as part of the Patient Care Protection and Affordable Care Act are likely to
use case managers extensively.
Historically, however, the focus of case management has been episodic or component
style orientation to the treatment of disease in inpatient settings and post acute care settings
for insured individuals. Acute care case management integrates utilization management and
discharge planning functions and may be unit based, assigned by patient, disease based, or
primary nurse case managed.
Case managers often manage care using critical pathways (Chapter 10) and
multidisciplinary action plans (MAPs) to plan patient care. The care MAP is a combination
of a critical pathway and a nursing care plan. In addition, the care MAP indicates times
when nursing interventions should occur. All health-care providers follow the care MAP
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322 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
to facilitate expected outcomes. If a patient deviates from the normal plan, a variance is
indicated. A variance is anything that occurs to alter the patient’s progress through the
normal critical path.
Because the role expectations and scope of knowledge required to be a case manager are
extensive, some experts have argued that this role should be reserved for the advance practice
nurse or RN with advanced training, although this is not usually the case in the practice
setting today. In fact, board certification as a case manager is available to any individual
with a four-year degree in a health or human service area, with completed supervised
field experience in case management, health, or behavioral health as part of their degree
requirements (Commission for Case Management Certification, 2013).
Some feel that the role of case manager should be reserved for the advance practice nurse or
RN with advanced training.
Other implementation challenges associated with case management nursing revolve around
confusion related to the specific job of the case manager since case management entails
different roles and functions in different settings (Gray & White, 2012). For example, in some
settings, case managers participate in direct care or have direct communication with patients.
In others, the case manager is an advocate for patients although the patient may have no direct
knowledge or interaction with that individual.
Smith (2011) suggests that most nurses will experience role ambiguity and role conflict
when they first take on the case manager role, primarily because of inadequate role definition,
unexpected ethical challenges, and lack of prior insight into the case manager role. Gray and
White (2012) suggest that the role of the nurse case manager must be clear and concise before
care can be delivered efficiently, at the right level, and in a way that produces improved
patient outcomes.
LEARNING EXERCISE 14.3
Developing a Case Management Plan
Jimmy Jansen is a 44-year-old man with type 1 diabetes mellitus. he was recently referred
to your home health agency for case management follow-up at home. he is experiencing
multiple complications from his diabetes, including the recent onset of blindness and
peripheral neuropathy. his left leg was amputated below the knee last year as a result of
a gangrenous infection of his foot. he is unable to wear his prosthesis at present because
he has a small ulcer at the stump site. his chart states that he has been only “intermittently
compliant” with blood glucose testing or insulin administration in the past despite the visit of
a community health nurse on a weekly basis over the past year. his renal function has become
progressively worse over the past 6 months, and it is anticipated that he will need to begin
hemodialysis soon.
his social history reveals that he recently separated from his wife and has no contact with
an adult son who lives in another state. he has not worked for more than 10 years and has
no insurance other than Medicaid. the home he lives in is small, and he says that he has not
been able to keep it up with his wife gone. No formal safety assessment of his home has been
conducted. he also acknowledges that he is not eating right because he now must do his own
cooking. he cannot drive and states, “i don’t know how i’m going to get to the clinic to have my
blood cleaned by the kidney machine.”

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Chapter 14 Organizing Patient Care 323
DISEASE MANAGEMENT
One role that is increasingly assumed by case managers is coordinating disease management
(DM) programs. DM, also known as population-based health-care and continuous health
improvement, is a comprehensive, integrated approach to the care and reimbursement of
high-cost, chronic illnesses.
The goal of DM is to address such illnesses or conditions with maximum efficiency
across treatment settings regardless of typical reimbursement patterns. Thus, a continuum of
chronic illness care is established that includes early detection and early intervention. This
prevents or reduces exacerbation of the disease, acute episodes (known as cost drivers),
and the use of expensive resources such as hospital inpatient care, making prevention and
proactive case management two important areas of emphasis. In addition, DM programs
include comprehensive tracking of patient outcomes. Thus, the goals for DM are focused on
integrating components and improving long-term outcomes.
In DM programs, common high-cost, high-resource utilization diseases are identified,
and population groups are targeted for implementation. This is one of the most important
differences between case management and DM. In population-based health care, the focus is
on “covered lives” or populations of patients, rather than on the individual patient. The goal
in DM is to service the optimal number of covered lives required to reach operational and
economic efficiency. In other words, DM is effective when cost drivers are reduced at the
same time that patient needs are met.
Providing optimum, cost-effective care to individual patients is critical to the success of a DM
program; however, the focus for planning, implementation, and evaluation is population based.
Other primary features of DM programs include the use of a multidisciplinary health-care
team, including specialists in the area, the selection of large population groups to reduce
adverse selection, the use of standardized clinical guidelines—clinical pathways reflecting
best practice research to guide provider practice, and the use of integrated data management
systems to track patient progress across care settings and allow continuous and ongoing
improvement of treatment algorithms. Common features of DM programs are shown in
Display 14.3.
One thing is clear—DM continues to grow as a means of organizing patient care. This
is particularly true in the government sector, which did not really begin embracing DM
demonstration projects until early in the 21st century, many of which are now mainstream
initiatives, in an effort to deliver better outcomes at better prices. In addition, DM continues
to hold significant promise as a strategy for promoting cost-effective, quality health care in
Assignment: Mr. Jansen has many problems that would likely benefit from case management
intervention.
1. Make a list of five nursing diagnoses for Mr. Jansen that you would use to prioritize your
interventions.
2. then make a list of at least five goals that you would like to accomplish in planning Mr.
Jansen’s care. Make sure that these goals reflect realistic patient outcomes.
3. What referrals would you make? What interventions would you implement yourself? Would
you involve other disciplines in his plan of care?
4. What is your plan for follow-up and evaluation?
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324 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
the future, and DM programs can only be expected to expand in scope and quantity. Similarly,
RNs, in their roles as case managers, will continue to experience new and expanded roles as
key players in the development, coordination, and evaluation of DM programs.
1. provide a comprehensive, integrated approach to the care and reimbursement of common, high-
cost, chronic illnesses.
2. Focus on prevention as well as early disease detection and intervention to avoid costly acute
episodes but provide comprehensive care and reimbursement.
3. target population groups (population based) rather than individuals.
4. employ a multidisciplinary health-care team, including specialists.
5. Use standardized clinical guidelines—clinical pathways reflecting best practice research to guide
providers.
6. Use integrated data management systems to track patient progress across care settings and allow
continuous and ongoing improvement of treatment algorithms.
7. Frequently employ professional nurses in the role of case manager or program coordinator.
DISPLAY 14.3 Common Features of Disease Management Programs
LEARNING EXERCISE 14.4
Researching Disease Management Programs
Search the internet for dM (disease management, not diabetes mellitus) programs. What chronic
diseases were most commonly represented in the dM programs that you identified? What entities
(private insurance companies, managed care insurers, government, pharmaceutical companies,
private companies, etc.) sponsored these programs? What is the process for referral? are
the programs accredited? are rNs used as case managers or program coordinators? What
standardized clinical guidelines are used in the program, and are they evidence based?
Assignment: Select one of the programs that you found, and write a one-page summary
regarding your findings.
SELECTING THE OPTIMUM MODE OF ORGANIZING PATIENT CARE
Most health-care organizations use one or more modes to organize patient care. While not
all care must be provided by RNs, the care delivery system chosen should be based on
patient acuity and not on economics alone. In addition, the knowledge and skill required for
particular activities with specific populations should always be the true driver in determining
appropriate care delivery models. Nursing departments need to organize delivery of patient
care based on the best method for their particular situation.
Many nursing units have a history of selecting methods of organizing patient care based upon
the most current popular mode rather than objectively determining the best method for a
particular unit or department.
If evaluation of the present system reveals deficiencies, the manager needs to examine
available resources and compare those with resources needed for the change. Nursing
managers often elect to change to a system that requires a high percentage of RNs, only to
discover resources are inadequate, resulting in a failed planned change. One of the leadership
responsibilities in organizing patient care is to determine the availability of resources

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Chapter 14 Organizing Patient Care 325
and support for proposed changes. There must be a commitment on the part of top-level
administration and a majority of the nursing staff for a change to be successful. Because
health care is multidisciplinary, the care delivery system used will have a heavy impact on
many others outside the nursing unit; therefore, those affected by a system change must be
involved in its planning. Change affects other departments, the medical staff, and the health-
care consumer. Perhaps, most importantly, the philosophy of the nursing services division
must support the delivery model selected.
Another mistake frequently made when changing modes of patient care delivery
is to not fully understand how the new system should function or be implemented.
Managers must carry out adequate research and be well versed in the system’s proper
implementation if the change is to be successful. It is important also to remember
that not every nurse desires a challenging job with the autonomy of personal decision
making. Many forces interact simultaneously in employee job design situations.
Satisfaction does not occur only because of role fulfillment but also because of social
and interpersonal relations. Therefore, the nurse-leader-manager needs to be aware that
redesigning work that disrupts group cohesiveness may result in increased levels of job
dissatisfaction.
Not every nurse desires a challenging job, with the autonomy of personal decision making.
Such change should not be taken lightly. The leader-manager should consider the following
when evaluating the current system and considering a change:
• Is the method of patient care delivery providing the level of care that is stated in the
organizational philosophy? Does the method facilitate or hinder other organizational
goals?
• Is the delivery of nursing care organized in a cost-effective manner?
• Does the care delivery system satisfy patients and their families? (Satisfaction and
quality care differ; either may be provided without the other being present.)
• Does the organization of patient care delivery provide some degree of fulfillment and
role satisfaction to nursing personnel?
• Does the system allow implementation of the nursing process?
• Does the system promote and support the profession of nursing as both independent and
interdependent?
• Does the method facilitate adequate communication among all members of the health-
care team?
• How will a change in the patient care delivery system alter individual and group decision
making? Who will be affected? Will autonomy decrease or increase?
• How will social interactions and interpersonal relationships change?
• Will employees view their unit of work differently? Will there be a change from a partial
unit of work to a whole unit? (For example, total patient care would be a whole unit of
work, whereas team nursing would be a partial unit.)
• Will the change require a wider or more restricted range of skills and abilities on the part
of the caregiver?
• Will the redesign change how employees receive feedback on their performance, either
by self-evaluation or by others?
• Will communication patterns change?
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326 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
The most appropriate organizational model to deliver patient care for each unit or
organization depends on the skill and expertise of the staff, the availability of registered
professional nurses, the economic resources of the organization, the acuity of the patients,
and the complexity of the tasks to be completed.
Newer Health-Care Delivery Models and Nursing Roles
Beattie (2009) suggests that health-care delivery models have emerged that are expanding
the role of nurses beyond caregivers to be key integrators, care coordinators, and efficiency
experts who are redesigning the patient experience. A white paper, entitled Innovative Care
Delivery Models: Identifying New Models That Effectively Leverage Nurses, was published
by Health Workforce Solutions in 2009. This white paper suggested that nurses form the
backbone of almost all these new models and that eight common themes could be identified
among the most successful care delivery models. These are shown in Display 14.4.
In addition, three emerging roles are detailed in this chapter: nurse navigators, Clinical Nurse
Leaders (CNLs), and nurses working in settings that embrace patient- and family-centered care.
1. elevating the role of nurses and transitioning from caregivers to “care integrators.”
2. taking a team approach to interdisciplinary care.
3. Bridging the continuum of care outside of the primary care facility.
4. defining the home as a setting of care.
5. targeting high users of health care, especially older adults.
6. Sharpening focus on the patient, including an active engagement of the patient and her or his family
in care planning and delivery, and a greater responsiveness to the patient’s wants and needs.
7. Leveraging technology.
8. improving satisfaction, quality, and cost.
DISPLAY 14.4 Common Themes Found Among Emerging Care Delivery Models
Nurse Navigators
The nurse navigator role is a relatively new role for professional nurses. Nurse navigators
help patients and families navigate the complex health-care system by providing information
and support as they traverse their illness (Llewellyn, 2013). Nurse navigation commonly
occurs in targeted clinical settings such as oncology, whereby a breast cancer nurse navigator
might work with a woman from the time she is first diagnosed and then follow her throughout
the course of her illness.
Nurse navigators are also expected to be increasingly visible with the new Insurance
Exchanges (Healthcare Marketplace) that will roll out with health-care reform (Llewellyn,
2013). In this case, consumers are expected to go to nurse navigators to learn about and
purchase an insurance plan from the Exchanges. Critics suggest, however, that further role
definition is needed to differentiate between the role case managers and nurse navigators will
play in the coming decade.
The Clinical Nurse-Leader
Many of the newer patient care delivery models include the nurse as a clinical expert leading
other members of a team of partners. For example, the American Association of Colleges of
Nursing (AACN) identified a new nursing role in the early 1990s, that of the CNL, that is
more responsive to the realities of the modern health-care system. The CNL, as an advanced
generalist with a master’s degree in nursing, is expected to provide clinical leadership at
the point of care in all health-care settings, implement outcomes-based practice and quality
improvement strategies, engage in clinical practice, and create and manage microsystems of
care that are responsive to the health-care needs of individuals and families (AACN, 2007).

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Chapter 14 Organizing Patient Care 327
The CNL role, however, is not one of administration or management. Instead, the CNL
“assumes accountability for healthcare outcomes for a specific group of clients within a
unit or setting through the assimilation and application of research-based information to
design, implement, and evaluate client plans of care” (AACN, 2007, p. 6). The CNL then is a
provider and a manager at the point of care to individuals and cohorts, and as such, designs,
implements, and evaluates client care by coordinating, delegating, and supervising the care
provided by the health-care team (AACN).
The CNL also plays a key role in collaborating with interdisciplinary teams. Susan
B. Hasmiller, a Robert Wood Johnson Senior Advisor for Nursing, suggested that the CNL
as a leader of these teams identifies risk-analysis strategies and resources needed to ensure
the safe delivery of care and then relies on patient-centered, evidence-based practice and
performance data to make needed decisions (Robert Wood Johnson Foundation [RWJ],
2009). As such, the CNL shows “enormous promise” in redesigning the way healthcare is
delivered (RWJ, para 1).
In addition, the Veterans Health Administration became an early adopter of the CNL
role, implementing the CNL initiative across all VA settings. At the VA, CNLs serve as the
point person on patient care teams and are leaders in the health-care delivery system. “This
revolutionary role is providing an increasingly positive impact on patient care outcomes, and
professional career satisfaction for many staff nurses” (US Department of Veterans Affairs,
2013, para 2).
Patient- and Family-Centered Care
While not specifically a patient care delivery model, patient- and family-centered care does
represent a change in the paradigm of care and does strongly influence how care must be
delivered. Abraham and Moretz (2012) suggest that patient- and family-centered care is an
innovative approach to the planning, delivery, and evaluation of health care grounded in
mutually beneficial partnerships between patients, families, and health-care providers.
The philosophy of patient-centered care is based on the premise that care should be
organized first and foremost around the needs of patients (Planetree, 2013). The Institute
for Patient- and Family-Centered Care (IPFCC) (2013) agrees, suggesting that patient- and
family-centered care is an approach to the planning, delivery, and evaluation of health care
that is grounded in mutually beneficial partnerships among health-care providers, patients,
and families, thus redefining the relationships in health care.
The Institute of Medicine identified patient-centered care as one of six points for health-
care redesign and one way to provide care “that is respectful of and responsive to individual
patient preferences, needs, and values, and ensuring that patient values guide all clinical
decisions” (Warren, 2012). Core concepts of patient- and family-centered care are shown in
Display 14.5.
l patient care is organized first and foremost around the needs of patients.
l patient and family perspectives are sought out and their choices are honored.
l health-care providers communicate openly and honestly with patients and families to empower
them to be effective partners in their health-care decision making.
l patients, families, and health-care providers collaborate regarding facility design and the imple-
mentation of care.
l the voice of the patient and family are represented at both the organizational and policy levels as
well as in the health system’s strategic planning.
Source: Planetree (2013); Moretz and Abraham (2012); Abraham and Moretz (2012); Institute for Patient- and
Family-Centered Care (IPFCC) (2013).
DISPLAY 14.5 Core Concepts of Patient- and Family-Centered Care
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328 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
Warren (2012) notes that Planetree, and the IPFCC have been two of the most prominent
pioneers in developing and promoting patient- and family-centered care. According to
its mission statement, “Planetree is a non-profit organization that provides education and
information in a collaborative community of healthcare organizations, facilitating efforts
to create patient-centered care in healing environments” (Planetree, 2013, para 15). The
Planetree model encourages the use of soft colors, lighting, home-like fabrics, and music for
patient rooms and common areas as well as opportunities for patients and families to learn
about their illness in order to foster participation in their care.
Founded in 1992, the IPFCC is a not-for-profit organization offering health-care providers
and institutions information and core guiding concepts related to patient- and family-
centered care. These concepts include open visitation; family presence during all procedures;
patient, family, and staff communication and collaboration in care plan development,
multidisciplinary rounds, and bedside handoffs between nurses; information availability in
patient and family resource centers; and the use of patient and family advisors in performance
and safety improvement efforts (IPFCC, 2013).
Abraham and Moretz (2012) suggest that while nurses do not bear the sole responsibility
for advancing patient- and family-centered care, nurses must act as catalysts for initiating and
integrating the health-care provider, patient, and family partnership practices in daily care. Moretz
and Abraham (2012, p. 106) agree, suggesting that “no matter what one’s nursing role – clinical,
educational, administrative – it is possible to champion patient- and family-centered change so
true collaboration with patients and families becomes embedded in the organizational culture.”
This requires the leadership skills of vision, planned change, team building, and collaboration.
LEARNING EXERCISE 14.5
Changing Organization Cultures to Be Patient- and Family-Centered
Assignment: adoption of patient- and family-centered care often requires changing an
organization culture so that patients and families are truly recognized as partners in care,
whether at the bedside or at the institutional level in strategic planning. it also requires a
reconsideration of many of the rules and barriers often in place that pose obstacles for patients
and families to be active participants in care decisions.
Assignment: Select any one of the following rules/procedures/situations common to many
hospitals and write a one-page essay outlining why it would not be consistent with a patient- and
family-centered care approach. include in the discussion how the rule/procedure/situation could
be changed to better reflect the core concepts shown in Learning exercise 14.4.
1. Visiting hours end at 9 pm unless someone is willing to “bend the rules.”
2. Only one visitor is allowed at a time in the critical care units and then for only 20 minutes
every hour.
3. Flat, comfortable sleeping surfaces are not readily available for family members who wish to
spend the night in patient rooms.
4. physicians typically make patient care rounds between 0700 and 0800, before family
members have arrived.
5. handoff report occurs behind closed doors and family members do not participate.
6. Family lounges are too small to accommodate all visitors during peak visiting hours.
7. Staff complain in handoff report that patients are unwilling to follow the plan of care, rather
than asking if the patients themselves were involved in determining the plan of care.
8. dining halls are open only to staff in the middle of the night.

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Chapter 14 Organizing Patient Care 329
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN
ORGANIZING PATIENT CARE
Organizing is an all-important management function. The work must be organized so that
organizational goals are sustained. Activities must be grouped so that resources, people, materials,
and time are used fully. The integrated leader-manager understands that the organization and
unit’s nursing philosophy and the availability of resources greatly influence the type of patient
care delivery system that should be chosen and the potential success of future work redesign.
The integrated leader-manager, then, is responsible for selecting and implementing a
patient care delivery system that facilitates the accomplishment of unit goals. All members of
the work group should be assisted with role clarification, especially when work is redesigned
or new systems of patient care delivery are implemented. This team effort in work activity
increases productivity and worker satisfaction. The emphasis is on seeking solutions to poor
organization of work rather than finding fault.
There is no one “best” mode for organizing patient care. Integrating leadership roles and
management functions ensures that the type of patient care delivery model selected will
provide quality care and staff satisfaction. It also ensures that change in the mode of delivery
will not be attempted without adequate resources, appropriate justification, and attention to
how it will affect group cohesiveness. Historically, nursing has frequently adopted models
of patient care delivery based on societal events (e.g., a nursing shortage and a proliferation
of types of health-care workers) rather than upon well-researched models with proven
effectiveness that promote professional practice. The leadership role demands that the
primary focus of patient care delivery be on promoting a professional model of practice that
also reduces costs and improves patient outcomes.
Given projected health-care worker shortages, many health-care organizations are
concerned there will be too few health-care workers to deliver care using the same models
presently used. Health-care agencies must begin now to explore how newer nursing roles
such as case managers, nurse navigators, and CNLs might be used to better integrate
and coordinate care—before, not after, all answers and solutions are established. As
many forces come together to change the future of health care, it behooves all healthcare
profession to think smarter, to think outside the box, and to discover innovative ways to
organize and deliver care that is patient- and family-centered to clients both inside and
outside the acute care setting.
KEY CONCEPTS
● total patient care, utilizing the case method of assignment, is the oldest form of patient care organization
and is still widely used today.
● Functional nursing organization requires the completion of specific tasks by different nursing personnel.
● team nursing typically uses a nurse-leader who coordinates team members of varying educational
preparation and skill sets in the care of a group of patients.
● the use of multidisciplinary team increases the likelihood that care will be comprehensive and holistic,
although the responsibility for team leadership still typically falls to the nurse.
● Modular nursing uses mini-teams, typically an rN and unlicensed health-care worker(s), to provide care
to a small group of patients, usually centralized geographically.
● primary care nursing is organized so that the patient is at the center of the structure. One health-care
provider (typically the rN) has 24-hour responsibility for care planning and coordination.
(Continued )
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330 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
● interprofessional teams now also provide primary care in the form of phCts. these teams typically
include, but are not limited to, physicians, nurse practitioners, nurses, physical therapists, occupational
therapists, and social workers working collaboratively to deliver coordinated patient care.
● Case management is a collaborative process that assesses, plans, implements, coordinates, monitors,
and evaluates options and services to meet an individual’s health needs through communication and
available resources to promote quality and cost-effective outcomes.
● although the focus historically for case management has been the individual patient, the case manager
employed in a dM program plans the care for populations or groups of patients with the same chronic
illness.
● the care Map is a combination of a critical path and a nursing care plan, except that it shows times
when nursing interventions should occur as well as variances.
● delivery systems may have elements of the various designs present in the system in use in any
organization.
● each unit’s care delivery structure should facilitate meeting the goals of the organization, be cost-
effective, satisfy the patient, provide role satisfaction to nurses, allow implementation of the nursing
process, and provide for adequate communication among health-care providers.
● When work is redesigned, it frequently has personal consequences for employees that must be
considered. Social interactions, the degree of autonomy, the abilities and skills necessary, employee
evaluation, and communication patterns are often affected by work redesign.
● the nurse navigator assists patients and families to navigate the complex health-care system by
providing information and support as they traverse their illness.
● the CNL, is an experienced, nurse possessing a graduate degree, who provides clinical leadership in all
health-care settings, implements outcomes-based practice and quality improvement strategies, engages
in clinical practice, and creates and manages microsystems of care that are responsive to the health-
care needs of individuals and families.
● the philosophy of patient- and family-centered care is based on the premise that care should be
organized first and foremost around the needs of patients and family members.
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
LEARNING EXERCISE 14.6
Creating a Plan to Reduce Resistance
You work in an intensive care unit where there is an all-rN staff. the staff work 12-hour shifts,
and each nurse is assigned one or two patients, depending on the nursing needs of the patient.
the unit has always used total patient care delivery assignments. recently, your unit manager
informed the staff that all patients in the unit would be assigned a case manager in an effort
to maximize the use of resources and to reduce LOS in the unit. Many of the unit staff resent
the case manager and believe that this has reduced the rN’s autonomy and control of patient
care. they are resistant to the need to document variances to the care Maps and are generally
uncooperative but not to the point that they are insubordinate.
although you feel some loss of autonomy, you also think that the case manager has been
effective in coordinating care to speed patient discharge. You believe that at present, the
atmosphere in the unit is very stressful. the unit manager and case manager have come to you
and requested that you assist them in convincing the other staff to go along with this change.
Assignment: Using your knowledge of planned change and case management, outline a plan
for reducing resistance.

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Chapter 14 Organizing Patient Care 331
LEARNING EXERCISE 14.7
Types of Patient Care Delivery Models Used in Your Area
in a group, investigate the types of patient care delivery models used in your area. do not limit
your investigation to hospitals. if possible, conduct interviews with nurses from a variety of
delivery systems. Share the report of your findings with your classmates. how many different
models of patient care delivery did you find? What is the most widely used method in health-
care facilities in your area? does this vary from models identified most frequently in current
nursing literature?
LEARNING EXERCISE 14.8
Implementing a Managed Care System
You are the director of a home health agency that has recently become part of a managed
care system. in the past, only a physician’s order was necessary for authorization from the
Medicare system, but now approval must come from the managed care organization (MCO).
in the past, public health certified nurses (all BSNs) have acted as case managers for their
assigned caseload. Now the MCO case manager has taken over this role, creating much
conflict among the staff. in addition, there is pressure from your board to cut costs by using
more nonprofessionals who are less skilled for some of the home care. You realize that unless
you do so, your agency will not survive financially.
You have visited other home health agencies and researched your options carefully. You have
decided that you must use some type of team approach.
Assignment: develop a plan, objectives, and a time frame for implementation. in your plan,
discuss who will be most affected by your changes. as a change agent, what will be your most
important role?
LEARNING EXERCISE 14.9
The Clinical Nurse-Leader Application
You are the unit coordinator of a medical/surgical unit in a small acute care hospital. One of
your greatest management challenges has been implementing evidence-based practice at
the unit level. Your staff nurses have access to many health-care resources via their computer
workstations. in addition, computerized provider order entry is used in your hospital, which
includes links to best practices and standardized clinical guidelines. Yet, you are aware that
some of your staff continue to do things as they have always been done, despite repeated
workshops on how best to integrate new evidence into their clinical practice. You hope to
address this problem by hiring someone with the leadership skills needed to champion the
change effort and the management skills necessary to direct staff in their new roles.
When you return to your office today, you find an application for employment from a CNL.
She recently completed her CNL program as part of a master’s entry program so her clinical
experience is limited to what she received in nursing school. You are aware though that her
educational background will have prepared her to lead a change effort on the unit to foster
evidence-based decision making and outcomes-focused practice.
(Continued)
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332 UNIT IV ROLES AND FUNCTIONS IN ORGANIZING
REFERENCES
You also have an employment application from a master’s prepared nurse with many years of clinical
experience as a staff and charge nurse although she is just returning from a 5-year leave of absence
to care for a sick family member. She completed a master’s thesis as part of her graduate nursing
education 20 years ago, so you know she has at least some expertise in nursing research and its
translation to practice. Given your budget constraints, you can hire only one of these individuals.
Assignment: identify the driving and restraining forces for hiring the CNL or for hiring the experienced
nurse with clinical and research expertise. do you believe that the limited clinical experience of the
CNL would impact her ability to serve as a leader and change agent on the floor? Would the CNL
have the management skill set you also want in your new hire? do you believe that the CNL would be
better prepared as a leader in this change effort? Justify which employee you would choose to hire
and suggest strategies you might use to help this individual acquire the leadership, management,
and change skill sets they may be lacking to achieve your desired outcomes.
Abraham, M., & Moretz, J. (2012). Implementing patient-
and family-centered care: Part I—Understanding the
challenges. Pediatric Nursing, 38(1), 44–47.
American Association of Colleges of Nursing. (2007,
February). White paper on the education and role
of the clinical nurse leader. Retrieved December 22,
2009, from http://www.aacn.nche.edu/Publications/
WhitePapers/CNL2-07
Beattie, L. (2009). New health care delivery models are
redefining the role of nurses. Nursezone.com.
Retrieved June 2, 2013, from http://www.nursezone
.com/nursing-news-events/more-features/New-Health
-Care-Delivery-Models-are-Redefining-the-Role-of
-Nurses_29442.aspx
Carlyle, D. D., Crowe, M. M., & Deering, D. D. (2012).
Models of care delivery in mental health nursing
practice: A mixed method study. Journal of
Psychiatric & Mental Health Nursing, 19(3), 221–230.
Case Management Society of America. (2008–2012).
Glossary/FAQs. Case management—Definition.
Retrieved June 2, 2013, from http://www.cmsa.org/
Consumer/GlossaryFAQs/tabid/102/Default.aspx
Commission for Case Management Certification. (2013).
Certification & renewal. Retrieved June 3, 2013,
from http://ccmcertification.org/node/428
Gray, F. C., & White, A. (2012). Concept analysis: Case
manage ment role confusion. Nursing Forum, 47(1), 3–8.
Institute for Patient- and Family-Centered Care (IPFCC).
(2013). Institute for patient- and family-
centered care. Retrieved June 3, 2013, from
http://www.ipfcc.org/
Llewellyn, A. (2013, April 15). Nurse navigators: How do they
differ from case managers? Dorland Health. Retrieved
June 3, 2013, from http://www.dorlandhealth.com/
cip_weekly/Nurse-Navigators-How-Do-They-Differ
-From-Case-Managers_2734.html
Manthey, M. (2009). The 40th anniversary of primary
nursing: Setting the record straight. Creative Nursing,
15(1), 36–38.
Moretz, J., & Abraham, M. (2012). Implementing patient- and
family-centered care: Part II—Strategies and resources
for success. Pediatric Nursing, 38(2), 106–171.
Nagi, C., Davies, J., Williams, M., Roberts, C., & Lewis, R.
(2012). A multidisciplinary approach to team
nursing within a low secure service: The team leader
role. Perspectives in Psychiatric Care, 48(1), 56–61.
Planetree (2013). About us. Retrieved June 3, 2013, from
http://planetree.org/?page_id=510
Primary Care—The New Frontier for Case Managers?
(2013). Case Management Advisor, 24(5), 49–51.
Robert Wood Johnson Foundation. (2009). Clinical nurse
leaders as agents of change. Retrieved June 2, 2013,
from http://www.rwjf.org/en/about-rwjf/newsroom/
newsroom-content/2009/02/clinical-nurse-leaders-as
-agents-of-change.html
Robert Wood Johnson Foundation. (2011). Initiative on the
future of nursing. IOM recommendations. Retrieved
June 2, 2013, from http://thefutureofnursing.org/
recommendations
Sibbald, S. L., Wathen, C., Kothari, A., & Day, B. (2013).
Knowledge flow and exchange in interdisciplinary
primary health care teams (PHCTs): An exploratory
study. Journal of the Medical Library Association,
101(2), 128–137.
Smith, A. C. (2011, August). Role ambiguity and role conflict
in nurse case managers: An integrative review.
Professional Case Management, 16(4), 182–196.
Speck, R. M., Jones, G., Barg, F. K., & McCunn, M. (2012).
Team composition and perceived roles of team
members in the trauma bay. Journal of Trauma
Nursing, 19(3), 133–138.
US Department of Veterans Affairs. (2013). VA partners with
you for career success. Retrieved June 3, 2013, from
https://www.vacareers.va.gov/careers/nurses/quality
-initiatives.asp
Warren, N. (2012). Involving patient and family advisors
in the patient and family-centered care model.
MEDSURG Nursing, 21(4), 233–239.

http://www.aacn.nche.edu/Publications/WhitePapers/CNL2-07

http://www.nursezone.com/nursing-news-events/more-features/New-Health-Care-Delivery-Models-are-Redefining-the-Role-of-Nurses_29442.aspx

http://www.cmsa.org/Consumer/GlossaryFAQs/tabid/102/Default.aspx

http://www.dorlandhealth.com/cip_weekly/Nurse-Navigators-How-Do-They-Differ-From-Case-Managers_2734.html

http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2009/02/clinical-nurse-leaders-as-agents-of-change.html

http://thefutureofnursing.org/recommendations

https://www.vacareers.va.gov/careers/nurses/quality-initiatives.asp

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Unit v
Roles and Functions
in Staffing
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334
Employee Recruitment, Selection,
Placement, and Indoctrination
… Employee selection is so crucial that nothing else—not leadership, not team building, not training,
not pay incentives, not total quality management—can overcome poor hiring decisions …
—Gerald Graham
… I have always surrounded myself with the best people to do their jobs, because I do not want to
learn what they already know better than I do.
—Shirley Sears Chater
CROSSWALK thiS Chapter addreSSeS:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential V: health-care policy, finance, and regulatory environments
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: teamwork and collaboration
QSEN Competency: Safety
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l describe demand and supply factors leading to nursing shortages
l determine the number and types of personnel needed to fulfill an organizational philosophy,
meet fiscal planning responsibilities, and carry out a chosen patient care delivery system
l identify variables that impact an organization’s ability to recruit candidates successfully for job
openings
l delineate the relationship between recruitment and retention
l describe interview techniques that reduce subjectivity and increase reliability and validity
during the interview process
l develop appropriate interview questions to determine whether an applicant is qualified and
willing to meet the requirements of a position
l differentiate between legal and illegal interview inquiries
l analyze how personal values and biases affect employment selection decisions
15

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 335
l consider organizational needs and employee strengths in making placement decisions
l select appropriate activities to be included in the induction and orientation of employees
After planning and organizing, staffing is the third phase of the management process.
In staffing, the leader-manager recruits, selects, places, and indoctrinates personnel to
accomplish the goals of the organization. These steps, which are depicted in Display 15.1, are
typically sequential, although each step has some interdependence with all staffing activities.
1. determine the number and types of personnel needed to fulfill the philosophy, meet fiscal planning
responsibilities, and carry out the chosen patient care delivery system selected by the organization.
2. recruit, interview, select, and assign personnel based on established job description performance
standards.
3. Use organizational resources for induction and orientation.
4. ascertain that each employee is adequately socialized to organization values and unit norms.
5. Use creative and flexible scheduling based on patient care needs to increase productivity and
retention.
DISpLAy 15.1 Sequential Steps in Staffing
Staffing is an especially important phase of the management process in health-care
organizations because such organizations are usually labor intensive (i.e., numerous
employees are required for an organization to accomplish its goals). In addition, many health-
care organizations are open 24 hours a day, 365 days a year, and client demands and needs
are often variable. This large workforce must reflect an appropriate balance of highly skilled,
competent professionals and ancillary support workers.
The workforce should also reflect the gender, culture, ethnicity, age, and language diversity
of the communities that the organization serves. The lack of ethnic, gender, and generational
diversity in the workforce has been linked to health disparities in the populations served
(Huston, 2014b). The importance of this goal cannot be overstated.
This chapter examines national and regional trends for professional nurse staffing. It also
addresses preliminary staffing functions, namely determining staffing needs and recruiting,
interviewing, selecting, and placing personnel. It also reviews two employee indoctrination
functions: induction and orientation. The management functions and leadership roles inherent
in these staffing responsibilities are shown in Display 15.2.
DISpLAy 15.2 Leadership Roles and Management Functions Associated with Preliminary
Staffing Functions
LEADERSHIP ROLES
1. plans for future staffing needs proactively by being knowledgeable regarding current and histori-
cal staffing variables.
2. identifies and recruits talented people to the organization.
3. encourages and seeks diversity in staffing.
4. is self-aware regarding personal biases during the preemployment process.
5. Seeks to find the best possible fit between employees’ unique talents and organizational staffing
needs.
6. periodically reviews induction and orientation programs to ascertain they are meeting unit needs.
7. ensures that each new employee understands appropriate organizational policies.
8. Continually aspires to create a work environment that promotes retention and worker satisfaction.
9. promotes hiring based on preferred criteria rather than minimum criteria.
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336 UNIT V RolES and FUnctionS in StaFFing
pREDICTING STAFFING NEEDS
Accurately predicting staffing needs is a crucial management skill because it enables the
manager to avoid staffing crises. Managers should know the source of their nursing pool,
the number of students enrolled in local nursing schools, the usual length of employment
of newly hired staff, peak staff resignation periods, and times when the patient census is
highest. In addition, managers must consider the patient care delivery system in place, the
education and knowledge level of needed staff, budget constraints, historical staffing needs
and availability, and the diversity of the patient population to be served.
Managers also need to have a fairly sophisticated understanding of third-party insurer
reimbursement since this has a significant impact on staffing in contemporary health-care
organizations. For example, as government and private insurer reimbursements declined
in the 1990s, many health-care organizations—hospitals in particular—began downsizing
by replacing registered nurse (RN) positions with unlicensed assistive personnel. Even
hospitals that did not downsize during this period often did little to recruit qualified RNs. This
downsizing and shortsightedness regarding recruitment and retention contributed to an acute
shortage of RNs in many health-care settings in the late 1990s.
Hospital downsizing and shortsightedness regarding recruitment and retention contributed to
the beginning of an acute shortage of RNs in many health-care settings by the late 1990s.
The manager also should be aware of the role that national and local economics play in
staffing. Historically, nursing shortages occur when the economy is on the upswing and
decline when the economy recedes, because many unemployed nurses return to the workforce
and part-time employees return to full-time employment. This is only a guideline, however,
as some workforce shortages have occurred regardless of the economic climate. There is little
doubt, however, that the current projected shortages would be even worse, had the economic
downturn not occurred, since the recession caused many part-time nurses to return to full-
time employment and others to delay their retirement.
Historically, when the economy improves, nursing shortages occur. When the economy declines,
nursing vacancy rates decline as well.
IS THERE A CURRENT NURSING SHORTAGE?
Health-care managers have long been sensitive to the importance of physical (technology and
space) and financial resources to the success of service delivery. It is the shortage of human
resources, however, that likely poses the greatest challenge to most health-care organizations
MANAGEMENT FUNCTIONS
1. ensures that there is an adequate skilled workforce to meet the goals of the organization.
2. Shares responsibility for the recruitment of staff with organization recruiters.
3. plans and structures appropriate interview activities.
4. Uses techniques that increase the validity and reliability of the interview process.
5. applies knowledge of the legal requirements of interviewing and selection to ensure that the
organization is not unfair in its hiring practices.
6. develops established criteria for employment selection purposes.
7. Uses knowledge of organizational needs and employee strengths to make placement decisions.
8. interprets information in employee handbook and provides input for handbook revisions.
9. participates actively in employee orientation.

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 337
today. Indeed, the world is experiencing an international nursing shortage although it has been
obscured by a number of factors, most noteworthy is the global recession.
Economists suggest that as a result of that recession, many nurses who had planned to
retire have put off their retirements; many nurses who were working part time increased their
employment to full time; and some nurses who had been out of the profession for 5 years or
more returned to the workforce. Economists call this situation a nursing employment bubble
and warn that all “bubbles eventually burst” (Schaeffer, 2013, p. 3). This certainly could be
the case if the economy were to dramatically improve and these nurses were to suddenly retire
or reduce their workhours. A significant nursing shortage could emerge literally overnight.
Schaeffer (2013) notes that an additional 712,000 nursing jobs will be created between
2010 and 2020 and that 495,500 jobs will be vacated by retired nurses between 2010
and 2020. Both of these predictions suggest a shortage of approximately 285,000 nurses
between 2015 and 2020. This projection is significantly less than the early 21st-century
projections of shortfalls of close to 1 million nurses by 2020, but it is still substantial enough
to warrant concern.
One could reasonably assume then that each and every nurse as well as potential nurse
would be valued and treated as a scarce commodity today. Yet, we know this is not the case.
Many new RN graduates currently report difficulty finding jobs. Why is this occurring? In
some cases, it reflects skittishness on the part of health-care organizations to take on new
staff during an economic downturn, particularly inexperienced ones who may need prolonged
orientation and training. Instead, health-care organizations are seeking to hire experienced
nurses, with specialty certifications in hand, who can assume full patient loads upon hire.
One must at least question, however, whether this is shortsighted, since it is likely that these
organizations will be desperate to hire these same graduates in a few short years when the
economy improves and large groups of nurses once again exit the workforce or reduce their
working hours.
Supply and Demand Factors Leading to the Shortage
Resolving projected shortages will be difficult since the shortage will be compounded by
both supply and demand factors. The Bureau of Labor Statistics’ Employment Projections
2010 to 2020 released in February 2012 suggest the Registered Nursing workforce will be
the top occupation in terms of job growth through 2020, accounting for one out of every five
new jobs created in 2012 (AACN, 2012). This demand is expected to continue or accelerate.
In addition, demand will be driven by technological advances in patient care and by the
increasing emphasis on preventive health care. Also, the growing elderly population will
require more nursing care.
Supply factors contributing to the nursing shortage will include an aging workforce with
imminent retirements expected and inadequate nursing education enrollments. Too few
students are being enrolled in nursing education programs to replace the nurses who are
retiring. Ironically, the inadequate number of new nurses is not caused by a lack of nursing
school applicants. The problem is that there are inadequate resources to provide nursing
education to those interested in pursuing nursing as a career.
Indeed, the American Association of Colleges of Nursing (AACN) (2012) reports that in
2011, US nursing schools turned away 75,587 qualified applicants from baccalaureate and
graduate nursing programs due to insufficient numbers of faculty, clinical sites, classroom
space, clinical preceptors, and budget constraints. Indeed, almost two-thirds of nursing
schools responding to the survey pointed to faculty shortages as a reason for not accepting all
qualified applicants into their programs (AACN, September, 2012).
The “graying” of the nursing faculty also contributes to the projected shortage. The
average age of nursing faculty members continues to increase, narrowing the number
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338 UNIT V RolES and FUnctionS in StaFFing
of productive years nurse-educators can teach. McNeal (2012) notes that of the 32,000
nurse-educators nationwide, on average they are 55 years of age or older. This finding is in
sharp contrast to other academic disciplines in which only 35% are above the age of 54; and,
in the health sciences, only 29% of faculty are above 54 years of age (McNeal).
One must question where the faculty will come from to teach the new nurses that will be
needed to solve the current shortage. Nursing faculty salaries have also failed to keep pace
with that of nurses employed in clinical settings, making it even more difficult to attract and
keep graduate and doctorally prepared nurses in academic settings. Clearly then, given the
lag time required to educate master’s- or doctorally prepared faculty, the faculty shortage may
end up being the greatest obstacle to solving the nursing shortage (Huston, 2014a). Long-
term planning and aggressive intervention will be needed for some time to ensure that an
adequate, highly qualified nursing workforce will be available to meet the health-care needs
of US citizens.
The nursing faculty shortage will likely be the greatest obstacle to solving the projected nursing
shortage.
RECRUITMENT
Recruitment is the process of actively seeking out or attracting applicants for existing positions
and should be an ongoing process. In complex organizations, work must be accomplished by
groups of people; therefore, the organization’s ability to meet its goals and objectives relates
directly to the quality of its employees. Unfortunately, some managers feel threatened by
bright and talented people and surround themselves with mediocrity. Wise leader-managers
surround themselves with people of ability, motivation, and promise.
In addition, organizations must remember that nonmonetary factors are just as important,
if not more so, in recruiting new employees. Before recruiting begins, organizations must
identify reasons a prospective employee would choose to work for them over a competitor.
Organizations considered best places to work generally have two characteristics: They’re
“financially fit” organizations whose leadership is “keeping the ball rolling to keep revenue
and patient satisfaction going upward” (Best Places, 2012, para 3).
The Nurse-Recruiter
The manager may be greatly or minimally involved with recruiting, interviewing, and
selecting personnel depending on (a) the size of the institution, (b) the existence of a separate
personnel department, (c) the presence of a nurse-recruiter within the organization, and (d)
the use of centralized or decentralized nursing management.
Generally speaking, the more decentralized nursing management and the less complex the
personnel department is, the greater the involvement of lower level managers in selecting
personnel for individual units or departments. When deciding whether to hire a nurse-
recruiter or decentralize the responsibility for recruitment, the organization needs to weigh
benefits against costs. Costs include more than financial considerations. For example, an
additional cost to an organization employing a nurse-recruiter might be the eventual loss of
interest by managers in the recruiting process. The organization loses if managers relegate
their collective and individual responsibilities to the nurse-recruiter.
When organizations use nurse-recruiters, a collaborative relationship must exist between
managers and recruiters. Managers must be aware of recruitment constraints and the recruiter
must be aware of individual department needs and culture. Both parties must understand the
organization’s philosophy, benefit programs, salary scale, and other factors that influence
employee retention.

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 339
Recruitment and Retention
Recruiting adequate numbers of nurses is less difficult if the organization is located in a
progressive community with several schools of nursing and if the organization has a good
reputation for quality patient care and fair employment practices. It will likely be much more
difficult to recruit nurses to rural areas that historically have experienced less appropriation
of health-care professionals per capita than urban areas. In addition, some health-care
organizations find it necessary to do external recruitment, partly because of their lack of
attention to retention.
Because most recruitment is expensive, health-care organizations often seek less costly
means to achieve this goal. One of the best ways to maintain an adequate employee pool is
by word of mouth; the recommendation of the organization’s own satisfied and happy staff.
Recruitment, however, is not the key to adequate staffing in the long term. Retention is and
it only occurs when the organization is able to create a work environment that makes staff
want to stay.
Some turnover, however, is normal and, in fact, desirable. Turnover infuses the
organization with fresh ideas. It also reduces the probability of groupthink, in which everyone
shares similar thought processes, values, and goals. However, excessive or unnecessary
turnover reduces the ability of the organization to produce its end product and is expensive.
Such costs generally include human resource expenses for advertising and interviewing;
recruitment fees such as sign-on bonuses; increased use of traveling nurses, overtime, and
temporary replacements for the lost worker; lost productivity; and the costs of training time
to bring the new employee up to desired efficiency.
The leader-manager recognizes the link between retention and recruitment. The middle-
level manager often has the greatest impact in creating a positive social climate to promote
retention. In addition, the closer the fit between what the nurse is seeking in employment and
what the organization can offer, the greater the chance that the nurse will be retained.
LEARNING EXERCISE 15.1
Examining Recruitment Advertisements
Select one of the following:
1. in small groups, examine several nursing journals that carry job advertisements. Select
three advertisements that particularly appeal to you. What do these advertisements say or
what makes them stand out? are similar key words used in all three advertisements? What
bonuses or incentives are being offered to attract qualified professional nurses?
2. Select a health-care agency in your area. Write an advertisement or recruitment poster that
accurately depicts the agency and the community. Compare your completed advertisement
or recruitment flyer with those created by others in your group.
INTERVIEWING AS A SELECTION TOOL
An interview may be defined as a verbal interaction between individuals for a particular
purpose. Although other tools such as testing and reference checks may be used, the interview
is frequently accepted as the foundation for hiring, despite its well-known limitations in terms
of reliability and validity.
The purposes or goals of the selection interview are threefold: (a) the interviewer seeks to
obtain enough information to determine the applicant’s suitability for the available position;
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340 UNIT V RolES and FUnctionS in StaFFing
(b) the applicant obtains adequate information to make an intelligent decision about accepting
the job, should it be offered; and (c) the interviewer seeks to conduct the interview in such
a manner that regardless of the interview’s result, the applicant will continue to have respect
for and goodwill toward the organization.
There are many types of interviews and formats for conducting them. For example,
interviews may be unstructured, semistructured, or structured. The unstructured interview
requires little planning because the goals for hiring may be unclear, questions are not prepared
in advance, and often the interviewer does more talking than the applicant. The unstructured
interview continues to be the most common selection tool in use today (McKay, 2009).
Semistructured interviews require some planning since the flow is focused and
directed at major topic areas although there is flexibility in the approach. The structured
interview requires greater planning time yet because questions must be developed in
advance that address the specific job requirements, information must be offered about
the skills and qualities being sought, examples of the applicant’s experience must
be received, and the willingness or motivation of the applicant to do the job must be
determined. The interviewer who uses a structured format would ask the same essential
questions of all applicants.
Limitations of Interviews
The major defect of the hiring interview is subjectivity. Most interviewers feel confident
that they can overcome this subjectivity and view the interview as a reliable selection
tool, despite the element of subjectivity. In fact, McKay (2009) warns that interviewing is
a lot more difficult than people think, and many people think they are better interviewers
than they really are. “There is also a belief that interviewing is all about talking to people,
and interviewing is just about good conversation. The selection interview is much more
than a conversation, and good conversationalists aren’t necessarily good interviewers”
(McKay, para 3).
Many people think they are better interviewers than they really are.
Research findings regarding the validity and reliability of interviews vary; however, the
following findings are generally accepted:
• The same interviewer will consistently rate the interviewee the same. Therefore, the
intrarater reliability is said to be high.
• If two different interviewers conduct unstructured interviews of the same applicant,
their ratings will not be consistent. Therefore, interrater reliability is extremely low in
unstructured interviews.
• Interrater reliability is better if the interview is structured and the same format is used
by both interviewers.
• Even if the interview has reliability (i.e., it measures the same thing consistently),
it still may not be valid. Validity occurs when the interview measures what it is
supposed to measure, which in this case, is the potential for productivity as an
employee. Structured interviews have greater validity than unstructured interviews
and thus should be better predictor of job performance and overall effectiveness than
unstructured interviews.
O’Brien and Rothstein (2011) note, however, that even with a structured interview and
established validity, inter-rater reliability can be poor. This is especially true if interviewers
must complete rating scales, since variation is commonplace in terms of either the leniency or
stringency of rankings by different reviewers. This then obscures true differences in validity
(see Examining the Evidence 15.1).

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 341
• High interview assessments are not related to subsequent high-level job performance.
• Validity increases when there is a team approach to the interview.
• The attitudes and biases of interviewers greatly influence how candidates are rated.
Although steps can be taken to reduce subjectivity, it cannot be eliminated entirely.
• The interviewer is more influenced by unfavorable information than by favorable
information. Negative information is weighed more heavily than positive information
about the applicant.
• Interviewers tend to make up their minds about hiring applicants very early in the job
interview. Decisions are often formed in the first few minutes of the interview.
• In unstructured interviews, the interviewer tends to do most of the talking, whereas in
structured interviews, the interviewer talks less. The goal should always be to have the
interviewee do most of the talking.
In addition, Sutherland (2012) suggests that interviews do not allow candidates to
demonstrate their clinical skills, and interviewers run the risk of biasing their decisions on
“first impressions.” In addition, interviewers may be overly impressed with superficial signs
such as composure, manner of speech, and physical appearance (Sutherland).
Regardless of these inherent defects, interviewing continues to be widely used as a
selection tool. By knowing the limitations of interviews and using findings from current
Source: O’Brien, J., & Rothstein, M. G. (2011). Leniency: Hidden threat to large-scale, interview-based selection
systems. Military psychology (taylor & Francis Ltd), 23(6), 601–615.
the researchers noted the challenges in making hiring selection decisions when individual inter-
views from different locations are pooled, and selection occurs on a top-down basis, even when
structured interview formats are used. these challenges are compounded when ratings from
individual interviewers are not comparable, for example, because interviewers vary in the validity
of their judgments or tend to use the rating scales in different ways.
in this study, the researchers investigated variability in individual interviewer performance,
including both validity and rater error. data sources included the interview ratings and basic
training performance outcomes of 2,552 applicants as well as the survey responses of 59 inter-
viewers who evaluated applicants in interviews held in multiple settings across canada.
an interview guide was provided in reference materials used by interviewers. the guide
included interviewer questions and content areas to address as part of the interview
process. interviewers were trained, used anchored rating scales, and took notes as part of
the process. then, validity and rater error were evaluated using multilevel logistic regression
models.
this study found no evidence that interviewers varied in the validity of their judgments. this
was consistent with previous evidence on the possible effects of structure-related interventions
like training on interviewer performance. interviewers did, however, vary, in their use of rating
scales. this finding suggests that interview structure may be limited in its effect on interviewer
judgment.
the researchers concluded that exclusive concern with interview validity may contribute to
neglect of other important interview outcomes and properties, to the detriment of the selection
system overall. For example, when individual interviewer validity is estimated, those who are
lenient or stringent are not evaluated on equivalent, comparable sets of interviewees, obscuring
true differences in validity. this suggests that those managing large-scale selection systems
should pay particular attention to the consistent and accurate use of rating scales by interviewers,
or selection decisions may be negatively affected.
Examining the Evidence 15.1
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342 UNIT V RolES and FUnctionS in StaFFing
research evidence, interviewers should be able to conduct interviews so that they will have
an increased predictive value.
As a predictor of job performance and overall effectiveness, the structured interview is much
more reliable than the unstructured interview.
Overcoming Interview Limitations
Interview research has helped managers to develop strategies for overcoming its limitations.
The following strategies will assist the manager in developing an interview process with
greater reliability and validity.
Use a Team Approach
Having more than one person interview the job applicant reduces individual bias. Staff
involvement in hiring can be viewed on a continuum from no involvement to a team approach,
using unit staff for the hiring decisions. When hiring a manager, using a staff nurse as part of
the interview team is effective, especially if the staff nurse is mature enough to represent the
interests and needs of the unit rather than his or her own self-interests.
Develop a Structured Interview Format for Each Job Classification
Managers should obtain a copy of the job description and know the educational and
experiential requirements for each position prior to the interview. In addition, because each job
has different position requirements, interviews must be structured to fit the position. The same
structured interview should be used for all employees applying for the same job classification.
A well-developed structured interview uses open-ended questions and provides ample
opportunity for the interviewee to talk. The structured interview is advantageous because it
allows the interviewer to be consistent and prevents the interview from becoming sidetracked.
O’Brien and Rothstein (2011) warn, however, that although structured interviews are often
considered a panacea, individual differences in interviewer performance persist in the face of
even the most rigorous structure. Display 15.3 is an example of a structured interview.
MOTIVATION
Why did you apply for employment with this organization?
PHYSICAL
do you have any physical limitations that would prohibit you from accomplishing the job?
how many days have you been absent from work during the last year of employment?
EDUCATION
What was your grade point average in nursing school?
What were your extracurricular activities, offices held, awards conferred?
For verification purposes, are your school records listed under the name on your application?
PROFESSIONAL
in what states are you licensed to practice?
do you have your license with you?
What certifications do you hold?
What professional organizations do you currently participate in that would be of value in the job for
which you are applying?
MILITARY EXPERIENCE
What are your current military obligations?
Which military assignments do you think have prepared you for this position?
DISpLAy 15.3 Sample Structured Interview

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 343
PRESENT EMPLOYER
how did you secure your present position?
What is your current job title? What was your title when you began your present position?
What supervisory responsibilities do you currently have?
how would you describe your immediate supervisor?
What are some examples of success at your present job?
how do you get along with your present employer?
how do you get along with your present colleagues?
What do you like most about your present job?
What do you like least about your present job?
May we contact your present employer?
Why do you want to change jobs?
For verification purposes only, is your name the same as it was while employed with your current employer?
PREVIOUS POSITION(S)
ask similar questions about recent past employment. depending on the time span and type of other
positions held, the interviewer does not usually review employment history that took place beyond
the position just previous to the current one.
SPECIFIC QUESTIONS FOR REGISTERED NURSES
What do you like most about nursing?
What do you like least about nursing?
What is your philosophy of nursing?
PERSONAL CHARACTERISTICS
Which personal characteristics are your greatest assets?
Which personal characteristics cause you the most difficulty?
PROFESSIONAL GOALS
What are your career goals?
Where do you see yourself 10 years from now?
CONTRIBUTIONS TO ORGANIZATION
What can you offer this organization? this unit or department?
GENERAL QUESTIONS
What questions do you have about the organization?
What questions do you have about the position?
What other questions do you have?
LEARNING EXERCISE 15.2
Creating Additional Interview Criteria
You are a home health nurse with a large caseload of low-income, inner-city families. Because of
your spouse’s job transfer, you have just resigned from your position of 3 years to take a similar
position in another public health district. Your agency supervisor has asked you to assist her with
interviewing and selecting your replacement. Five applicants meet the minimum criteria. they each
have at least 2 years of acute care experience, a baccalaureate nursing degree, and a state public
health credential. Because you know the job requirements better than anyone, your supervisor
has asked that you develop additional criteria and a set of questions to ask each applicant.
Assignment:
1. Use a decision grid (see Fig. 1.3 on page 21) to develop additional criteria. Weight the
criteria so that the applicants will have a final score.
2. develop an interview guide of six appropriate questions to ask the applicants.
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344 UNIT V RolES and FUnctionS in StaFFing
Use Scenarios to Determine Decision-Making Ability
Use scenarios to determine decision-making ability. In addition to obtaining answers to a
particular set of questions, the interview also should be used to determine the applicant’s
decision-making ability. This can be accomplished by designing scenarios that require
problem-solving and decision-making skills. The same set of scenarios should be used with
each category of employee. For example, a set could be developed for new graduates, critical
care nurses, unit secretaries, and licensed practical nurses. Patient care situations, as shown
in Display 15.4, require clinical judgment and are very useful for this purpose.
each recent graduate applying for a position at Country hospital will be asked to respond to the
following:
CASE 1
You are working on the evening shift of a surgical unit. Mr. Jones returned from the postanesthesia
care unit following a hip replacement 2 hours ago. While in the recovery room, he received 10 mg
of morphine sulfate intravenously for incisional pain. thirty minutes ago, he complained of mild
incisional pain but then drifted off to sleep. he is now awake and complaining of moderate to
severe incisional pain. his orders include the following pain relief order: morphine sulfate 8 to 10
mg, iV push every 3 hours for pain. it has been 2½ hours since Mr. Jones’ last pain medication.
What would you do?
CASE 2
One of the licensed professional nurses (LpNs)/licensed vocational nurses (LVNs) on your team
seems especially tired today. She later tells you that her new baby kept her up all night. When you
ask her about the noon finger-stick blood glucose level on Mrs. White (82 years old), she looks at
you blankly and then says quickly that it was 150. Later, when you are in Mrs. White’s room, she
tells you that she does not remember anyone checking her blood glucose level at noon. What do
you do?
DISpLAy 15.4 Sample Interview Questions Using Case Situations
Conduct Multiple Interviews
Candidates should be interviewed more than once on separate days. This prevents applicants
from being accepted or rejected merely because they were having a good or bad day.
Regardless of the number of interviews held, the person should be interviewed until all the
interviewers’ questions have been answered, and they feel confident that they have enough
information to make the right decision.
Provide Training in Effective Interviewing Techniques
Training should focus on communication skills and advice on planning, conducting, and
controlling the interview. It is unfair to expect a manager to make appropriate hiring decisions
if he or she has never had adequate training in interview techniques. Unskilled interviewers
often allow subjective data rather than objective data affect their hiring evaluation. In
addition, unskilled interviewers may ask questions that could be viewed as discriminatory or
that are illegal.
Planning, Conducting, and Controlling the Interview
Planning the interview in advance is vital to its subsequent success as a selection tool. If
other interviewers are to be present, they should be available at the appointed time. The plan
also should include adequate time for the interview. Before the interview, all interviewers
should review the application, noting questions concerning information supplied by the

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 345
applicant. Although it takes considerable practice, consistently using a planned sequence in
the interview format will eventually yield a relaxed and spontaneous process. The following
is a suggested interview format:
1. Introduce yourself and greet the applicant.
2. Make a brief statement about the organization and the available positions.
3. Clarify the position for which the person is applying.
4. Discuss the information on the application and seek clarification or amplification as
necessary.
5. Discuss employee qualifications and proceed with the structured interview format.
6. If the applicant appears qualified, discuss the organization and the position further.
7. Explain the subsequent procedures for hiring, such as employment physicals, and
hiring date. If the applicant is not hired at this time, discuss how and when he or she
will be notified of the interview results.
8. Terminate the interview.
Try to create and maintain a comfortable environment throughout the interview, but
do not forget that the interviewer is in charge of the interview. If the interview has begun
well and the applicant is at ease, the interview will usually proceed smoothly. During the
meeting, the manager should pause frequently to allow the applicant to ask questions. The
format should always encourage and include ample time for questions from the applicant.
Often, interviewers are able to infer much about applicants by the types of questions that
they ask.
Remember that the interviewer should have control of the interview and set the tone.
Moving the conversation along, covering questions on a structured interview guide, and
keeping the interview pertinent but friendly becomes easier with experience. Methods that
help reach the goals of the interview follow:
• Ask only job-related questions.
• Use open-ended questions that require more than a “yes” or “no” answer.
• Pause a few seconds after the applicant has seemingly finished before asking the next
question. This gives the applicant a chance to talk further.
• Return to topics later in the interview on which the applicant offered little information
initially.
• Ask only one question at a time.
• Restate part of the applicant’s answer if you need elaboration.
• Ask questions clearly, but do not verbally or nonverbally indicate the correct answer.
Otherwise, by watching the interviewer’s eyes and observing other body language, the
astute applicant may learn which answers are desired.
• Always appear interested in what the applicant has to say. The applicant should never
be interrupted, nor should the interviewer’s words ever imply criticism of or impatience
with the applicant.
• Use language that is appropriate for the applicant. Terminology or language that makes
applicants feel the interviewer is either talking down to them or talking over their heads
is inappropriate.
• Keep a written record of all interviews. Note taking ensures accuracy and serves as a
written record to recall the applicant. Keep note taking or use of a checklist, however, to
a minimum so that you do not create an uncomfortable climate.
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346 UNIT V RolES and FUnctionS in StaFFing
In addition, McNamara (n.d.) suggests that
• Applicants should be involved in the interview as soon as possible.
• Factual data should be elicited before asking about controversial matters (such as
feelings and conclusions).
• Fact-based questions should be interspersed throughout the interview to avoid having
respondents disengage.
• The interviewer should ask questions about the present before questions about the past
or future.
• Applicant should be allowed to close the interview with information they want to add or
to comment regarding their impressions of the interview.
As the interview draws to a close, the interviewer should make sure that all questions have
been answered and that all pertinent information has been obtained. Usually, applicants are
not offered a job at the end of a first interview unless they are clearly qualified and the labor
market is such that another applicant would be difficult to find. In most cases, interviewers
need to analyze their impressions of the applicant, compare these perceptions with members
of the selection team, and incorporate those impressions with other available data about
the applicant. It is important, however, to let applicants know if they are being seriously
considered for the position and how soon they can expect to hear a final outcome.
When the applicant is obviously not qualified, the interviewer should not give false hope
and instead should tactfully advise the person as soon as possible that he or she does not have
the proper qualifications for the position. Such applicants should believe that they have been
treated fairly. The interviewer should, however, maintain records of the exact reasons for
rejection in case of later questions.
Evaluation of the Interview
Interviewers should plan post-interview time to evaluate the applicant’s interview performance.
Interview notes should be reviewed as soon as possible and necessary points clarified or
amplified. Using a form to record the interview evaluation is a good idea. The final question
on the interview report form is a recommendation for or against hiring. In answering this
question, two aspects must carry the most weight:
• The requirements for the job. Regardless of how interesting or friendly people are,
unless they have the basic skills for the job, they will not be successful at meeting the
expectations of the position. Likewise, those overqualified for a position will usually be
unhappy in the job.
• Personal bias. Because completely eliminating the personal biases inherent in the
interview is impossible, it is important for the interviewer to examine any negative
feelings that occurred during the interview. Often, the interviewer discovers that the
negative feelings have no relation to the criteria necessary for success in the position.
Legal Aspects of Interviewing
The organization must be sure that the application form does not contain questions that
violate various employment acts. Likewise, managers must avoid unlawful inquiries during
the interview. Inquiries cannot be made regarding age, marital status, children, race, sexual
preference, financial or credit status, national origin, or religion.
Interview inquiries regarding age, marital status, children, race, sexual preference, financial or
credit status, national origin, or religion are illegal because they are deemed discriminatory.
In addition to federal legislation, many states have specific laws pertaining to information
that can and cannot be obtained during the process. For example, some states prohibit asking

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 347
Subject Acceptable Inquiries Unacceptable Inquiries
Name if applicant has worked for the organization under
a different name. if school records are under
another name. if applicant has another name.
inquiries about name that would indicate
lineage, national origin, or marital or
criminal status.
Marital and
family status
Whether applicant can meet specified work
schedules or has commitments that may
hinder attendance requirements. inquiries as to
anticipated stay in the position.
any question about applicant’s marital
status or number or age of children.
information about child care arrangements.
any questions concerning pregnancy.
address or
residence
place of residence and length resided in city or
state.
Former addresses, names or relationships of
people with whom applicant resides, or if
owns or rents home.
age if older than 18 or statement that hire is subject
to age requirement. Can ask if the applicant is
between 18 and 70.
inquiry of specific age or date of birth.
Birthplace Can ask for proof of US citizenship. Birthplace of the applicant or spouse or any
relative.
religion No inquiries allowed.
race or color Can be requested for affirmative action but not
as employment criteria.
all questions about race are prohibited.
Character inquiry into actual convictions that relate to
fitness to perform job.
Questions relating to arrests or conviction
of a crime.
relatives relatives employed in organization. Names and
addresses of parents if the applicant is a minor.
Questions about who the applicant lives
with or the number of dependents.
Notify in case of
emergency
Name and address of a person to be notified. Name and address of a relative to be
notified.
Organizations professional organizations. requesting a list of all memberships.
references professional or character reference. religious references.
physical
condition
all applicants can be asked if they are able to
carry out the physical demands of the job.
employers must be prepared to justify any
mental or physical requirements. Specific
questions regarding handicaps are
forbidden.
photographs Statement that a photograph may be required
after employment.
requirement that a photograph be taken
before interview or hiring.
National origin if necessary to perform job, languages applicant
speaks, reads, or writes.
inquiries about birthplace, native language,
ancestry, date of arrival in the United
States, or native language.
education academic, vocational, or professional education.
Schools attended. ability to read, speak, and
write foreign languages.
inquiries about racial or religious affiliation of
a school. inquiry about dates of schooling.
Sex inquiry or restriction of employment is only for
bona fide occupational qualification, which is
interpreted very narrowly by the courts.
Cannot ask sex on application. Sex cannot
be used as a factor for hiring decisions.
Credit rating No inquiries. Questions about car or home ownership are
also prohibited.
Other Notice may be given that misstatements or
omissions of facts may be cause for dismissal.
TABLE 15.1 Acceptable and Unacceptable Interview Inquiries
about a woman’s ability to reproduce or her attitudes toward family planning. Table 15.1
lists subjects that are most frequently part of the interview process or applicant form, with
examples of acceptable and unacceptable inquiries.
Managers who maintain interview records and receive applicants with an open and
unbiased attitude have little to fear regarding charges of discrimination. Remember that each
applicant should feel good about the organization when the interview concludes and be able
to recall the experience as a positive one. It is a leadership responsibility to see that this goal
is accomplished.
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348 UNIT V RolES and FUnctionS in StaFFing
TIpS FOR THE INTERVIEWEE
Just as there are things that the interviewer should do to prepare and conduct the interview,
there are things interviewees should do to increase the likelihood that the interview will be
a mutually satisfying and enlightening experience (Display 15.5). The interviewee must also
prepare in advance for the interview. Obtaining copies of the philosophy and organization
chart of the organization to which you are applying should give you some insight as to the
organization’s priorities and help you to identify questions to ask the interviewer. Speaking
to individuals who already work at the organization should be helpful in determining whether
the organization philosophy is implemented in practice.
1. prepare in advance for the interview.
2. Obtain copies of the philosophy and organization chart of the organization to which you are
applying.
3. Schedule an appointment for the interview.
4. dress professionally and conservatively.
5. practice responses to potential interview questions in advance.
6. arrive early on the day of the interview.
7. Greet the interviewer formally and do not sit down before he or she does unless given permission
to do so.
8. Shake the interviewer’s hand upon entering the room and smile.
9. during the interview, sit quietly, be attentive, and take notes only if absolutely necessary.
10. do not chew gum, fidget, slouch, or play with your hair, keys, or writing pen.
11. ask appropriate questions about the organization or the specific job for which you are applying.
12. avoid a “what can you do for me?” approach and focus instead on whether your unique talents
and interests are a fit with the organization.
13. answer interview questions as honestly and confidently as possible.
14. Shake the interviewer’s hand at the close of the interview, and thank him or her for his or her time.
15. Send a brief, typed thank you note to the interviewer within 24 hours of the interview.
DISpLAy 15.5 Interviewing Tips for Applicants
Schedule an appointment for the interview. Do not allow yourself to be drawn into an
impromptu interview when you are dropping off an application or seeking information from
the human resource department. You will want to be professionally dressed and will likely
need time to reflect and prepare for the interview.
Practice responses to potential interview questions. It is difficult to spontaneously answer
interview questions about your personal philosophy of nursing, your individual strengths and
weaknesses, and your career goals if you have not given them advance thought.
On the day of the interview, arrive about 10 minutes early to allow time for you to collect
your thoughts and be mentally ready. Anticipate some nervousness (this is perfectly normal).
Greet the interviewer formally (not by first name) and do not sit down before the interviewer
does unless given permission to do so. Be sure to shake the interviewer’s hand upon entering
the room and to smile. Smiling will reduce both your anxiety and that of the interviewer.
Remember that many interviewers make up their mind early in the interview process, so first
impressions count a lot.
During the interview, sit quietly, be attentive, and take notes only if absolutely necessary.
Do not chew gum, fidget, slouch, or play with your hair, keys, or writing pen. Dress
conservatively and make sure that you are neatly groomed. Ask appropriate questions about
the organization or the specific job for which you are applying. Questions about wages,

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 349
benefits, and advancement opportunities should likely come later in the interview. Avoid
a “what can you do for me?” approach, and focus instead on whether your unique talents
and interests are a fit with the organization. Answer interview questions as honestly and
confidently as possible. Avoid rambling and never lie. If you do not know the answer to a
question, say so. Also, if you need a few moments to reflect on a complex question before
answering, state that as well.
At the close of the interview, shake the interviewer’s hand and thank him or her for taking
time to talk with you. It is always appropriate to clarify at that point when hiring decisions
will be made and how you will be notified about the interview’s outcome. You may want to
send a brief thank you note to the interviewer as well, so be sure to note their correct title and
the spelling of their name before you leave.
The Connecticut Department of Labor (2002–2012) also suggests that candidates should
assess the interview itself as soon as it is completed. This assessment should include reactions
to the interview, including what went well and what went poorly. In addition, candidates
should assess what they learned from the experience and what they might do differently in
future interviews.
SELECTION
After applicants have been recruited, completed their applications, and been interviewed,
the next step in the preemployment staffing process is selection. Selection is the process of
choosing from among applicants the best-qualified individual or individuals for a particular
job or position. This process involves verifying the applicant’s qualifications, checking his or
her work history, and deciding if a good match exists between the applicant’s qualifications
and the organization’s expectations. Determining whether a “fit” exists between an employee
and an organization is seldom easy.
Educational and Credential Requirements
Consideration should be given to educational requirements and credentials for each job
category as long as a relationship exists between these requirements and success on the job.
If requirements for a position are too rigid, the job may remain unfilled for some time. In
addition, people who might be able to complete educational or credential requirements for
a position are sometimes denied the opportunity to compete for the job. Therefore, many
organizations have a list of preferred criteria for a position and a second list of minimal
criteria. In addition, frequently, organizations will accept substitution criteria in lieu of
preferred criteria. For example, a position might require a bachelor’s degree, but a master’s
degree is preferred. However, 5 years of nursing experience could be substituted for the
master’s degree.
Clearly, there is a movement among health-care employers to hire more nurses with at
least a BSN degree and to urge staff to pursue higher degrees (Trossman, 2012). Nurse
executives value what all nurses bring to patient care, but they want to ensure staff can
meet the challenges that continue to come their way and that patient care is optimized. With
research supporting that educational entry level matters and that improvements in patient
outcomes correlate with the number of baccalaureate or higher educated nurses, it is difficult
to support not having higher education levels as preferred criteria, if not required criteria for
nursing hires (Trossman).
In addition, the American Nurses Credentialing Center’s (ANCC) Magnet Recognition
Program® requires nurse-managers and leaders to have a degree in nursing at either
the baccalaureate or graduate level (Trossman, 2012). Also, as of June 2013, Magnet
applicants will be required to provide an action plan and set a target demonstrating their
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350 UNIT V RolES and FUnctionS in StaFFing
progress toward having 80% of direct care RNs having a baccalaureate or higher degree
in nursing by 2020 (Trossman).
Reference Checks and Background Screening
All applications should be examined to see if they are complete and to ascertain that the
applicant is qualified for the position. It is very important to check the academic and
professional credentials of all job applicants. In a competitive job market, candidates may
succumb to the pressure of “embroidering” their qualifications. Once a determination is made
that an applicant is qualified, references are requested, and employment history is verified. In
addition, a background check is often required.
Clearly, a strong application and excellent references do not necessarily guarantee
excellent job performance; however, carefully reviewing applications and checking references
may help prevent a bad hiring decision. Ideally, whenever possible, these actions as well
as verifying work experience and credentials should be done before the interview. Some
managers prefer to interview first so that time is not wasted in processing the application if
the interview results in a decision not to hire, and this is a personal choice. A position should
never be offered until applications have been verified and references obtained.
Positions should never be offered until information on the application has been verified and
references have been checked.
Occasionally, reference calls will reveal unsolicited information about the applicant.
Information obtained by any method may not be used to reject an applicant unless a justifiable
reason for disqualification exists. For example, if the applicant volunteers information about
his or her driving record or if this information is discovered by other means, it cannot be used
to reject a potential employee unless the position requires driving.
Mandatory background checks have also become commonplace in health-care settings.
This has occurred because health-care providers have access to vulnerable patients or
protected health and financial information (Avoiding Bad Hires, 2013). Some concerns exist,
however, as to who may be overseeing this screening and whether they are truly qualified
to assess the risk. In some cases, the individuals responsible for screening background
checks are administrative recruiters with no previous experience in health care, who may not
understand the dynamic of what is involved in hiring health-care providers (Avoiding Bad
Hires).
Complicating the issue are guidelines issued in 2012 by the Equal Employment Opportunity
Commission (EEOC) that stopped short of banning criminal background checks but said that
refusing to hire someone with a criminal record could constitute illegal discrimination if
such decisions disproportionately affected minority groups (Avoiding Bad Hires, 2013). The
EEOC went on to suggest that any decision not to hire must be “job related and consistent
with business necessity” and must take into account factors such as the nature and gravity of
the criminal offense, the amount of time since the conviction, and the relevance of the offense
to the job being sought.
Preemployment Testing
Preemployment testing is generally used only when such testing is directly related to the
ability to perform a specific job, although the use of personality tests is becoming much more
common in health-care organizations. Curry (2011) suggests that assessing an applicant’s
baseline personality traits and compatibility with an organization’s culture makes all the
difference in his/her success as an employee. “Employees who fit in well with a staff and
clinic culture have greater longevity than do new hires with higher skill levels but less
compatible personalities” (Curry 2011, p. 141). That is because applicants who cannot align

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 351
with coworkers typically do not emotionally commit to the organization and thus have higher
turnover rates.
Although testing is not a stand-alone selection tool, it can, when coupled with excellent
interviewing and reference checking, provide additional information about candidates
to make the best selection. Lawsuits, however, have resulted from allegedly improper
implementation and interpretation of preemployment testing and this makes some employers
shy away from doing it.
Physical Examination as a Selection Tool
A medical examination is often a requirement for hiring. This examination determines if the
applicant can meet the requirements for a specific job and provides a record of the physical
condition of the applicant at the time of hiring. The physical examination also may be used
to identify applicants who will potentially have unfavorable attendance records or may file
excessive future claims against the organization’s health insurance.
Only those selected for hire can be required to have a physical examination, which is
nearly always conducted at the employer’s expense. If the physical examination reveals
information that disqualifies the applicant, he or she is not hired. Most employers make job
offers contingent on meeting certain health or physical requirements.
Making the Selection
When determining the most appropriate person to hire, the leader must be sure that the same
standards are used to evaluate all candidates. Final selection should be based on established
criteria, not on value judgments and personal preferences.
Frequently, positions are filled with internal applicants. These positions might be entry
level or management. Internal candidates should be interviewed in the same manner as
newcomers to the organization; however, some organizations give special consideration and
preference to their own employees. Every organization should have guidelines and policies
regarding how transfers and promotions are to be handled.
Finalizing the Selection
Once a final selection has been made, the manager is responsible for closure of the
preemployment process as follows:
1. Follow up with applicants as soon as possible, thanking them for applying and
informing them when they will be notified about a decision.
2. Candidates not offered a position should be notified of this as soon as possible.
Reasons should be provided when appropriate (e.g., insufficient education and work
experience), and candidates should be told whether their application will be considered
for future employment or if they should reapply.
3. Applicants offered a position should be informed in writing of the benefits, salary, and
placement. This avoids misunderstandings later regarding what employees think they
were promised by the nurse-recruiter or the interviewer.
4. Applicants who accept job offers should be informed as to preemployment procedures
such as physical examinations and supplied with the date to report to work.
5. Applicants who are offered positions should be requested to confirm in writing their
intention to accept the position.
Because selection involves a process of reduction (i.e., diminishing the number of
candidates for a particular position), the person making the final selection has a great deal
of responsibility. These decisions have far-reaching consequences, both for the organization
and for the people involved. For these reasons, the selection process should be as objective
as possible. The selection process is shown in Figure 15.1.
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352 UNIT V RolES and FUnctionS in StaFFing
Completion of application
Notification of applicants
Reference checks
Preemployment testing
Employment interview
Physical examination
Adequate applicant pool
Preemployment screening
Employer decision
FIGURE 15.1 • the selection process.
LEARNING EXERCISE 15.3
Making a Hiring Selection and Assessing Its Impact
You are the head nurse of a surgical unit, a position that you have held for 6 years. You are
comfortable with your role and know your staff well. recently, the day charge nurse resigned.
two of your staff, Nancy and Sally, have applied for the position.
Nancy, an older nurse, has been with the organization for 8 years but has been assigned to
your department for only 5 years. She has 12 years of experience in acute care nursing. She
performs her job competently and has good interpersonal relationships with the other staff and
with patients and physicians. although her motivation level is adequate for her current job, she
has demonstrated little creativity or initiative in helping the surgical unit to establish a reputation
for excellence. Nor has she demonstrated specific skills in predicting or planning for the future.
Sally, a nurse in her mid-30s, has been with the organization and the unit for 3 years. She
has been a positive driving force behind many of the changes that have occurred. She is an
excellent clinician and is highly respected by physicians and staff. the older staff, however,
appear to resent her because they feel she attempted too much change before “paying her
dues.”
Both nurses have baccalaureate degrees and meet all the position qualifications for the job.
Both nurses can be expected to work at least another 5 years in the new position. there is no
precedent for your decision.

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 353
pLACEMENT
The astute leader is able to assign a new employee to a position within his or her sphere
of authority, where the employee will have a reasonable chance for success. Nursing units
and departments develop subcultures that have their own norms, values, and methods of
accomplishing work. It is possible for one person to fit in well with an established group,
whereas another equally qualified person would never become part of that group.
In addition, many positions within a unit or department require different skills. For
example, in a hospital, decision-making skills might be more important on a shift where
leadership is less strong; communication skills might be the most highly desired skill on a
shift where there is a great deal of interaction among a variety of nursing personnel.
Frequently, newcomers suffer feelings of failure because of inappropriate placement
within the organization. This can be as true for the newly hired experienced employee as for
the novice nurse. Appropriate placement is as important to the organization’s functioning as
it is to the new employee’s success. Faulty placement can result in reduced organizational
efficiency, increased attrition, threats to organizational integrity, and frustration of personal
and professional ambitions.
Conversely, proper placement fosters personal growth, provides a motivating climate for
the employee, maximizes productivity, and increases the probability that organizational goals
will be met. Leaders who are able to match employee strengths to job requirements facilitate
unit functioning, accomplish organizational goals, and meet employee needs.
You must make a selection. if you do not use seniority as a primary selection criterion, many of
the long-term employees may resent both Sally and you, and they may become demotivated.
You are aware that Nancy is limited in her futuristic thinking and that the unit may not grow and
develop under her leadership as it could under that of Sally.
Assignment: identify how your own values will affect your decision. rank your selection
criteria and make a decision about what you will do. determine the personal, interpersonal, and
organizational impact of your decision.
LEARNING EXERCISE 15.4
Which Two Graduates Would You Choose—and Why?
You are the supervisor of a critical care surgical unit. For the past several years, you have
been experimenting with placing four newly graduated nurses directly into the unit, two
from each spring and fall graduating class. these nurses are from the local BSN program.
You consult closely with the nursing faculty and their former employers before making a
selection.
Overall, this experiment has worked well. Only two new graduates were unable to develop into
critical care nurses. Both of these nurses later transferred back into the unit after 2 years in a
less intensive medical–surgical area.
Because of the new graduates’ motivation and enthusiasm, they have complemented your
experienced critical care staff nicely. You believe that your success with this program has been
due to your well-planned and structured 4-month orientation and education program, careful
selection, and appropriate shift placement.
(Continued )
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354 UNIT V RolES and FUnctionS in StaFFing
INDOCTRINATION
As a management function, indoctrination refers to the planned, guided adjustment of an
employee to the organization and the work environment. Although the words “induction” and
“orientation” are frequently used to describe this function, the indoctrination process includes
this spring, you have narrowed the selection down to four acceptable and well-qualified
candidates. You plan to place one on the 3 pm to 11 pm shift and one on the 11 pm to 7 pm shift.
You sit in your office and review the culture of each shift and your notes on the four candidates.
You have the following information:
3 pm to 11 pm shift: a very assertive, all-female staff; 85% rNs and 15% LpNs/LVNs. this is
your most clinically competent group. they are highly respected by everyone, and although
the physicians often have confrontations with them, the physicians also tell you frequently
how good they are. the nurses are known as a group that lacks humor and does not welcome
newcomers. however, once the new employee earns their trust, they are very supportive. they
are intolerant of anyone not living up to their exceptionally high standards. Your two unsuccessful
new graduate placements were assigned to this shift.
11 pm to 7 am shift: a very cohesive and supportive group. although overall these nurses are
competent, this shift has some of your more clinically weak staff. however, it is also the shift
that rates the highest with families and patients. they are caring and compassionate. every new
graduate that you have placed on this shift has been successful. Of the nurses on this shift,
30% are men. the group tends to be very close and has a number of outside social activities.
Your four applicants consist of the following:
● John: a 30-year-old married man without children. he has had a great deal of emergency
department experience as a medical emergency technician. he appears somewhat aloof.
his definite career goals are 2 years in critical care, 3 years in emergency department,
and then flight crew. instructors praise his independent judgment but believe that he was
somewhat of a loner in school. Former employers have rated him as an independent thinker
and very capable.
● Sally: a 22-year-old unmarried woman. She is at the top of her class clinically and
academically. She has not had much work experience other than the last 2 years as a
summer nursing intern at a medical center, where her performance appraisal was very good.
instructors believe that she lacks some maturity and interpersonal skills but praise her clinical
judgment. She does not want to work in a regular medical–surgical unit. She believes that
she can adapt to critical care.
● Joan: a mature, divorced 38-year-old woman. She has no children. She has had a great deal of
health-related work experience in counseling and has had limited clinical work experience (only
nursing school). Former employers praise her attention to detail and her general competence.
instructors praise her interpersonal skills, maturity, and intelligence. She is quite willing to work
elsewhere if not selected. She has a long-term commitment to nursing.
● Mary: a dynamic, 28-year-old married mother of two. She was previously an LpN/LVN and
returned to school to get her degree. She did not do as well academically due to working and
family commitments. Former employers and instructors speak of her energy, organization, and
interpersonal skills. She appears to have fewer independent decision-making skills than the
others do. She previously worked in a critical care unit.
Assignment: Select the two new graduates and place them on the appropriate shift. Support
your decisions with rationale.

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 355
three separate phases: induction, orientation, and socialization. Because socialization is part
of the staff development and team-building process, it will be covered in the next chapter.
Indoctrination denotes a much broader approach to the process of employment adjustment
than either induction or orientation. It seeks to (a) establish favorable employee attitudes
toward the organization, unit, and department; (b) provide the necessary information and
education for success in the position; and (c) instill a feeling of belonging and acceptance.
Effective indoctrination programs result in higher productivity, fewer rule violations, reduced
attrition, and greater employee satisfaction. The employee indoctrination process begins as
soon as a person has been selected for a position and continues until the employee has been
socialized to the norms and values of the work group. An example of employee indoctrination
content is shown in Display 15.6. Effective indoctrination programs assist employees in
having successful employment tenure.
1. Organization history, mission, and philosophy
2. Organization service and service area
3. Organizational structure, including department heads, with an explanation of the functions of the
various departments
4. employee responsibilities to the organization
5. Organizational responsibilities to the employee
6. payroll information, including how increases in pay are earned and when they are given (progres-
sive or unionized companies publish pay scales for all employees)
7. rules of conduct
8. tour of the facility and of the assigned department
9. Work schedules, staffing, and scheduling policies
10. When applicable, a discussion of the collective bargaining agreement
11. Benefit plans, including life insurance, health insurance, pension, and unemployment
12. Safety and fire programs
13. Staff development programs, including in-service, and continuing education for relicensure
14. promotion and transfer policies
15. employee appraisal system
16. Workload assignments
17. introduction to paperwork/forms used in the organization
18. review of selection in policies and procedures
19. Specific legal requirements, such as maintaining a current license and reporting of accidents
20. introduction to fellow employees
21. establishment of a feeling of belonging and acceptance, showing genuine interest in the new
employee
Note: Much of this content could be provided in an employee handbook, and the fire and safety regulations could be
handled by a media presentation. Appropriate use of videotapes or film strips can be very helpful in the design of a
good orientation program. All indoctrination programs should be monitored to see if they are achieving their goals. Most
programs need to be revised at least annually.
DISpLAy 15.6 Employee Indoctrination Content
Induction
Induction, the first phase of indoctrination, takes place after the employee has been selected
but before performing the job role. The induction process includes all activities that educate
the new employee about the organization and employment and personnel policies and
procedures.
Induction activities are often performed during the placement and preemployment
functions of staffing or may be included with orientation activities. However, induction
and orientation are often separate entities, and new employees suffer if content from either
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356 UNIT V RolES and FUnctionS in StaFFing
program is omitted. The most important factor is to provide the employee with adequate
information.
Employee handbooks, an important part of induction, are usually developed by the
personnel department. Managers, however, should know what information the employee
handbooks contain and should have input into their development. Most employee handbooks
contain a form that must be signed by the employee, verifying that he or she has received and
read it. The signed form is then placed in the employee’s personnel file.
The handbook is important because employees cannot assimilate all the induction
information at one time, so they need a reference for later. However, providing an
employee with a personnel handbook is not sufficient for real understanding. The
information must be followed with discussion by various people during the employment
process, such as the personnel manager and staff development personnel during
orientation. The most important link in promoting real understanding of personnel
polices is the first-level manager.
Orientation
Induction provides the employee with general information about the organization, whereas
orientation activities are more specific for the position. A sample 2-week orientation
schedule is shown in Display 15.7. Organizations may use a wide variety of orientation
programs. For example, a first-day orientation could be conducted by the hospital’s
personnel department, which could include a tour of the hospital and all of the induction
items listed in Display 15.6.
WEEK 1
Day 1, Monday:
8:00 am–10:00 am Welcome by personnel department; employee handbooks distributed and
discussed
10:00 am–10:30 am Coffee and fruit served; welcome by staff development department
10:30 am–12:00 pm General orientation by staff development
12:00 pm–12:30 pm tour of the organization
12:30 pm–1:30 pm Lunch
1:30 pm–3:00 pm Fire and safety films; hipaa training
3:00 pm–4:00 pm afternoon tea and introduction to each unit supervisor
Day 2, Tuesday:
8:00 am–10:00 am report to individual units
time with unit supervisor; introduction to assigned preceptor
10:00 am–10:30 am Coffee with preceptor
10:30 am–12:00 pm General orientation of policies and procedures
12:00 pm–12:30 pm Lunch
12:30 pm–4:30 pm electronic health record orientation
Day 3, Wednesday: assigned all day to unit with preceptor
Day 4, Thursday: assigned all day to unit with preceptor
Day 5, Friday: Morning with preceptor, afternoon with supervisor and staff development for
wrap-up
WEEK 2
Monday to Wednesday: Work with preceptor on shift and unit assigned, gradually assuming greater
responsibilities
Thursday: assign 80% of normal assignment with assistance and supervision from
preceptor
Friday: Carry normal workload. have at least a 30-minute meeting with immediate
supervisor to discuss progress
DISpLAy 15.7 Sample Two-Week Orientation Schedule for Experienced Nurses

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 357
The next phase of the orientation program could take place in the staff development
department, where aspects of concern to all employees such as fire safety, accident prevention,
and health promotion would be presented The third phase would be the individual orientation
for each department. At this point, specific departments such as dietary, pharmacy, and
nursing would each be responsible for developing their own programs. A sample distribution
of responsibilities for orientation activities is shown in Display 15.8.
1. personnel or human resources department: performs salary and payroll functions, insurance
forms, physical examinations, income withholding forms, tour of the organization, employee
responsibilities to the organization and vice versa, additional labor–management relationships,
and benefit plan.
2. Staff development department: hands out and reviews employee handbook; discusses organi-
zational philosophy and mission; reviews history of the organization; shows media presentation
of various departments and how they function (if a media presentation is not available, introduc-
es various department heads, and shares how departments function); discusses organizational
structure, fire and safety programs, hipaa certification and ehr training, and verifications; dis-
cusses available educational and training programs; and reviews selected policies and proce-
dures, including medication, treatment, and charting policies.
3. the individual Unit: tour of the department, introductions, review of specific unit policies that differ
in any way from general policies, review of unit scheduling and staffing policies and procedures,
work assignments, promotion and transfer policies, and establishment of a feeling of belonging,
acceptance, and socialization.
DISpLAy 15.8 Responsibilities for Orientation
Because induction and orientation involve many different people from a variety of
departments, they must be carefully coordinated and planned to achieve preset goals. The
overall goals of induction and orientation include helping employees by providing them with
information that will smooth their transition into the new work setting and health-care team.
The purpose of the orientation process is to make the employee feel like a part of the team. This
will reduce burnout and help new employees become independent more quickly in their new
roles.
It is important to look at productivity and retention as the orientation program is planned,
structured, and evaluated. Organizations should periodically assess their induction and
orientation program in light of organizational goals; programs that are not meeting
organizational goals should be restructured. For example, if employees consistently have
questions about the benefit program, this part of the induction process should be evaluated.
Too often, various people having partial responsibility for induction and orientation “pass
the buck” regarding failure of or weaknesses in the program. It is the joint responsibility
of the personnel/human resources department, the staff development department, and each
nursing service unit to work together to provide an indoctrination program that meets the
needs of employees and the organization.
For some time, managers in health-care organizations, especially hospitals, did not fulfill
their proper role in the orientation of new employees. Managers assumed that between
the personnel/human resources and staff development, or in-service, departments, the new
employee would become completely oriented. This often frustrated new employees because
although they received an overview of the organization, they received little orientation to the
specific unit. Because each unit has many idiosyncrasies, the new employee was left feeling
inadequate and incompetent. The latest trend in orientation is for the nursing unit to take a
greater responsibility for individualizing orientation.
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358 UNIT V RolES and FUnctionS in StaFFing
The unit leader-manager must play a key role in the orientation of the new employee. An
adequate orientation program minimizes the likelihood of rule violations, grievances, and
misunderstandings; fosters feelings of belonging and acceptance; and promotes enthusiasm
and morale.
INTEGRATING LEADERSHIp ROLES AND MANAGEMENT FUNCTIONS IN
EMpLOyEE RECRUITMENT, SELECTION, pLACEMENT, AND INDOCTRINATION
Productivity is directly related to the quality of an organization’s personnel. Active
recruitment allows institutions to bring in the most qualified personnel for a position. After
those applicants have been recruited, managers—using specified criteria—have a critical
responsibility to see that the best applicant is hired. To ensure that all applicants are evaluated
by using the same standards and that personal bias is minimized, the nurse-manager must be
skilled in interviewing and other selection processes.
Leadership roles in preliminary staffing functions include planning for future staffing
needs and keeping abreast of changes in the health-care field. Predicted nursing shortages
will pose staffing challenges for some time to come. Leadership is also necessary in the
preemployment interview process to ensure that all applicants are treated fairly and that the
interview terminates with applicants having positive attitudes about the organization. Because
leaders are fully aware of nuances, strengths, and weaknesses within their sphere of authority,
they are able to assign newcomers to areas that offer the greatest potential for success.
The integration of leadership roles and management functions in the organization ensures
positive public relations because applicants know that they will be treated fairly. In addition,
there is greater likelihood that the pool of applicants will be sufficient because future needs
are planned for proactively. The leader-manager uses the selection and placement process as
a means to increase productivity and retention, accomplish the goals of the organization, and
meet the needs of new employees.
The integrated leader-manager also knows that a well-planned and implemented induction
and orientation program is a wise investment of organizational resources. It provides the
opportunity to mold a team effort and infuse employees with enthusiasm for the organization.
New employees’ impressions of an organization during this period will stay with them for a
long time. If the impressions are positive, they will be remembered in the difficult times that
will ultimately occur during any long tenure of employment.
KEY CONCEPTS
● the first step in the staffing process is to determine the type and number of personnel needed.
● a number of factors are contributing to a projected, severe nursing shortage, including the aging of
the nursing workforce, accelerating demand for professional nurses, inadequate enrollment in nursing
programs of study, and the aging of nursing faculty.
● Successfully recruiting an adequate workforce depends on many variables, including financial resources,
an adequate nursing pool, competitive salaries, the organization’s reputation, the location’s desirability,
and the status of the national and local economy.
● effective recruiting methods include advertisements, career days, literature, and the informal use of
members of the organization as examples of satisfied employees.
● despite their limitations in terms of reliability and validity, interviews continue to be widely used as a
method of selecting employees for hire.

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 359
● the limitations of interviews are reduced when a structured approach is used in asking questions of
applicants.
● the interview should meet the goals of both the applicant and the manager.
● Managers must be skilled in planning, conducting, and controlling interviews.
● Because of numerous federal acts that protect the rights of job seekers, interviewers must be cognizant
of the legal constraints on interviews.
● Selection should be based on the requirements necessary for the job; these criteria should be
developed before beginning the selection process.
● Leaders should seek to proactively recruit and hire staff with age, gender, cultural, ethnic, and language
diversity to better mirror the rapidly increasing diversity of the communities they serve.
● New employees should be placed on units, departments, and shifts where they have the best chance of
succeeding.
● indoctrination consists of induction, orientation, and socialization of employees.
● a well-prepared and executed orientation program educates the new employee about the desired
behaviors and expected goals of the organization and actively involves the new employee’s immediate
supervisor.
LEARNING EXERCISE 15.5
Assessing Personal Bias in Interviewing
You are a new evening charge nurse on a medical floor in an acute care hospital. this is your first
management position. You graduated 18 months ago from the local university with a bachelor’s
degree in nursing. Your immediate supervisor has asked you to interview two applicants who
will be graduating from nursing school in 3 months. Your supervisor believes that they both are
qualified. Because the available position is on your shift, she wants you to make the final hiring
decision.
Both applicants seem equally qualified in academic standing and work experience. Last evening,
you interviewed Lisa and were very impressed. tonight, you interviewed John. during the
meeting, you kept thinking that you knew John from somewhere but could not recall where. the
interview went well, however, and you were equally impressed with John.
after John left, you suddenly remembered that one of your classmates used to date him and that
he had attended some of your class parties. You recall that on several occasions, he appeared
to abuse alcohol. this recollection bothers you, and you are not sure what to do. You know that
tomorrow your supervisor wants to inform the applicants of your decision.
Assignment: decide what you are going to do. Support your decision with appropriate
rationale. explain how you would determine which applicant to hire. how great a role did your
personal values play in your decision?
ADDITIONAL LEARNING EXERCISES AND AppLICATIONS
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360 UNIT V RolES and FUnctionS in StaFFing
LEARNING EXERCISE 15.6
How Would You Strengthen This Orientation Process?
as a new head nurse, one of your goals is to reduce attrition. You plan to do this by increasing
retention, thus reducing costs for orienting new employees. in addition, you believe that the
increased retention will provide you with a more stable staff.
in studying your notes from exit interviews, it appears that new employees seldom develop a
loyalty to the unit but instead use the unit to gain experience for other positions. You believe
that one difficulty with socializing new employees might be your unit’s orientation program. the
agency allows 2 weeks of orientation time (80 hours) when the new employee is not counted
in the nursing care hours. these are referred to as nonproductive hours and are charged to the
education department. Your unit has the following 2-week schedule for new employees:
Week 1
Monday, tuesday 9 am to 5 pm Classroom
Wednesday, thursday, Friday 7 am to 11 am assigned to work with someone on the unit
Week 2
Monday, tuesday 7 am to 3:30 pm assigned to unit with an employee
Wednesday, thursday, Friday assigned to shift they will be working for orientation
to shift
Following this 2-week orientation, the new employee is expected to function at 75% productivity
for 2 or 3 weeks and then perform at full productivity. the exception to this is the new graduate
(rN) orientation. these employees spend one extra week on 7 am to 3 pm and one extra week
assigned to their particular shift before being counted as staff.
Your nursing administrator has stated that you may alter the orientation program in any way you
wish as long as you do not increase the nonproductive time and you ensure that the employee
receives information necessary to meet legal requirements and to function safely.
Assignment: is there any way for you to strengthen the new employee orientation to your unit?
Outline your plans (if any), and state the rationale for your decision.
LEARNING EXERCISE 15.7
Choosing Your Place in the Workforce
You are a nursing student who will graduate in 3 months. You are aware that most of the acute
care hospitals in the immediate area are not hiring new graduates although there are a few
openings in a small, rural hospital about 40 miles from where you live. there are some openings
in home health, public health, community health, telehealth, and case management in the local
community as well. You need to get a job as soon as possible as you are a single parent and
have accrued significant debt in your educational degree quest.
Your career goal is to work in a high-paced, skill-intensive, acute care hospital environment like
the ed, iCU, or trauma, but you have not yet achieved the specialty certifications you need to do
so and there are no openings in these units for new graduates at present anyway. You enjoyed
the autonomy and patient interaction that you experienced in your public health practicum as
part of school, and the Monday to Friday work schedule of the public health nurses appeals to
you since you have small children. the salary, however, would be significantly lower than if you
worked in an acute care setting and you are not sure that this would be enough to make ends
meet. Moreover, the orientation period at the public health facility would be fairly brief.
Finally, you also have an interest in pediatric oncology, a specialty not available to you unless
you relocate to a regional medical center almost 200 miles from where you currently live.

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Chapter 15 Employee Recruitment, Selection, Placement, and indoctrination 361
there are opportunities for advancement and professional development there but it would
likely be necessary for you to take a job on the night shift on a general medical–surgical unit
first, to get your foot in the door.
Assignment:
1. determine how you will move forward in making a decision about where you will seek employment.
2. Make a list of 10 factors that you need to consider in weighting conflicting wants, needs, and
obligations.
3. What evaluation criteria can you generate to look at both the process you used to make your
decision and the decision itself?
LEARNING EXERCISE 15.8
Ethical Issues in Hiring
You are the head nurse of an intensive care unit and are interviewing Sam, a prospective charge
nurse for your evening shift. Sam is currently the unit supervisor at Memorial hospital, which
is the other local hospital and your organization’s primary competitor. he is leaving Memorial
hospital for personal reasons.
Sam, well qualified for the position, has strong management and clinical skills. Your evening shift
needs a strong manager with the excellent clinical skills, which Sam also has. You feel fortunate
that Sam is applying for the position.
Just before the close of the interview, however, Sam shuts the door, lowers his voice secretively,
and tells you that he has vital information regarding Memorial’s plans to expand and reorganize
its critical care unit. he states that he will share this information with you if you hire him.
Assignment: how would you respond to Sam? Should you hire him? identify the major issues
in this situation. Support your hiring decision with rationale from this chapter and other readings.
LEARNING EXERCISE 15.9
Reducing Your Anxiety About Possible Hiring Interview Questions
Assignment: Make a list of three or four interview questions you may face in your new graduate
interview, which you feel most insecure about answering. then, share your questions with
a small group of your peers. Work together to identify strong and weak responses to those
interview questions. Make sure that every individual in the group has a chance to get feedback
about the interview questions they are most anxious about.
LEARNING EXERCISE 15.10
Your Best Interview
Assignment: do you remember your first interview for a job? how would you evaluate your
abilities as someone being interviewed? have you ever had the responsibility to interview
someone for an employment position? What would you identify as your strengths and
weaknesses in the interview process as both interviewer and interviewee? if you hired someone
in the past how would you rate their performance as an employee? Were they more competent
or less competent than they seemed at the time you interviewed them?
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362 UNIT V RolES and FUnctionS in StaFFing
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http://www.ctdol.state.ct.us/progsupt/jobsrvce/intervie.htm

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363
16
Socializing and Educating Staff for Team
Building in a Learning Organization
… environments rich in continuing education ripen staff development, morale and retention.
—Diane Postlen-Slattery and Kathryn Foley
… as part of the lifelong learning process, nurse leaders will increasingly use mentors and personal
coaches to help them refine their tools and skills and to identify new lenses through which to view
current concerns or issues.
—Karen S. Haase-Herrick
CROSSWALK tHiS cHaPter aDDreSSeS:
BSN Essential I: Liberal education for baccalaureate generalist nursing practice
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential III: Scholarship for evidence-based practice
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential VIII: Professionalism and professional values
MSN Essential I: Background for practice from sciences and humanities
MSN Essential II: Organizational and systems leadership
MSN Essential IV: translating and integrating scholarship into practice
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: evidence-based practice
QSEN Competency: teamwork and collaboration
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: Professionalism
LEARNING OBJECTIVES The learner will:
l describe characteristics of learning organizations
l differentiate between education and training
l select an appropriate sequence of events for educational planning
l identify problems that may occur when the responsibility for staff development is shared
l select appropriate educational strategies that facilitate learning in a variety of situations
l discuss criteria that should be used to evaluate staff development activities
l demonstrate knowledge of the needs of the adult learner versus the needs of the child learner
and describe teaching strategies that best meet the needs of both groups of learners
l explain the difference between motivation to learn and readiness to learn
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364 UNIT V ROLES AND FUNCTIONS IN STAFFING
l apply principles of social learning theory
l identify strategies that could be used to help staff deal successfully with role transitions
l select strategies to assist the new graduate nurse with socialization to the nursing role
l explain why experienced nurses may have difficulty in role transition
l compare and contrast the roles of mentor, preceptor, and role model
l choose criteria for the selection of preceptors that would likely result in effective role
transition for the protégé
l develop coaching techniques that enhance learning
l address the unique challenges of building a cohesive team through education and
socialization, when a diverse workforce exists
Health-care organizations face major challenges in upgrading the skills of their workforce and
in maintaining a competent staff. This is especially true in times of exponential knowledge
growth and limitless new technology applications. Educating staff and assuring continuing
competency then is a critical and difficult task for most 21st-century organizations.
This chapter begins by introducing the concept of the learning organization (LO) and the
various components of staff development. Education and training are differentiated as are
role models, preceptors, and mentors. The needs of the adult learner are explored, and the
concept of coaching as a staff development tool is introduced. The role of the organization,
leader-managers, and staff development departments in creating a culture that supports and
promotes evidence-based practice is emphasized. Finally, the need to build a cohesive team,
including the needs of a culturally diverse workforce, is explored. The leadership roles and
management functions associated with socializing and educating staff for team building are
shown in Display 16.1.
DISPLAY 16.1 Leadership Roles and Management Functions Associated with Socializing
and Educating Staff for Team Building in a Learning Organization
LEADERSHIP ROLES
1. clarifies unit norms and values to all new employees.
2. infuses a team spirit among employees.
3. Serves as a role model to all employees and a mentor to select employees.
4. encourages mentorship between senior staff and junior employees.
5. Observes carefully for signs of knowledge or skill deficit in new employees and intervenes
appropriately.
6. assists employees in developing personal strategies to cope with role transition.
7. applies adult learning principles when helping employees learn new skills or information.
8. coaches employees spontaneously regarding knowledge and skill deficits.
9. is sensitive to the unique socialization and education needs of a culturally and ethnically diverse
staff.
10. continually promotes aspects of the LO to employees.
11. assists nursing staff in overcoming organization barriers to effective evidence-based practice.
12. encourages and supports workers as they pursue lifelong learning individually and collectively.
MANAGEMENT FUNCTIONS
1. is aware of and clarifies organizational and unit goals for all employees.
2. clarifies role expectations for all employees.
3. Uses positive and negative sanctions appropriately to socialize new employees.
4. carefully selects preceptors and encourages positive role modeling by experienced staff.
5. Provides methods of meeting the special orientation needs of new graduates, international
nurses, and experienced nurses changing roles.

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 365
THE LEARNING ORGANIZATION
A growing body of literature supports the concept that learning should go beyond the
boundaries of individual learning and that organizations that incorporate learning as a major
part of their philosophy will be more successful. This concept was first introduced by Senge
(1994), who called such organizations LOs. Since learning is viewed as an important part of
quality, LOs view learning as the key to the future for individuals, as well as for organizations.
In addition, the LO promotes a shared vision and collective learning in order to create positive
and needed organizational change.
The LO promotes a shared vision and collective learning in order to create positive and needed
organizational change.
The key characteristics of Senge’s model of LOs (five disciplines) include the following:
• Systems thinking. The organization encourages staff to see themselves as connected to
the whole organization and work activities are seen as having an impact beyond the
individual. This creates a sense of community and builds a commitment on the part of
individual workers not only to the organization but also to each other.
• Personal mastery. Each member of the staff has a commitment to improve his or her
personal abilities. This personal and professional learning is then integrated into the
team and organization.
• Team learning. It is through the collaboration of team members that LOs achieve their
goals.
• Mental models. The goal in the LO is to foster organizational development through
diverse thinking. Assumptions held by individuals then are challenged since this releases
individuals from traditional thinking and promotes the full potential of individuals to learn.
• Shared vision. When all the employees of the LO share a common vision, they are more
willing to put their personal goals and needs aside and instead focus on teamwork and
collaboration.
Since Senge, many theorists have furthered our understanding of LOs. For example, Green,
Reid, and Larson (2012) suggest that the conceptual foundation of a rapid learning health
system has both human and technological aspects. The human factors include stakeholders
motivated by a desire to continuously improve the system for patients. The technological
aspects include a search for and use of current, robust data to guide clinical and administrative
decision making, based on evidence and reporting systems that are accessible system-wide,
allowing learning to permeate throughout the organization.
Glaser and Overhage (2013) agree, suggesting that the foundation for an LO in health
care is continuous knowledge development—the formation of a closed “learning loop,” in
which information generated by clinical research is methodically captured and translated
6. Works with the education department to delineate shared and individual responsibility for staff
development.
7. ensures that there are adequate resources for staff development and makes appropriate deci-
sions regarding resource allocation during periods of fiscal restraint.
8. assumes responsibility for quality and fiscal control of staff development activities.
9. ensures that all staff are competent for roles assigned.
10. Provides input in formulating staff development policies.
11. ensures that the organization provides resources to promote evidence-based nursing practice.
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366 UNIT V ROLES AND FUNCTIONS IN STAFFING
into evidence that can provide the basis for improving patient care. Glaser and Overhage
suggest that while some individuals still view the LO as an ideal, it should be viewed as an
imperative and note that “many organizations are already engaged in constantly revamping
and retooling themselves, perhaps unknowingly reaching for that ideal goal of becoming a
learning organization” (Glaser & Overhage, 2012, p. 62).
In addition, in September 2012, the Institute of Medicine (2012) released a 4,000 page
report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
In this report, the IOM outlined a series of recommendations to improve the nation’s health-
care system. One of the key recommendations was to reward providers for continuous
learning and quality. This quest for continuous learning and quality creates a health-care
delivery system that learns from and evolves with every patient interaction (Glaser &
Overhage, 2013).
STAFF DEVELOPMENT
This recognition by LOs that learning is never ending and that the organization has at least
some responsibility for developing their employees is responsible in part for the growth in
staff development programs. An LO does not just meet licensure requirements for education
and training but encourages individual growth and supports staff development activities both
financially and philosophically.
This fostering of growth and learning in employees is not, however, solely the result of
altruistic motives by the organization. The staff’s knowledge level and capabilities often
determine the number of staff required to carry out unit goals. Therefore, the better trained
and more competent the staff, the fewer the number of staff required, which in turn saves the
organization money and increases productivity.
Staff development is a cost-effective method of increasing productivity.
Training Versus Education
Education and training are two components of staff development. Managers historically had
a greater responsibility for seeing that staff were properly trained than they did for meeting
educational needs. A more equal balance has been achieved in the past two decades.
Training may be defined as an organized method of ensuring that people have knowledge
and skills for a specific purpose and that they have acquired the necessary knowledge to
perform the duties of the job. The knowledge may require increased affective, motor, or
cognitive skills.
To assist employees with their training needs, the manager must first determine what
those needs are. This requires more than just asking employees about their knowledge
deficits or giving employees a skills checklist or test; it requires careful observation
so that deficiencies are identified and corrected before they handicap the employee’s
socialization. This is a leadership role. When such deficiencies are not corrected early,
other employees often create a climate of nonacceptance that prevents assimilation of the
new employee.
Education is more formal and broader in scope than training. Whereas training has an
immediate use, education is designed to develop individuals in a broader sense. Recognizing
educational needs and encouraging educational pursuits are roles and responsibilities of the
leader. Managers may appropriately be requested to teach classes or courses; however, unless
they have specific expertise, they would not normally be responsible for an employee’s
formal education.

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 367
Responsibilities of the Education Department
Staff development is a broad area of responsibility and is borne by many people in
the organization. Its official functions are often housed, however, within an education
department. Since most education departments have staff or advisory authority rather than
line authority on the organization chart, education personnel generally have little or no formal
authority over those for whom they are providing educational programs. Likewise, the unit
manager may have little authority over personnel in the education department. Because of
the ambiguity of overlapping roles and difficulties inherent in line and staff positions, it
is important that those responsible for educating and training be identified and given the
authority to carry out the programs.
If staff development activities are to be successful, it is necessary to delineate and communicate
the authority and responsibility for all components of education and training.
In some organizations, the responsibility for staff development is decentralized. This has
occurred as a result of fiscal concerns, the awareness of the need to socialize new employees
at the unit level, and recognition of the relationship between employee competence and
productivity. Some difficulties associated with decentralized staff development include the
conflict created by role ambiguity whenever two people share responsibility. Role ambiguity
is sometimes reduced when staff development personnel and managers delineate the
difference between training and education.
Other difficulties arising from the shared responsibility among managers, personnel
department staff, and educators for the indoctrination, education, and training of personnel
may include a lack of cost-effectiveness evaluation and limited accountability for the
quality and outcomes of the educational activities. The following suggestions can help
overcome the difficulties inherent in a staff development system in which there is shared
authority:
• The education department must ensure that all parties involved in the indoctrination,
education, and training of nursing staff understand and carry out their responsibilities in
that process.
• If a non-nursing administrator is responsible for the staff development department, there
must be input from the nursing department in formulating staff development policies and
delineating duties.
• An education advisory committee should be formed with representatives from top-,
middle-, and first-level management; staff development; and the human resource
department. Representatives from all classifications of employees receiving training or
education should be part of this committee.
• Accountability for various parts of the staff development program must be clearly
communicated.
• Some method of determining the cost and benefits of various programs should be used.
LEARNING THEORIES
All managers have a responsibility to improve employee performance through teaching.
Therefore, they must be familiar with basic learning theories. Understanding teaching–
learning theories allows managers to structure training and use teaching techniques
to change employee behavior and improve competence, which is the goal for all staff
development.
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368 UNIT V ROLES AND FUNCTIONS IN STAFFING
Adult Learning Theory
Many managers attempt to teach adults with pedagogical or child-learning strategies. This
type of teaching is usually ineffective for mature learners because adults have special needs.
Knowles (1970) developed the concept of andragogy, or adult learning, to separate adult
learner strategies from pedagogy, or child learning. Knowles suggested that the point at
which an individual achieves a self-concept of essential self-direction is the point at which
he or she psychologically becomes an adult (Atherton, 2011).
Adult learners then are mature, self-directed people who have learned a great deal from life
experiences and are focused toward solving problems that exist in their immediate environments.
This is because adult learners need to know why they need to learn something before they are
willing to learn it. In addition, Knowles believed that adults need to be responsible for their
own decisions and to be treated as capable of self-direction (Atherton, 2011).
Adult learning theory has contributed a great deal to the manner in which adults are
currently taught in staff development programs. Table 16.1 shows how child and adult
(pedagogical and andragogical) learning environments typically differ. Display 16.2
identifies the implications of Knowles’ work for trainers and educators.
TABLE 16.1 Characteristics and Learning Environment of Pedagogy and Andragogy
Pedagogy Andragogy
Characteristics
Learner is dependent Learner is self-directed
Learner needs external rewards and punishment Learner is internally motivated
Learner’s experience is inconsequential or limited Learner’s experiences are valued and varied
Subject centered task or problem centered
teacher directed Self-directed
Learning Environment
the climate is authoritative the climate is relaxed and informal
competition is encouraged collaboration is encouraged
teacher sets goals teacher and class set goals
Decisions are made by teacher Decisions are made by teacher and students
teacher lectures Students process activities and inquire about
projects
teacher evaluates teacher, self, and peers evaluate
DISPLAY 16.2 Implications of Knowles’ Work for Trainers and Educators
● a climate of openness and respect will assist in the identification of what the adult learner wants
and needs to learn.
● adults enjoy taking part in and planning their learning experiences.
● adults should be involved in the evaluation of their progress.
● experiential techniques work best with adults.
● Mistakes are opportunities for adult learning.
● if the value of the adult’s experience is rejected, the adult will feel rejected.
● adults’ readiness to learn is greatest when they recognize that there is a need to know (such as
in response to a problem).
● adults need the opportunity to apply what they have learned very quickly after the learning.
● assessment of need is imperative in adult learning.
While most adults enjoy and take pride in being treated as an adult in terms of learning,
there are some obstacles to learning for adults that do not exist in children. Since learning
tends to become problem centered as we age, adults often miss out on opportunities to enjoy
learning for the sheer sake of learning itself. Similarly, adults often experience more external

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 369
obstacles to learning, including time, energy, and institutional barriers. These and other
obstacles to adult learning are shown in Display 16.3 as are the assets or driving forces, which
encourage learning in the adult.
DISPLAY 16.3 Obstacles and Assets to Adult Learning
OBSTACLES TO LEARNING
institutional barriers
time
Self-confidence
Situational obstacles
Family reaction
Special individual obstacles
ASSETS FOR LEARNING
High self-motivation
Self-directed
a proven learner
Knowledge experience reservoir
Special individual assets
Social Learning Theory
Social learning theory is also an important part of LOs since it suggests we learn from our
interactions with others in a social context. (This is a part of the teamwork and mental model
development in LOs.) Albert Bandura, a social psychologist, is often credited with developing
social learning theory in the 1970s. Bandura (1977) believed that direct reinforcement could
not account for all types of learning, and that instead, most people learn their behavior by direct
experience and observation, known as observational learning or modeling (Cherry, 2013).
Indeed, Bandura felt that four separate processes were involved in social learning. First,
people learn as a result of the direct experience of the effects of their actions. Second,
knowledge is frequently obtained through vicarious experiences, such as by observing
someone else’s actions. Third, people learn by judgments voiced by others, especially when
vicarious experience is limited. Fourth, people evaluate the soundness of the new information
by reasoning through inductive and deductive logic. If observational learning is to become
successful, individuals must be motivated to imitate the behavior that has been modeled
(Cherry, 2013). Figure 16.1 depicts Bandura’s social learning theory process.
Other Learning Theories
The following learning concepts may also be helpful to the leader-manager in meeting the
learning needs of staff in LOs:
• Readiness to learn. This refers to the maturational and experiential factors in the
learner background that influence learning and is not the same as motivation to learn.
Maturation means that the learner has received the prerequisites for the next stage of
learning. The prerequisites could be behaviors or prior learning. Experiential factors are
skills previously acquired that are necessary for the next stage of learning.
• Motivation to learn. If learners are informed in advance about the benefits of learning
specific content and adopting new behaviors, they are more likely to be motivated
to attend the training sessions and learn. Telling employees why and how specific
educational or training programs will benefit them personally is a vital management
function in staff development.
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370 UNIT V ROLES AND FUNCTIONS IN STAFFING
• Reinforcement. Because a learner’s first attempts are often unsuccessful, a preceptor is
essential. Good preceptors can reinforce desired behavior. Once the behavior or skill is
learned, it needs continual reinforcement until it becomes internalized.
• Task learning. The learning of complex tasks is facilitated when tasks are broken into
parts, beginning with the simplest and continuing to the most difficult. It is necessary,
however, to combine part learning with whole learning. When learning motor skills,
spaced practice is more effective than massed practice.
• Transfer of learning. The goal of training is to transfer new learning to the work setting.
For this to occur, there should first be as much similarity between the training context
and the job as possible. Second, adequate practice is mandatory, and overlearning
(learning repeated to the degree that it is difficult to forget) is recommended. Third,
the training should include a variety of different situations so that the knowledge is
generalized. Fourth, whenever possible, important features or steps in a process should
be identified. Finally, the learner must understand the basic principles underlying the
tasks and how a variety of situations will modify how the task is accomplished. Learning
in the classroom will not be transferred without adequate practice in a simulated or real
situation and without an adequate understanding of underlying principles.
Behavior is internalized and attitude change occurs
New behavior
Reinforcement of behavior continues
Behavior is reproduced
Retention processes Cognitive learning
Select and observe a model
Anticipated reinforcement
FIGURE 16.1 • the social learning theory process.

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 371
• Span of memory. The effectiveness of staff development activities depends to some extent on
the ability of the participants to retain information. Effective strategies include the chance for
repeated rehearsal, grouping items to be learned (three or four items for oral presentations and
four to six visually), having the material presented in a well-organized manner, and chunking.
• Chunking. This occurs when two independent items of information are presented and
then grouped together into one unit. Although the mind can remember only a limited
number of chunks of data, experienced nurses can include more data in the chunks than
can novice nurses.
• Knowledge of results. Research has demonstrated that people learn faster when they are
informed of their progress. The knowledge of results must be automatic, immediate, and
meaningful to the task at hand. People need to experience a feeling of progress, and they
need to know how they are doing when measured against expected outcomes.
ASSESSING STAFF DEVELOPMENT NEEDS
Although managers may not be involved in implementing all educational programs, they are
responsible for identifying learning needs. If educational resources are scarce, staff desires
for specific educational programs may need to be sacrificed to fulfill competency and new
learning needs. Because managers and staff may identify learning needs differently, an
educational needs assessment should be carried out before developing programs.
Staff development activities are normally carried out for one of three reasons: to establish
competence, to meet new learning needs, and to satisfy interests the staff may have in learning
in specific areas.
Many staff development activities are generated to ensure that workers at each level are
competent to perform the duties assigned to the position. Competence is defined as having
the abilities to meet the requirements for a particular role. Health-care organizations use
many resources to determine competency. State board licensure, national certification, and
performance review are some of the methods used to satisfy competency requirements
(Huston, 2014a). Other methods are self-administered checklists, record audits, and peer
evaluation. Many of these methods are explained in Unit VII. For staff development purposes,
it is important to remember that in the case of deficient competencies, some staff development
activity must be implemented to correct the deficiencies. Another learning need that frequently
affects health-care organizations is the need to meet new technological and scientific challenges.
Much of a manager’s educational resources will be used to meet these new learning needs.
Some organizations implement training programs because they are faddish and have been
advertised and marketed well. Educational programs are expensive, however, and should not
be undertaken unless a demonstrated need exists.
In addition to developing rationale for educational programs, the use of an assessment plan
will be helpful in meeting learner needs. The sequence that should be used in developing an
educational program is shown in Display 16.4.
DISPLAY 16.4 Sequence for Developing an Educational Program
1. identify the desired knowledge or skills that the staff should have.
2. identify the present level of knowledge or skill.
3. Determine the deficit of desired knowledge and skills.
4. identify the resources available to meet needs.
5. Make maximum use of available resources.
6. evaluate and test outcomes after use of resources.
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372 UNIT V ROLES AND FUNCTIONS IN STAFFING
EVALUATION OF STAFF DEVELOPMENT ACTIVITIES
Because staff development includes participation and involvement from many departments,
it may be very difficult to control the evaluation of staff development activities effectively.
It would be very easy for the personnel department, middle-level managers, and the
education department to “pass the buck” among one another for accountability regarding
these activities.
In addition, the evaluation of staff development must consist of more than merely having
class participants fill out an evaluation form at the end of the class session, signing an
employee handbook form, or assigning a preceptor for each new employee. Evaluation of
staff development should include the following four criteria:
• Learner’s reaction. How did the learner perceive the orientation, the class, the training,
or the preceptor?
• Behavior change. What behavior change occurred as a result of the learning? Was the
learning transferred? Testing someone at the end of a training or educational program
does not confirm that the learning changed behavior. There needs to be some method of
follow-up to observe if behavior change occurred.
• Organizational impact. Although it is often difficult to measure how staff development
activities affect the organization, efforts should be made to measure this criterion.
Examples of measurements are assessing quality of care, medication errors, accidents,
quality of clinical judgment, turnover, and productivity.
• Cost-effectiveness. All staff development activities should be quantified in some manner.
This is perhaps the most neglected aspect of accountability in staff development. All staff
development activities should be evaluated for quality control, impact on the institution,
and cost-effectiveness. This is true regardless of whether the education and training
activities are carried out by the manager, the preceptor, the personnel department, or the
education department.
LEARNING EXERCISE 16.1
Designing a Teaching Plan
You have been working in a home health agency for 3 years. During that time, the acuity of your
caseload has increased dramatically, and you find that teaching home health aides has become
more difficult, as the equipment they need to use has become more complex. the home health
aides seem motivated to learn, but you believe that part of the difficulty lies with how you are
presenting the material. Many of them have a limited knowledge of nursing procedures.
One of your clients is Mr. Jones, who has no family. His insurance company has approved a
visit from a home health aide every other day to bathe him and help him ambulate with a walker.
Because of his chronic severe respiratory disease, he must be ambulated with oxygen but does
not need it when resting. today, you have scheduled a session with Mr. Jones’ home health aide
for a demonstration and return demonstration on how to connect and disconnect the oxygen
and how to use the walker. the aide is very competent in basic hygiene skills but has not always
used good body mechanics when providing patient care, and she seems intimidated by new
equipment.
Assignment: Using your knowledge of the learning theories presented in this chapter, construct
a teaching plan for this aide. Support your plan with appropriate rationale.

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 373
SHARED RESPONSIBILITY FOR IMPLEMENTING EVIDENCE-BASED PRACTICE
Chapter 11 discussed the individual’s responsibility for a professional practice that was
evidenced based. However, the organization, as well as the individual, has a responsibility
to promote best practices. One way that health-care organizations can demonstrate their
commitment to becoming an LO is to promote and facilitate professional practice that is
evidenced based, since nurses often find that barriers to evidence-based practices exist within
organizations.
In discussing such organizational constraints, Prevost (2014) delineates various difficulties
nurses face in their attempt to use best practices, including inadequate access to research
findings and poor administrative support. Prevost suggests organizations employ the
strategies shown in Display 16.5 to encourage the use of evidence-based decision making in
establishing clinical best practices:
Although much progress has been made in developing research experts to collect
and critique findings to adopt evidence-based practice, much still needs to be done by
organizations and staff development departments. Organizational cultures often do not
support the nurse who seeks out and uses research to change long-standing practices rooted
in tradition (Prevost, 2014). It is the integrated leader-manager who must create and support
an organizational culture that values and uses research to improve clinical practice.
Facilitating evidence-based practice is a shared responsibility of the professional nurse, the
organization, leader-managers, and the education or staff development department.
SOCIALIZATION AND RESOCIALIZATION
In addition to training and educating staff, the leader-manager is also responsible for
socializing employees to their roles and to the organization. This role is not limited, however,
to the leader-manager; the education department, especially during orientation, other
employees, and many members of an organization are also expected to assist with employee
socialization. Socialization then refers to a learning of the behaviors that accompany each role
by instruction, observation, and trial and error.
Socialization and the New Nurse
The first socialization to the nursing role occurs during nursing school and continues after
graduation. Because nurse administrators and nursing faculty may hold different values and
both assist in socializing the new nurse, there is potential for the new nurse to develop conflict
and frustration, often termed reality shock. Indeed, the first year of employment is often cited
as the most difficult time in a nurse’s career (Martin & Wilson, 2011).
DISPLAY 16.5 Strategies for Promoting Evidence-Based Decision Making in Establishing
Clinical Best Practices
● Develop and refine research-based policies and procedures.
● Build consensus from the interdisciplinary team through the development of protocols, decision
trees, standards of care and institutional clinical practice guidelines, and other such mechanisms.
● Make research findings accessible through libraries and computer resources.
● Provide organization support such as time to do research and educational assistance in showing
staff how to interpret research statistics and use findings.
● encourage cooperation among professionals.
● When possible, hire nurse researchers or consultants to assist staff.
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374 UNIT V ROLES AND FUNCTIONS IN STAFFING
Several mechanisms do exist, however, to ease the role transition of new graduates.
Anticipatory socialization carried out in educational settings helps prepare new nurses
for their professional role. However, managers should not assume that such anticipatory
socialization has occurred. Instead, they should build opportunities for sharing and clarifying
values and attitudes about the nursing role into orientation programs. Use of the group
process is an excellent mechanism to promote the sharing that provides support for new
graduates and assists them in recovering from reality shock.
In addition, managers should be alert for signs and symptoms of role stress and role
overload in new nurses; they should intervene by listening to these graduates and helping
them to develop appropriate coping behaviors. In addition, managers must recognize the
intensity of new nurses’ practice experience, encourage them to have a balanced life, foster a
work environment that has zero tolerance for disrespect, and strive to create work relationship
models that promote interdependency of physicians and nursing staff.
Martin and Wilson (2011) go one step further; they suggest that managers must actively
create a caring work environment that includes two things: helping the new RN adapt to
the culture of nursing and helping them to develop the skills they need to function as a
professional nurse. In their phenomenological study, Martin and Wilson found that all new
graduates described aspects significant to their professional acculturation, including unrealistic
expectations, a desire for perfectionism, and having to learn to work in a stressful environment.
However, they also noted that caring relationships with colleagues played a role in how well
they adapted to the culture of nursing, as well as the length and quality of the movement from
novice to advanced beginner to competent nurse (see Examining the Evidence 16.1).
Source: Martin, K., & Wilson, C. B. (2011). Newly registered nurses’ experience in the first year of practice: A phe-
nomenological study. international Journal For Human caring, 15(2), 21–27.
A purposive convenience sample (n = 7) was chosen from newly licensed RNs who had been
in practice in an acute care setting for at least 1 year, and who had participated in an intensive
“transitions program,” to ease new graduates into nursing practice. The transitions program was a
dynamic, 2-week course that provided the newly graduated nurse with a variety of experiences to
help ease the transition from nursing student to professional nurse. These experiences included
interactive classroom activities on topics such as delegation, time management, conflict resolu-
tion, managing change, communication and personality styles, recognizing the art of nursing, the
importance of self-care to transition into nursing practice and the opportunity to practice caring
in a small group format, and skills lab activities.
Semistructured audio-taped individual interviews were conducted by the primary researcher
until redundancy in data was achieved. The interview question guiding this study was, “Tell me
your experience as a new nurse during your first year of practice.” A seven-step process for data
analysis using interpretive phenomenological inquiry was chosen as a framework for approaching
the data.
Findings of the study suggested two themes that were congruent with the literary and theo-
retical context within which the study was situated; adapting to the culture of nursing and the
development of professional responsibilities. Adapting to the culture of nursing for these novice
nurses, was sometimes a treacherous journey, and their stories were congruent with Kramer’s
(1974) theoretical framework of reality shock. Adaptation was also linked to the level of caring
experienced in the relationships developed with colleagues and interprofessional team members,
such as physicians.
The second category, development of professional responsibilities, included surviving as a
novice nurse, excitement in becoming an advanced beginner, and success in achieving compe-
tent practice. Again, adaptation was linked to the quality of the caring relationships experienced.
Examining the Evidence 16.1

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 375
Managers should also ensure that the new nurse’s values are supported and encouraged so
that work and academic values can blend. New professionals need to understand the universal
nature of role transition and know that it is not limited to nurses. Providing a class on role
transition also may assist new graduates in socialization.
It is important to remember that no one is immune to a loss of idealism and commitment in
response to stress in the workplace.
In addition, some hospitals have developed prolonged orientation periods for new graduates
that last from 6 weeks to 6 months. This extended orientation, or internship, contrasts sharply
with the routine 2-week orientation that is normal for most other employees. During this
time, graduate nurses are usually assigned to work with a preceptor and gradually take on a
patient assignment equal to that of the preceptor. Even longer internships, known as nurse
residencies, were discussed in Chapter 11.
LEARNING EXERCISE 16.2
Investigating Emotional Exhaustion in New Graduates
talk with at least four nursing graduates who have been working as nurses for at least
3 months and no more than 3 years. Make sure at least two of them are recent graduates
and two of them have been working at least 18 months. ask them about their socialization to
nursing after graduation. Did any of them experience difficulty transitioning from academe to
clinical practice? if so, how long did it last? Did they recover? if so, how? Share your findings
with other members of your group.
Resocialization and the Experienced Nurse
Resocialization occurs when individuals are forced to learn new values, skills, attitudes, and
social rules as a result of changes in the type of work they do, the scope of responsibility they
hold, or in the work setting itself. Individuals who frequently need resocialization include
experienced nurses who change work settings, either within the same organization or in a new
organization; and nurses who undertake new roles.
For example, the transition from expert to novice is very difficult. Many nurses transfer or
change jobs because they no longer find their present job challenging. However, this results in
the need to assume a learning role in their new environment. The employee assigned to orient
the nurse in role transition should be aware of the difficulties that this nurse will experience.
Transferred employees’ lack of knowledge in the new area should never be belittled; and
whenever possible, the special expertise they bring from their former work area should be
acknowledged and utilized.
Another transition that is difficult is from the familiar to the unfamiliar. In new positions,
employees must not only learn new job skills, they typically must work in an unfamiliar
LEARNING EXERCISE 16.3
Great Influences
Who or what has been the greatest influence on your socialization to the nursing role? Were
positive or negative sanctions used? Write a short essay (three or four paragraphs) describing
this socialization. if appropriate, share this in a group.
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376 UNIT V ROLES AND FUNCTIONS IN STAFFING
environment. Special orientation materials should be developed and made available in
departments to which nurses transfer more often than others. In addition to providing
necessary staff development content, these orientation programs should focus on efforts to
promote the self-esteem of these nurses as they learn the skills necessary for their new role.
The managers of departments that receive frequent transfers should prepare a special
orientation for experienced nurses transferring to the department.
Transitioning into a new job would result in less role strain if programs were designed to
facilitate role modification and role expansion. For example, when a nurse transfers from a
medical floor to labor and delivery, the nurse does not know the group norms, is unsure of
expected values and behaviors, and goes from being an expert to being a novice. All of this
creates a great deal of role strain. This same type of role stress occurs when experienced
nurses move from one organization to another or from an inpatient setting to a community
setting. Often, nurses feel powerless during role transitions, which may culminate in anger
and frustration as they seek socialization to a different role.
Programs to assist nurses with the transition to a new position should do more than just
provide an orientation to the new position; they also should address specific values and
behaviors necessary for the new roles. The values and attitudes expected in a hospice nursing
role may be quite different from those expected of a trauma nurse. Managers should not
assume that the experienced nurse is aware of the new role’s expected attitudes.
In addition, employees adopting new values often experience role strain and managers
need to support employees during this value resocialization. Members of the reference group
may use negative sanctions, saying things like, “Well, we don’t believe in doing that here.”
This can make new, experienced employees feel as though the values held in other nursing
roles were bad or wrong. Therefore, the manager should make efforts to see that formerly held
values are not belittled. Excellent companies have leaders who take responsibility for shaping
the values of new employees. By instilling and clarifying organizational values, managers
promote a homogeneous staff that functions as a team.
Values and attitudes may be a source of conflict as nurses learn new roles.
The Socialization and Orientation of New Managers
Probably, no other aspect of an employee’s work life has as great an influence on productivity
and retention as the quality of supervision exhibited by the immediate manager. Unfortunately,
the orientation and socialization of new managers is often neglected by organizations.
In addition, many restructured hospital organizational designs have created different and
expanded roles for existing managers without ensuring that managers are adequately prepared
for these new roles.
There is a growing recognition that good managers do not emerge from the workforce without a
great deal of conscious planning on the part of the organization.
A management development program should be ongoing, and individuals should receive
some management development instruction before their appointment to a management
position. When an individual is filling a position where the previous manager is still available
for orientation, the orientation period should be relatively short. The previous manager
usually spends no longer than 1 week working directly with the new manager, especially
when the new manager is familiar with the organization. A short orientation by the outgoing
manager allows the newly appointed manager to gain control of the unit quickly and establish
his or her own management style. If the new manager has been recruited from outside the
organization, the orientation period may need to be extended.

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 377
Frequently, a new manager will be appointed to a vacant or newly established position. In
either case, no one will be readily available to orient the new manager. In such cases, the new
manager’s immediate superior appoints someone to assist the new manager in learning the
role. This could be a manager from another unit, the manager’s supervisor, or someone from
the unit who is familiar with the manager’s duties and roles.
A new manager’s orientation does not cease after the short introduction to the various
tasks. Every new manager needs guidance, direction, and continued orientation and
development during the first year in this new role. This direction comes from several sources
in the organization:
• The new manager’s immediate superior. This could be the unit supervisor if the new
manager is a charge nurse, or it could be the chief nursing executive if the new manager
is a unit supervisor. The immediate superior should have regularly scheduled sessions
with the new manager to continue the ongoing orientation process.
• A group of the new manager’s peers. There should be a management group in the
organization with which the new manager can consult. The new manager should be
encouraged to use the group as a resource.
• A mentor. If someone in the organization decides to mentor the new manager, it will
undoubtedly benefit the organization. Although mentors cannot be assigned, the
organization can encourage experienced managers to seek out individuals to mentor.
Clinical nurses who have recently assumed management roles often experience guilt when
they decrease their involvement with direct patient care. When employees and physicians
see a nurse-manager assuming the role of caregiver, they often make disparaging remarks
such as, “Oh, you’re working as a real nurse today.” This tends to reinforce the nurse’s value
conflict in the new role.
Nurses moving into positions of increased responsibility also experience role stress created
by role ambiguity and role overload. Role ambiguity describes the stress that occurs when
job expectations are unclear. Role overload, often a major stress for nurse-managers, occurs
when the demands of the role are excessive. In addition, as nurses move into positions with
increased status, their job descriptions may become more general. Therefore, clarifying job
roles becomes an important tool in the resocialization process.
Socializing International Nurses
One solution to nursing shortages has been the active recruitment of nurses from overseas.
Huston (2014c) suggests that the ethical obligation to the foreign nurse does not end with his
or her arrival in a new country. Instead, the sponsoring country must do whatever it can to
see that the migrant nurse is assimilated into the new work environment as well as the new
culture.
For example, language skills are often a significant issue for foreign nurses and this is made
even more challenging by the use of American slang and the shorthand abbreviations that are
a common part of nursing. Differing interpretations of nonverbal behavior may further cloud
the picture. In addition, foreign-born nurses may find it difficult to fit into a unit’s organization
culture and thus fail to establish a sense of community life within the organization. Finally,
many foreign nurses experience cultural, professional, and psychological dissonance that is
associated with anxiety, homesickness, and isolation.
Newton, Pillay, and Higginbottom (2012) agree, noting that although most foreign nurses
relocate for improved income and professional status, these overwhelmingly erode upon
relocation. Instead the internationally educated nurse experiences cultural displacement as a
consequence of communication and language differences, feelings of being an outsider, and
differences in nursing programs. The end result is a deskilling process and discrimination
that further hinders transition and demoralizes many of these nurses (Newton et al., 2012).
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378 UNIT V ROLES AND FUNCTIONS IN STAFFING
Bae (2011) notes that the challenges these foreign nurses face affect not only their
adaptation experiences but also their retention and the quality of patient care. International
nurses who have successfully adapted to their host cultures are more satisfied with their
jobs, have a better quality of life, and stay longer in their jobs; therefore, it is important
for them to have adequate support and assistance in their adaptation to the host country
(Bae, 2011).
Clarifying Role Expectations Through Role Models, Preceptors,
and Mentors
One additional strategy for promoting both socialization and resocialization as well as the
clarification of role expectations is the use of role models, preceptors, and mentors. Webster’s
New World College Dictionary (2010) defines a role model as someone who is unusually
effective or inspiring in some social role, job, etc., and thus serves as a model for others.
Role models in nursing are experienced, competent employees. The relationship between the
new employee and the role model, however, is a passive one (i.e., employees see that role
models are skilled and attempt to emulate them, but the role model does not actively seek this
emulation). One of the exciting aspects of role models is their cumulative effect. The greater
the number of excellent role models available for new employees to emulate, the greater the
possibilities for new employees to perform well.
A preceptor is an experienced nurse who provides knowledge and emotional support,
as well as a clarification of role expectations, on a one-to-one basis. An effective preceptor
can role model and adjust teaching to each learner as needed. Occasionally, however, the
fit between a preceptor and preceptee is not good. This risk is lower if preceptors willingly
seek out this responsibility and if they have attended educational courses outlining preceptor
duties and responsibilities. In addition, preceptors need to have an adequate knowledge of
adult learning theory.
Organizations that use preceptors to help new employees clarify their roles and improve
their skill level should be careful not to overuse preceptors to the point that they become tired
or demotivated. In addition, workload assignments for the preceptor should be decreased
whenever possible so that adequate time can be devoted to helping the preceptee problem
solve and learn. Incentive pay for preceptors reinforces that the organization values this role.
Finally, most organizations can avoid many of the potential hazards of preceptorship
programs by (a) carefully selecting the preceptors, (b) selecting only preceptors who have a
strong desire to be role models, (c) preparing preceptors for their role by giving formal classes
in adult learning and other social learning concepts, and (d) having either experienced staff
development or supervisory personnel monitor the preceptor and preceptee closely to ensure
that the relationship continues to be beneficial and growth producing for both.
LEARNING EXERCISE 16.4
Criteria for Preceptorship
You have been selected to represent your unit on a committee to design a preceptor program
for your department. One of the committee’s first goals is to develop criteria for selecting
preceptors.
Assignment: in groups, select a minimum of five and a maximum of eight criteria that would
be appropriate for selecting preceptors on your unit. Would you have minimum education or
experience requirements? What personality or behavioral traits would you seek? Which of the
criteria that you identified are measurable?

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 379
Mentors take on an even greater role in using education as a means for role clarification.
Madison (2014) describes mentoring as a distinctive interactive relationship between two
individuals, occurring most commonly in a professional setting. Although some individuals
use the terms preceptor and mentor interchangeably, this is not the case. For example,
preceptors are usually assigned, but true mentors freely choose who they will mentor. The
mentor makes a conscious decision to assist the protégé in attaining expert status and in
furthering his or her career. Preceptors have a relatively short relationship with the person to
whom they have been assigned, but the relationship between the mentor and mentee is longer
and more intense.
Schira (2007) as summarized by Madison (2014) describes typical phases in mentoring
relationships. The first phase includes finding and connecting with a more experienced person
in the workplace. A mentoring relationship can be established when a “chemistry” is present
that fosters reciprocal trust and openness. The second phase includes teaching, modeling,
and insider knowledge that fosters a sense of competence and confidence. The intensity
of the relationship can escalate to high levels during this learning, listening, and sharing
phase. The third phase includes a sense of change and growth as the mentoring relationship
begins to move to a conclusion. The intensity wanes as the mentee begins to move toward
independence. The last stage finds both the mentee and the mentor achieving a different,
independent relationship, hopefully based on positive, collegial characteristics. Display 16.6
depicts these stages of the mentoring relationship.
A mentor, as no other, is able to instill the values and attitudes that accompany each
role. This is because mentors lead by example. A mentor’s strong moral and ethical fiber
encourages mentees to think critically and take a stand on ethical dilemmas in the workplace.
Becoming a mentor requires committing to a personal relationship. It also requires teaching
skills and a genuine interest and belief in the capabilities of others. A mentor may have
LEARNING EXERCISE 16.5
The First-Time Preceptor
You are a new graduate nurse in your first job as a staff nurse on an oncology unit. You have
been assigned to orient with Steve, an experienced rN and longtime employee on the unit. this
is, however, Steve’s first experience as a preceptor.
Steve is an expert clinician and you marvel at how expert his assessments are and how intuitive
his nursing diagnoses seem to be. Steve is a role model for you in terms of being an expert
clinical nurse.
Steve, however, seems to have difficulty teaching in the preceptor role. He accomplishes his
work quickly and often, without explanation—even though you are at his side. He is also resistant
to allowing you to practice many of the basic skills and tasks you are qualified to do, suggesting
instead that you should just watch him do it and learn by shadowing. When you question Steve
about this practice, he reassures you that he believes you are competent and that you will be a
good nurse, but states that he does not yet feel comfortable in “letting you do things on your own.”
You are becoming increasingly frustrated with this preceptorship and worry that you are not
getting the experience you will need to autonomously function as a registered nurse when your
orientation ends in 6 weeks. Yet you also value the opportunity to work so closely with such a
skilled clinician and wonderful role model.
Assignment: Determine what you will do. What goals are driving your decision? What are the
potential risks and benefits inherent in your plan?
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380 UNIT V ROLES AND FUNCTIONS IN STAFFING
various roles in the mentor–mentee relationship. The mentor is often a role model and a
visionary for the mentee. Mentors may also open doors in the organization, be someone who
the mentee can use to bounce ideas off, or be a supporter or problem solver. The mentor is
often a teacher or counselor, especially in career advice. Last, Madison (2014) states that the
relationship is both intense and caring.
Not every nurse will be fortunate to have a mentor to facilitate each new career role. Most
nurses will be lucky if they have one or two mentors throughout their lifetimes.
OVERCOMING MOTIVATIONAL DEFICIENCIES
Sometimes, difficulties in socialization or resocialization occur because of motivational
deficiencies. A planned program should be implemented to correct the deficiencies by using
positive and negative sanctions.
Positive Sanctions
Positive sanctions can be used as an interactional or educational process of socialization. If
deliberately planned, they become educational. However, sanctions given informally through
the group process or reference group, use the social interaction process. The reference group
sets norms of behavior and then applies sanctions to ensure that new members adopt the
group norms before acceptance into the group. These informal sanctions offer an extremely
powerful tool for socialization and resocialization in the workplace. Managers should
become aware of what role behavior they reward and what new employee behavior the senior
staff is rewarding.
Negative Sanctions
Negative sanctions, like rewards, provide cues that enable people to evaluate their performance
consciously and to modify behavior when needed. For positive or negative sanctions to be
effective, they must result in the role learner internalizing the values of the organization.
Negative sanctions are often applied in very subtle and covert ways. Making fun of a
new graduate’s awkwardness with certain skills or belittling a new employee’s desire to
use nursing care plans is a very effective negative sanction that may be used by group
members to mold individual behavior to group norms. This is not to say that negative
sanctions should never be used. New employees should be told when their behavior is not
an acceptable part of their role. However, the sanctions used should be constructive and
not destructive.
The manager should know what the group norms are, be observant of sanctions used by the
group to make newcomers conform, and intervene if group norms are not appropriate.
DISPLAY 16.6 Stages of the Mentoring Relationship
1. Finding and connecting
2. Learning and listening
3. changing and shifting
4. Mentoring others
Source: Schira, M. (2007). Leadership: A peak and perk of professional development. Nephrology Nursing Journal:
Journal of the american Nephrology Nurses’ association, 34(3), 289–294.

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 381
COACHING AS A TEACHING STRATEGY
Coaching as a means to develop and train employees is a teaching strategy rather than a
learning theory. Coaching is one of the most important tools for empowering subordinates,
changing behavior, and developing a cohesive team. It is perhaps the most difficult role for
a manager to master. Coaching is one person helping the other to reach an optimum level of
performance. The emphasis is always on assisting the employee to recognize greater options,
to clarify statements, and to grow.
Coaching may be long term or short term. Short-term coaching is effective as a teaching
tool, for assisting with socialization, and for dealing with short-term problems. Long-
term coaching as a tool for career management and in dealing with disciplinary problems
is different and is discussed in other chapters. Short-term coaching frequently involves
spontaneous teaching opportunities. Learning Exercise 16.6 is an example of how a manager
can use short-term coaching to guide an employee in a new role.
LEARNING EXERCISE 16.6
Paul’s Complaint
Paul is the charge nurse on a surgical floor from 3 pm to 11 pm. One day, he comes to work a
few minutes early, as he occasionally does, so that he can chat with his supervisor, Mary, before
taking patient reports. Usually, Mary is in her office around this time. Paul enjoys talking over
some of his work-related management problems with her because he is fairly new in the charge
nurse role, having been appointed 3 months ago. today, he asks Mary if she can spare a minute
to discuss a personnel problem.
Paul: Sally is becoming a real problem to me. She is taking long break times and has not
followed through on several medication order changes lately.
Mary: What do you mean by “long breaks” and not following through?
Paul: in the last 2 months, she has taken an extra 15 minutes for dinner three nights a week
and has missed changes in medication orders eight times.
Mary: Have you spoken to Sally?
Paul: Yes, and she said that she had been an rN on this floor for 4 years, and no one had
ever criticized her before. i checked her personnel record, and there is no mention of those
particular problems, but her performance appraisals have only been mediocre.
Mary: What do you recommend doing about Sally?
Paul: i could tell her that i won’t tolerate her extended dinner breaks and her poor work
performance.
Mary: What are you prepared to do if her performance does not improve?
Paul: i could give her a written warning notice and eventually fire her if her work remains
below standard.
Mary: Well, that is one option. What are some other options available to you? Do you think
that Sally really understands your expectations? Do you feel that she might resent you?
Paul: i suppose i should sit down with Sally and explain exactly what my expectations are.
Since my appointment to charge nurse, i’ve talked with all the new nurses as they have
come on shift, but i just assumed that the old-timers knew what was expected on this unit.
i’ve been a little anxious about my new role; i never thought about her resenting my position.
(Continued )
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382 UNIT V ROLES AND FUNCTIONS IN STAFFING
MEETING THE EDUCATIONAL NEEDS OF A CULTURALLY DIVERSE STAFF
In the 21st century, nurse-leaders should expect to work with a more diverse workforce.
According to Huston (2014b), there are three main types of diversity in the workforce:
ethnicity, gender, and generational. Creating an organization that celebrates a diverse
workforce rather than merely tolerating it is a leadership role and requires well-planned
learning activities. There should also be sufficient opportunity for small groups so that
personnel can begin recognizing their own biases and prejudices.
Heterogeneity of staff in a teaching–learning setting may add strength or create difficulty.
Factors such as gender, age, English language proficiency, and culture may affect success and
cooperative learning of groups. Although meeting the educational needs of a heterogeneous
staff may be more time consuming and beset with communication challenges, the educational
needs must be met. The ability of all nurses to work well with a culturally diverse staff is
essential. Managers should respect cultural diversity and recognize the desirability of having
nurses from numerous cultures on their staff.
Education staff should be aware that learners with diverse learning styles and cultural
backgrounds may perceive both the classroom and instruction different from learners who have
never experienced a culture different from that of the mainstream United States. Managers
should also consider older nurses’ learning styles and preceptor needs. Older nurses often learn
best in a different manner than do new graduates and respond well to sharing anecdotal case
histories. In addition, whether teaching in a classroom or at the bedside, there are several things
that staff development personnel can do to facilitate the learning process, such as giving the
learner plenty of time to respond to questions and restating information that is not understood.
Mary: i think that is a good first option. Maybe Sally interpreted your not talking with her, as
you did all the new nurses, as a rejection. after you have another talk with her, let me know
how things are going.
Analysis: the supervisor has coached Paul toward a more appropriate option as a first choice
in solving this problem. although Mary’s choice of questions and guidance assisted Paul,
she never “took over” or directed Paul but instead let him find his own better solution. as
a result of this conversation, Paul had a series of individual meetings with all his staff and
shared with them his expectations. He also enlisted their assistance in his efforts to have
the shift run smoothly. although he began to see an improvement in Sally’s performance, he
realized that she was a marginal employee who would need a great deal of coaching. He
reported back to Mary and outlined his plans for improving Sally’s performance further. Mary
reinforced Paul’s handling of the problem by complimenting his actions.
LEARNING EXERCISE 16.7
Cultural Considerations in Teaching
You are the evening charge nurse for a large surgical unit. recently, your longtime and extremely
capable unit clerk retired, and the manager of the unit replaced the clerk with 23-year-old Nan,
who does not have a health-care background and is a recent immigrant. She speaks english
with an accent but can be easily understood. She is intelligent but is shy and unassertive.
Nan received a 2-week unit clerk orientation that consisted of actual classroom time and
working directly with the retiring clerk. She has been functioning on her own for 2 weeks, and

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 383
INTEGRATING LEADERSHIP AND MANAGEMENT IN TEAM BUILDING THROUGH
SOCIALIZING AND EDUCATING STAFF IN A LEARNING ORGANIZATION
The new momentum in organizations is toward team building and providing a continual
supportive learning environment. Health-care science and technology change so rapidly
that without adequate teaching–learning skills and educational services, organizations will
be left behind. Likewise, it has become obvious in the new millennium that teams, rather
than individuals, function more efficiently. Learning together and for the organization makes
the sum of the team more important than the individual and the workplace becomes more
productive when there is team compatibility.
The integrated leader-manager knows that a well-planned and well-implemented staff
development program is an important part of being an LO. The leader-manager accepts the
ultimate responsibility for staff development and uses appropriate teaching theories to assist with
teaching and training staff. In addition, he or she shares the responsibility for assessing educational
needs, educational quality, and fiscal accountability of all staff development activities.
The integrated leader-manager is also one who encourages continuous learning from all
individuals in the organization and is a role model of the lifelong learner. This is especially
important in promoting evidence-based nursing practice. The nurse-leader should use
evidence-based practice and make research resources available to the staff. He or she
understands that by building and supporting a knowledgeable team, the collective knowledge
generated will be greater than any single individual’s contribution.
There is perhaps no other part of management, however, that has as great an influence on
reducing burnout as successfully socializing new employees to the values of the organization.
Socialization, a critical component of introducing the employee into the organization, is a
complex process directed at the acquisition of appropriate attitudes, cognition, emotions,
values, motivations, skills, knowledge, and social patterns necessary to cope with the social
and professional environment. It differs from and has a greater impact than either induction
or orientation on subsequent productivity and retention. It can also help build loyalty and
team spirit. This is the time to instill the employee with pride in the organization and the unit.
This type of affective learning becomes the foundation for subsequent increased satisfaction
and motivation.
As part of socialization, the integrated leader-manager supports employees during difficult
role transitions. Mentoring and role modeling are encouraged, and role expectations are
clarified. The manager recognizes that employees who are not supported and socialized to the
organization will not develop the loyalty necessary in the competitive marketplace. Leaders
understand that creating a positive work environment where there is interdisciplinary respect
will assist employees in their role transitions.
you realize that her orientation was insufficient. Last evening, after her 10th mistake, you became
rather sharp with her, and she broke down in tears.
You are frustrated by this situation. Your unit is very busy in the evening with returning surgeries
and surgeons making rounds and leaving a multitude of orders. On the other hand, you believe
that Nan has great potential. You realize that there is much to learn in this job and, for a person
without a health-care background, that learning the terminology, physicians’ names, and unit
routine is difficult. You spend the morning devising a training plan for Nan.
Assignment: Using your knowledge of learning theories, explain your teaching plan, and
support your plan with appropriate rationale. How might Nan’s lack of an american education
and socialization influence her learning?
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384 UNIT V ROLES AND FUNCTIONS IN STAFFING
Finally, the manager ensures that resources for staff development are used wisely.
A focus of staff development should be keeping staff updated with new knowledge and
ascertaining that all personnel remain competent to perform their roles. By integrating
the leadership role with the management functions of staff development, the manager is
able to collaborate with education personnel and others so that the learning needs of unit
employees are met.
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
KEY CONCEPTS
● the philosophy of LOs is the concept that collective learning goes beyond the boundaries of individual
learning and releases gains for both the individual and the organization.
● the leader is a role model of the lifelong learner.
● training and education are important parts of staff development.
● all staff development activities should be evaluated for quality control and fiscal accountability.
● there is a shared responsibility for the promotion of evidence-based nursing practice.
● Managers and education department staff have a shared responsibility for the education and training of
staff.
● theories of learning and principles of teaching must be considered if staff development activities are to
be successful.
● Social learning theory suggests that people learn most behavior by direct experience and observation.
● the socialization of people into roles occurs with all professions and is a normal sociological process.
● Socialization and resocialization are often neglected areas of the indoctrination process.
● New graduates, international nurses, new managers, and experienced nurses in new roles have unique
socialization needs.
● Difficulties with resocialization usually centers on unclear role expectations (role ambiguity), an inability to
meet job demands, or deficiencies in motivation. role strain and role overload contribute to the problem.
● the terms role model, preceptor, and mentor are not synonymous, and all play an important role in
assisting with the socialization of employees.
● People from different cultures and age groups may have different socialization and learning needs.
LEARNING EXERCISE 16.8
Accepting Additional Responsibility
You are an experienced staff nurse on an inpatient specialty unit. today, a local nursing school
instructor approaches you and asks if you would be willing to become a preceptor for a nursing
student as part of his 10-week leadership–management clinical rotation. the instructor relays
that there will be no instructor on site and that the student has had only minimal exposure to
acute care clinical skills. the student will have to work very closely with you on a one-to-one
basis. the school of nursing can offer no pay for this role, but the instructor states that she

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 385
would be happy to write a thank you letter for your personnel file and that she would be available
at any time to address questions that might arise.
the unit does not reduce workload for preceptors, although credit for service is given on the
annual performance review. the unit supervisor states that the choice is yours but warns that
you may also be called upon to assist with the orientation of a nurse who will transfer to the
unit in 6 weeks time. You have mixed feelings about whether to accept this role. although you
enjoy having students on the unit and being in the teaching role, you are unsure if you can
do both your normal, heavy workload and give this student and the new employee the time
that they will undoubtedly need to learn. You do feel a “need to give back to your profession”
and personally believe that nurses need to be more supportive of each other, but you are
significantly concerned about role overload.
Assignment: Decide if you will accept this role. Would you place any constraints upon the
instructor, the student, the new employee, or your supervisor as a condition of accepting
the role? What were the strongest driving forces for your decision? What were the greatest
restraining forces? What evaluation criteria would you develop to assess whether your final
decision was a good one?
LEARNING EXERCISE 16.9
Addressing Resocialization Issues
You are one of the care coordinators for a home health agency. One of your duties is to orient
new employees to the agency. recently, the chief nursing executive hired Brian, an experienced
acute care nurse, to be one of your team members. Brian seemed eager and enthusiastic. He
confided in you that he was tired of acute care and wanted to be more involved with long-term
patient and family caseloads.
During Brian’s orientation, you became aware that his clinical skills were excellent, but
his therapeutic communication skills were inferior to those of the rest of your staff. You
discussed this with Brian and explained how important communication is in gaining the trust
of agency patients and that trust is necessary if the needs of the patients and the goals of
the agency are to be met. You referred Brian to some literature that you believed might be
helpful to him.
after a 3-week orientation program, Brian began working unsupervised. it is now 4 weeks later.
recently, you received a complaint from one of the other nurses and one from a patient regarding
Brian’s poor communication skills. Brian seems frustrated and has not gained acceptance
from the other nurses in your work group. You suspect that some of the nurses resent Brian’s
superior clinical skills, whereas others believe that he does not understand his new role, and
they are becoming impatient with him. You are genuinely concerned that Brian does not seem
to be fitting in.
Assignment: could this problem have been prevented? Decide what you should do now.
Outline a plan to resocialize Brian into his new role and make him feel like a valued part of the
staff.
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386 UNIT V ROLES AND FUNCTIONS IN STAFFING
REFERENCES
LEARNING EXERCISE 16.10
Effective Interpersonal Problem Solving
You have been working at Memorial Hospital for 3 months and have begun to feel fairly
confident in your new role. However, one of the older nurses working on your shift constantly
belittles your nursing education. Whenever you request assistance in problem solving or in
learning a new skill, she says, “Didn’t they teach you anything in nursing school?” Your charge
nurse has given you a satisfactory 3-month evaluation, but you are becoming increasingly
defensive regarding the comments of the other nurse.
Assignment: explain how you plan to evaluate the accuracy of the older nurse’s comments.
Might you be contributing to the problem? How will you cope with this situation? Would you
involve others? What efforts can you make to improve your relationship with this coworker?
Atherton, J. S. (2011). Learning and teaching; Knowles’
andragogy: An angle on adult learning. Retrieved
8 June 2013, from http://www.learningandteaching
.info/learning/knowlesa.htm
Bae, S. H. (2011). Organizational socialization of
international nurses in the New York metropolitan
area. International Nursing Review, 59(1), 81–87.
Bandura, A. (1977). Social learning theory. Englewood
Cliffs, NJ: Prentice-Hall.
Cherry, K. (2013). Social learning theory. An
overview of Bandura’s social learning theory.
About.com: Psychology. Retrieved June 8,
2013, from http://psychology.about.com/od/
developmentalpsychology/a/sociallearning.htm
Glaser, J., & Overhage, J. M. (2013). The role of healthcare
IT: Becoming a learning organization. Healthcare
Financial Management, 67(2), 56.
Greene, S., Reid, R., & Larson, E. (2012). Implementing
the learning health system: From concept to action.
Annals of Internal Medicine, 157(3), 207–210.
Huston, C. (2014a). Assuring provider competence through
licensure, continuing education and certification. In
C. Huston (Ed.), Professional issues in nursing
(3rd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins 292–307.
Huston, C. (2014b). Diversity in the nursing workforce. In
C. Huston (Ed.), Professional issues in nursing
(3rd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins 136–155.
Huston, C. (2014c). Importing foreign nurses to meet
America’s demand for nurses. In Professional
issues in nursing: Challenges and opportunities
(3rd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins 86–106.
Institute of Medicine. (2012, September). Best care at lower
cost: The path to continuously learning health care in
America. Retrieved June 8, 2013, from http://www
.iom.edu/Reports/2012/Best-Care-at-Lower-Cost
-The-Path-to-Continuously-Learning-Health-Care
-in-America.aspx
LEARNING EXERCISE 16.11
Changing Learning Needs
Learning needs and the maturity of those in a class often influence course content and
teaching methods. Look back at how your learning needs and maturity level have changed
since you were a beginning nursing student. When viewed as a whole, were you and the other
beginning nursing students child or adult learners? compare Knowles’s (1970) pedagogy and
andragogy characteristics to determine this.
are pedagogical teaching strategies appropriate for beginning nursing students? if so, when
does the nursing student make a transition from child to adult learner? What teaching modes
do you believe would be most conducive to learning for a beginning nursing student? Would
this change as students progressed through the nursing program? Support your beliefs with
rationale.

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Chapter 16 Socializing and Educating Staff for Team Building in a Learning Organization 387
Knowles, M. (1970). The modern practice of adult
education: Andragogy versus pedagogy. New York,
NY: Association Press.
Kramer, M. (1974). Reality shock: Why nurses leave nursing.
St. Louis, MO: CV Mosby.
Madison, J. (2014). Socialization and mentoring. In
C. Huston (Ed.), Professional issues in nursing
(3rd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins 121–135.
Martin, K., & Wilson, C. B. (2011). Newly registered
nurses’ experience in the first year of practice: A
phenomenological study. International Journal For
Human Caring, 15(2), 21–27.
Newton, S., Pillay, J., & Higginbottom, G. (2012).
The migration and transitioning experiences of
internationally educated nurses: A global perspective.
Journal of Nursing Management, 20(4), 534–550.
Prevost, S. S. (2014). Defining evidence-based best
practices. In C. Huston (Ed.), Professional issues
in nursing (3rd ed.). Philadelphia, PA: Lippincott
Williams & Wilkins 18–29.
Schira, M. (2007). Leadership: A peak and perk of
professional development. Nephrology Nursing
Journal: Journal of the American Nephrology Nurses’
Association, 34(3), 289–294.
Senge, P. (1994). The fifth discipline: The art and practice of
the learning organization. New York, NY: Currency
Doubleday.
Webster’s New World College Dictionary. (2010). As
cited in Your Dictionary. Wiley Publishing,
Cleveland, Ohio. Role model: Definition. Used
by arrangement with John Wiley & Sons, Inc.
Retrieved June 8, 2013, from http://www
.yourdictionary.com/role-model
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388
17
Staffing Needs and Scheduling Policies
… the accurate definition and quantification of the work of nursing is critical to the identification of
appropriate nursing resource requirements.
—Graf, Millar, Feilteau, Coakley, and Erickson
… for nurses, staffing is everything. It determines patient care, their own physical, emotional and mental
well being, the nature of their workplace, and whether or not they’ll choose to stay in the profession.
—QuadraMed Corporation (2013)
CROSSWALK this ChaptEr addrEssEs:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential IV: information management and application of patient care technology
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential V: health-care policy, finance, and regulatory environments
MSN Essential II: Organizational and systems leadership
MSN Essential III: Quality improvement and safety
MSN Essential V: informatics and health-care technologies
QSEN Competency: patient-centered care
QSEN Competency: teamwork and collaboration
QSEN Competency: Quality improvement
QSEN Competency: safety
QSEN Competency: informatics
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: professionalism
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l use an evidence-based approach in determining staffing needs
l differentiate between centralized and decentralized staffing, citing the advantages and
disadvantages of each
l identify organizational variables that impact the numbers of staff needed to carry out the goals
of the organization
l use standardized patient classification formulas to determine staffing needs based on patient
acuity
l calculate nursing care hours per patient-day if given total hours of care in a 24-hour period
as well as the patient census
l accurately use staffing formulas to avoid over- and understaffing

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Chapter 17 Staffing Needs and Scheduling Policies 389
LEADERSHIP ROLES
1. identifies creative and flexible staffing methods to meet the needs of patients, staff, and the
organization.
2. is knowledgeable regarding contemporary methods and tools used in staffing and scheduling.
3. assumes a responsibility toward staffing that builds trust and encourages a team approach.
4. role models the use of evidence in making appropriate staffing and scheduling decisions.
5. is alert to extraneous factors that have an impact on unit and organizational staffing.
6. is ethically accountable to patients and employees for adequate and safe staffing.
7. Encourages diversity of thought, gender, age, and culture in nursing staffing.
8. proactively plans for staffing shortages so that patient care goals will be met.
9. Communicates work schedules as well as scheduling policies clearly and effectively to staff.
10. assesses if and how workforce intergenerational values impact staffing needs and responds
accordingly.
MANAGEMENT FUNCTIONS
1. provides adequate staffing to meet patient care needs according to the philosophy of the orga-
nization and evidence-based needs.
2. Uses organizational goals and patient classification tools to minimize understaffing and overstaff-
ing as patient census and acuity fluctuate.
3. schedules staff in a fiscally responsible manner.
4. periodically examines the unit standard of productivity to determine if changes are needed.
DISPLAY 17.1 Leadership Roles and Management Functions Associated with Staffing
and Scheduling
l explain the relationship of flex time and self-scheduling to increased job satisfaction
l identify the driving and restraining forces for the implementation of mandatory minimum
staffing ratios in acute care hospitals
l provide examples of how generational (the veteran generation, baby boomers, generation X,
and generation Y) values differences may impact staffing and scheduling needs and wants
l recognize the need for workforce diversity to meet the unique cultural and linguistic needs
represented in the patient populations served
l select appropriate staffing policies for a given situation
l discuss the minimum written staffing and scheduling policies an agency should have
In addition to selecting, developing, and socializing staff, managers must be certain that
adequate numbers and an appropriate mix of personnel are available to meet unit needs and
organizational goals. These staffing determinations should be based on existing research
evidence that correlates staffing mix, numbers of staff needed, and patient outcomes.
In addition, because staffing patterns and scheduling policies directly affect the daily
lives of all personnel, they must be administered fairly as well as economically. This chapter
examines different methods for determining staffing needs, communicating staffing plans,
and developing and communicating scheduling policies. In addition, unit fiscal responsibility
for staffing is discussed, with sample formulas and instructions for calculating daily staffing
needs.
The manager’s responsibility for adequate and well-communicated staffing and scheduling
policies is stressed, as is the need for periodic reevaluation of staffing philosophy to meet
stated care delivery. There is a focus on the leadership responsibility for developing trust
through fair staffing and scheduling procedures. Existing and proposed legislation regarding
mandatory staffing requirements is also discussed, including the manager’s role for ensuring
that the organization can facilitate the changes required by law. The leadership roles and
management functions inherent in staffing and scheduling are shown in Display 17.1.
(Continued )
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390 UNIT V ROLES AND FUNCTIONS IN STAFFING
UNIT MANAGER’S RESPONSIBILITIES IN MEETING STAFFING NEEDS
The requirement for night, evening, weekend, and holiday work that is frequently necessary
in health-care organizations can be stressful and frustrating. Managers should do what they
can to see that employees feel they have some control over scheduling, shift options, and
staffing policies. Each organization has different expectations regarding the unit manager’s
responsibility in long-range human resource planning and in short-range planning for daily
staffing. Although many organizations now use staffing clerks and computers to assist with
staffing, the overall responsibility for scheduling continues to be an important function of
first- and middle-level managers.
CENTRALIZED AND DECENTRALIZED STAFFING
Some organizations decentralize staffing by having unit managers make scheduling decisions.
Other organizations use centralized staffing, where staffing decisions are made by personnel
in a central office or staffing center. Such centers may or may not be staffed by registered
nurses (RNs), although someone in authority would be a nurse even when a staffing clerk
carries out the day-to-day activity.
In organizations with decentralized staffing, the unit manager is often responsible for
covering all scheduled staff absences, reducing staff during periods of decreased patient
census or acuity, adding staff during periods of high patient census or acuity, preparing
monthly unit schedules, and preparing holiday and vacation schedules. Nursing management
is highly decentralized in most hospitals, with considerable variation found in staffing among
patient care units.
Advantages of decentralized staffing are that the unit manager understands the needs of the
unit and staff intimately, which leads to the increased likelihood that sound staffing decisions
will be made. In addition, the staff feels more in control of their work environment because
they are able to take personal scheduling requests directly to their immediate supervisor.
Decentralized scheduling and staffing also lead to increased autonomy and flexibility, thus
decreasing nurse attrition.
Decentralized staffing, however, carries the risk that employees will be treated unequally
or inconsistently. In addition, the unit manager may be viewed as granting rewards or
punishments through the staffing schedule. Decentralized staffing also is time consuming for
the manager and often promotes more “special pleading” than centralized staffing. However,
undoubtedly, the major difficulty with decentralized staffing is ensuring high-quality staffing
decisions throughout the organization.
In centralized staffing, the manager’s role is limited to making minor adjustments and
providing input. For example, the manager would communicate special staffing needs
and assist with obtaining staff coverage for illness and sudden changes in patient census.
Therefore, the manager in centralized staffing continues to have ultimate responsibility for
seeing that adequate personnel are available to meet the needs of the organization.
5. ascertains that scheduling policies are not in violation of state and national labor laws, organiza-
tional policies, or union contracts.
6. assumes accountability for quality and fiscal control of staffing.
7. Evaluates scheduling and staffing procedures and policies on a regular basis.
8. develops and implements fair and uniform scheduling policies and communicates these clearly
to all staff.
9. selects acuity-based staffing tools that reduce subjectivity and promote objectivity in patient
acuity determinations.

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Chapter 17 Staffing Needs and Scheduling Policies 391
Centralized staffing is generally fairer to all employees because policies tend to be
employed more consistently and impartially. In addition, centralized staffing frees the middle-
level manager to complete other management functions. Centralized staffing also allows
for the most efficient (cost-effective) use of resources because the more units that can be
considered together, the easier it is to deal with variations in patient census and staffing needs.
Centralized staffing, however, does not provide as much flexibility for the worker, nor can
it account as well for a worker’s desires or special needs. In addition, managers may be less
responsive to personnel budget control if they have limited responsibility in scheduling and
staffing matters. The strengths and limitations of decentralized and centralized staffing are
summarized in Display 17.2.
It is important, though, to remember that centralized and decentralized staffing are not
synonymous with centralized and decentralized decision making. For example, a manager
can work in an organization that has centralized staffing but decentralized organizational
decision making. Regardless of whether the organization has centralized or decentralized
staffing, all unit managers should understand scheduling options and procedures and accept
fiscal responsibility for staffing.
Decentralized scheduling and staffing lead to increased autonomy and flexibility but centralized
staffing is fairer to all employees because policies tend to be employed more consistently and
impartially.
COMPLYING WITH STAFFING MANDATES
As the current health-care system is evaluated, nurse-managers must be cognizant of new
recommendations and legislation affecting staffing. Many states in the United States, with
the backing of professional nursing organizations, have moved toward imposing mandatory
licensed staffing requirements, and one state (California) has enacted legislation requiring
mandatory staffing ratios that affect hospitals and long-term care facilities. In fact, as of
2013, 15 states (CA, CT, IL, ME, MN, NJ, NV, NY, NC, OH, OR, RI, TX, VT, and WA) plus
the District of Columbia had enacted legislation and/or adopted regulations addressing nurse
staffing (American Nurses Association [ANA], 2013).
COMPLYING WITH STAFFING MANDATES
As the current health-care system is evaluated, nurse-managers must be cognizant of new
recommendations and legislation affecting staffing. Many states in the United States, with
Strengths Limitations
Decentralized
Staffing
⎷ Manager retains greater control over
unit staffing
⎷ staff are able to take requests directly
to their manager
⎷ provides greater autonomy and
flexibility for individual staff member
⎷ Can result in more special pleading and
arbitrary treatment of employees
⎷ May not be cost-effective for
organization since staffing needs
are not viewed holistically
⎷ More time consuming for the unit
manager
Centralized
Staffing
⎷ provides organization-wide view of
staffing needs, which encourages
optimal utilization of staffing resources
⎷ staffing policies tend to be employed
more consistently and impartially
⎷ More cost-effective than decentralized
staffing
⎷ Frees the middle-level manager to
complete other management functions
⎷ provides less flexibility for the worker
and may not account for a specific
worker’s desires or special needs
⎷ Managers may be less responsive
to personnel budget control in
scheduling and staffing matters
DISPLAY 17.2 Strengths and Limitations of Decentralized and Centralized Staffing
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392 UNIT V ROLES AND FUNCTIONS IN STAFFING
Under Assembly Bill 394, passed in 1999 and crafted by the California Nurses Association,
all hospitals in California had to comply with the minimum staffing ratios shown in Display
17.2 by January 1, 2004 (National Nurses United, 2010–2013), with subsequent modifications
following in the next few years (also shown in Display 17.3). These ratios, developed by the
California Department of Health Services, represent the maximum number of patients an RN
can be assigned to care for under any circumstance.
Proponents of legislated minimum staffing ratios say that ratios are needed because many
hospitals’ current staffing levels are so low that both RNs and their patients are negatively
affected (Huston, 2014a). In addition, numerous articles have appeared in the media attesting
to grossly inadequate staffing in hospitals and nursing homes, and professional nursing
organizations such as the American Nurses Association have expressed concern about the
effect poor staffing has on nurses’ health and safety and on patient outcomes. Adequate
staffing, then, is needed to ensure that care provided is at least safe and hopefully more.
Proponents also suggest that such ratios protect the most basic elements of the public health
we take for granted and argue that the government must take on this responsibility to ensure
that safe health care is provided to all Americans (Huston, 2014a).
However, there are arguments against staffing ratios. Huston (2014a) notes that the current
nursing shortage makes it difficult to fill the slots when ratios exist, and the ratios may merely
serve as a Band-Aid to the greater problems of quality of care. In addition, numbers alone
do not ensure improved patient care, as not all RNs have equivalent clinical experience and
skill levels. There is also the argument that staffing may actually decline with ratios since
they might be used as the ceiling or as ironclad criteria if institutions are not willing to make
adjustments for patient acuity or RN skill level.
Unit
Minimum Nurse–Patient
Ratio January 2004
Minimum Nurse–Patient
Ratio January 2008
Critical care/iCU 1:2 1:2
Neonatal iCU 1:2 1:2
Operating room 1:1 1:1
Labor and delivery 1:2 1:2
antepartum 1:4 1:4
postpartum couplets 1:4 1:4
postpartum women only 1:6 1:6
pediatrics 1:4 1:4
step-down 1:4 1:3
Medical–surgical 1:6 1:5
Oncology (initial) 1:5 1:4
psychiatry 1:6 1:6
Emergency department 1:4 1:4
telemetry and specialty units 1:5 1:4
Source: National Nurses United (2010–2013). rN to patient ratios. Retrieved June 9, 2013, from
http://www.nationalnursesunited.org/page/-/files/pdf/ratios/basics-unit-0704
DISPLAY 17.3 Minimum Staffing Ratios for Hospitals in California January 2004 and
January 2008

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Chapter 17 Staffing Needs and Scheduling Policies 393
In addition, some critics suggest that mandatory staffing ratios create significant
opportunity costs that may restrict employers and payers from responding to market forces;
subsequently, they may be unable to take advantage of improved technological support
or respond to changes in patient acuity. In addition, mandatory staffing ratios may cause
conflicts between nurses and hospitals that might otherwise not exist.
The bottom line, however, is that minimum staffing ratios would not have been proposed
in the first place had staffing abuses and the resultant declines in the quality of patient care
not occurred. The implementation and subsequent evaluation of mandatory staffing ratios in
states having such ratios should provide greater insight into the ongoing debate about the need
for mandatory staffing ratios.
Minimum staffing ratios would not have been proposed in the first place had staffing abuses
and the resultant declines in the quality of patient care not occurred.
LEARNING EXERCISE 17.1
Comparing Staffing Ratios
Many states are currently considering the adoption of minimum staffing legislation, and as such
are closely monitoring the outcomes in states that have already taken such action.
Assignment: Compare the current staffing ratios used at the facility in which you work or do
clinical practicums with those shown in display 17.3. how do they compare? is there an effort
to legislate minimum staffing ratios in the state in which you live? Who or what would you
anticipate to be the greatest barrier to implementation of staffing ratios in your state?
STAFFING AND SCHEDULING OPTIONS
Because it is beyond the scope of this book to discuss all of the creative staffing and
scheduling options available, only a few are discussed here. Some of the more frequently used
creative staffing and scheduling options are shown in Display 17.4.
There are advantages and disadvantages to each type. Twelve-hour shifts have become
commonplace in acute care hospitals even though there continues to be debate about whether
extending the length of shifts results in increased judgment errors related to fatigue. In their
review of the literature, Geiger-Brown and Trinkoff (2010) found that nurses working 12-hour
l 10- or 12-hour shifts.
l premium pay for weekend work.
l part-time staffing pool for weekend shifts and holidays.
l Cyclical staffing, which allows long-term knowledge of future work schedules because a set staff-
ing pattern is repeated every few weeks. Figure 17.1 shows a master staffing pattern that repeats
every 4 weeks.
l Job sharing.
l allowing nurses to exchange hours of work among themselves.
l Flextime.
l Use of supplemental staffing from outside registries and float pools.
l staff self-scheduling.
l shift bidding, which allows nurses to bid for shifts rather than requiring mandatory overtime.
DISPLAY 17.4 Common Staffing and Scheduling Options in Health-Care Organizations
(Continued )
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394 UNIT V ROLES AND FUNCTIONS IN STAFFING
shifts experienced an increase in patient care errors; needlestick injuries; musculoskeletal
disorders, involving their neck, shoulder, and back; fatigue; and drowsy driving as a result
of sleep deprivation.
The Georgia Nurses Association (2012) agrees, suggesting that 12-hour shifts may cause
undue stress and fatigue in health-care workers and that this is especially true in older
workers. For this reason, many organizations often limit the number of consecutive 10- or
12-hour days a nurse can work or the number of hours that can be worked in a given day.
Yet, many nurses report a higher level of satisfaction with this staffing option since
they work less days each week and have more consecutive time for leisure and personal
obligations. In addition, some agencies pay overtime for any shift over 8 hours while others
do not. Extended work shifts also provide a solution for difficulties with child care, as they
reduce the number of working days. Estryn-Béhar and Van der Heijden (2012) suggest that
while these extended shifts seem to be an answer to work/family conflicts for nurses, the
risk of health and quality of care has been highly underestimated with 10- and 12-hour shifts
leading to higher rates of burnout, mistakes, and worse health for the nurse (Examining the
Evidence 17.1.
Week I
Every other weekend off
Maximum days worked: 4
Minimum days worked: 2
2 :doirep hcae ffo syad tilps fo rebmuN:stnemelE
Operates in multiples of 4, 8, 12 . . .
Schedule repeats itself every 4 weeks
X: Scheduled day off
Position Name
Full-time RN 1
Full-time RN 2
Full-time RN 3
Full-time RN 4
Full-time RN 5
Full-time RN 6
Full-time RN 7
Full-time RN 8
Part-time 8 hr/wk RN 9
Part-time 8 hr/wk RN 10
Part-time 8 hr/wk RN 11
Part-time
Total RNs on duty each day
8 hr/wk RN 12
S
On
On
M
X
T
X
W
X
X
T
X
F
X
X
XX
X
X X
S
X
X
X
X
6 7 7 6 6 6 6
On
On
Week Il
S
On
On
M
X
T
X
W
X
X
T
X
F
X
X
XX
X
X X
S
X
X
X
X
6 7 7 6 6 6 6
On
On
Week IV
S
On
On
M
X
T
X
W
X
X
T
X
F
X
X
XX
X
X X
S
X
X
X
X
6 7 6 7 6 6 6
On
On
Week Ill
S
On
On
M
X
T
X
W
X
X
T
X
F
X
X
XX
X
X X
S
X
X
X
X
6 7 7 6 6 6 6
On
On
FIGURE 17.1 • Four-week cycle master time sheet. Copyright ® 2006 Lippincott
Williams & Wilkins. instructor’s resource Cd-rOM to accompany Leadership roles and
Management Functions in Nursing, by Bessie L. Marquis and Carol J. huston.
Source: Estryn-Béhar, M., & Van der Heijden, B. I. (2012). Effects of extended work shifts on employee fatigue,
health, satisfaction, work/family balance, and patient safety. Work, 41, 4283–4290.
The objective of this study was to perform a secondary analysis of a large European data
base, collected in 2003, in order to determine the effect of work schedule on these three
parameters (work/family balance, health, and safety), after adjustment for various risk factors.
A survey regarding work schedule was sent to 77,681 nurses in three types of health-care
Examining the Evidence 17.1

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Chapter 17 Staffing Needs and Scheduling Policies 395
Another increasingly common staffing and scheduling alternative is the use of supplemental
nursing staff such as agency nurses and travel nurses. These nurses are usually directly
employed by an external nursing broker and work for premium pay (often two to three
times that of a regularly employed staff nurse), without benefits. While such staff provide
scheduling relief, especially in response to unanticipated increases in census or patient acuity,
their continuous use is expensive and can result in poor continuity of nursing care.
Some hospitals have created their own internal supplemental staff by hiring per diem
employees and creating float pools. Per diem staff generally have the flexibility to choose if
and when they want to work. In exchange for this flexibility, they receive a higher rate of pay
but usually no benefits.
Float pools are generally composed of employees who agree to cross-train on multiple units
so that they can work additional hours during periods of high census or worker shortages. Float
pools are adequate for filling intermittent staffing holes but, like agency or registry staff, they are
not an answer to the ongoing need to alter staffing according to census since they result in a lack
of staff continuity. In addition, many staff feel uncomfortable with floating if they have not been
adequately oriented to the new unit. Float staff must be able to perform the core competencies
of the unit they are floating to meet their legal and moral obligations as caregivers.
Float staff must be able to perform the core competencies of the unit they are floating to meet
their legal and moral obligations as caregivers.
LEARNING EXERCISE 17.2
Choosing 8- or 12-Hour Shifts
You are the manager of an intensive care unit. Many of the nurses have approached you
requesting 12-hour shifts. Other nurses have approached you stating that they will transfer out of
the unit if 12-hour shifts are implemented. You are exploring the feasibility and cost-effectiveness
(Continued )
institutions; hospitals (N =147), nursing homes (N = 185), and home care institutions (N = 76).
The response rate was 51.7% (N = 39,898). Adequate data were obtained from 25,924 to
complete a multivariate analysis, including 20 explanatory variables simultaneously.
The study found that nurses working 12-hour shifts during the night reported being satisfied
with working time for their private life. On the other hand, nurses working alternating shifts and
10-hour shifts at night reported more difficulties with their private and family life. Nurses working
12-hour shifts during the day and those working alternating shifts reported more interruptions and
disturbances in the job, high quantitative demand, and high physical load.
Health status in nurses working 10- or 12-hour shifts was worse than nurses who worked
8-hour shifts. They also reported feeling more tired, had lower quality and quantity of sleep, were
more afraid of making mistakes, and had higher burnout scores. Thus, while nurses often chose
night shifts or 12-hour shifts in order to reduce their work/home conflicts, it was at the expense
of their own health and safety.
In addition, the researchers noted that there are legitimate concerns about the safety of the
employee and the patient in an extended work hour environment. Shifts exceeding 8 hours do
carry an increased risk of accidents with the risk after 12 hours being about twice that of 8 hours.
The researchers concluded that although the implementation of 12-hour shifts seems to be
an answer to work/family conflicts for nurses, and, as such, responds to recruitment problems for
managers, the risk of health and quality of care has been highly underestimated. They suggest
that organizations develop measures such as extended child care, allowing naps during night
shifts, and reduction of changing shifts at short notice.
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396 UNIT V ROLES AND FUNCTIONS IN STAFFING
Some organizations have made an effort to meet the needs of a diverse workforce by using
flextime and self-scheduling. Flextime is a system that allows employees to select the time
schedules that best meet their personal needs while still meeting work responsibilities. In the
past, most flextime has been possible only for nurses in roles that did not require continuous
coverage. However, staff nurses recently have been able to take part in a flextime system
through prescheduled shift start times. Variable start times may be longer or shorter than
the normal 8-hour workday. When a hospital uses flextime, units have employees coming
and leaving the unit at many different times. Although flextime staffing creates greater
employee choices, it may be difficult for the manager to coordinate and could easily result in
overstaffing or understaffing.
Self-scheduling allows nurses in a unit to work together to construct their own schedules
rather than have schedules created by management. With self-scheduling, employees
typically are given 4- to 6-week schedule worksheets to fill out several weeks in advance of
when the schedule is to begin. The nurse-manager then reviews the worksheet to make sure
that all guidelines or requirements have been met. Although self-scheduling offers nurses
greater control over their work environment, it is not easy to implement. Success depends
on the leadership skills of the manager to support the staff and demonstrate patience and
perseverance throughout the implementation.
One of the newer methods of reducing staff shortages and also allowing nurses some
control over scheduling extra shifts and to reduce mandatory overtime is shift bidding. In most
organizations that use shift bidding, the organization sets the opening price for a shift. For
example, this may be at a higher rate of pay than the hourly wage of some nurses, and nurses
may bid down the price in order to be assigned the overtime shift. Generally, organizations
will choose the nurse with the lowest bid to work the shift, but some organizations may deny
bids to nurses who work too much overtime (Huston, 2014b).
Obviously, all scheduling and staffing patterns, from traditional to creative, have shortcomings.
Therefore, any changes in current policies should be evaluated carefully as they are implemented.
Because all scheduling and staffing patterns have a heavy impact on employees’ personal lives,
productivity, and budgets, it is wise to have a 6-month trial of new staffing and scheduling
changes, with an evaluation at the end of that time to determine the impact on financial costs,
retention, productivity, risk management, and employee and patient satisfaction.
of using both 8- and 12-hour shifts so that staff could select which type of scheduling they
wanted.
Assignment: Would this create a scheduling nightmare? Will you limit the number of 12-hour
shifts that staff could work in a week? Would you pay overtime for the last 4 hours of the
12-hour shift? Would you allow staff to choose freely between 8- and 12-hour shifts? What
other problems may result from mixing 8- and 12-hour shifts?
LEARNING EXERCISE 17.3
Self-Scheduling Holiday Dilemma
You graduated last year from your nursing program and were excited to obtain the job that
you wanted most. the unit where you work has a very progressive supervisor who believes in
empowering the nursing staff. approximately 6 months ago, after considerable instruction, the
unit began self-scheduling. You have enjoyed the freedom and control that this has given you
over your work hours. there have been some minor difficulties among staff, and occasionally the

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Chapter 17 Staffing Needs and Scheduling Policies 397
WORKLOAD MEASUREMENT TOOLS
Requirements for staffing are based on whatever standard unit of measurement for productivity
is used in a given unit. A formula for calculating nursing care hours per patient-day (NCH/
PPD) is reviewed in Figure 17.2. This is the simplest formula in use and continues to be used
widely. In this formula, all nursing and ancillary staff are treated equally for determining
hours of nursing care, and no differentiation is made for differing acuity levels of patients.
These two factors alone may result in an incomplete or even inaccurate picture of nursing care
needs, and the use of NCH/PPD as a workload measurement tool may be too restrictive, since
it may not represent the reality of today’s inpatient care setting, where staffing fluctuates not
only among shifts but within shifts as well.
As a result, patient classification systems (PCSs), also known as workload management,
or patient acuity tools, were developed in the 1960s. Oakes (2012) suggests that patient
acuity systems provide the language nurses need to make their work visible at all levels of
their organization. QuadraMed Corporation (2013) goes one step further in suggesting that
achieving the optimum balance between nurse staffing and patient acuity is key to a health-
care organization’s financial viability.
A PCS groups patients according to specific characteristics that measure acuity of illness
in an effort to determine both the number and mix of the staff needed to adequately care
for those patients. Because other variables within the system have an impact on NCH, it
is usually not possible to transfer a PCS from one facility to another. Instead, each basic
classification system must be modified to fit a specific institution.
unit was slightly overstaffed or understaffed. however, overall, the self-scheduling has seemed
to work well.
today (september 15), you come to work on the 3 pm to 11 pm shift after 2 days off and see
that the schedule for the upcoming thanksgiving and Christmas holiday period has been posted,
and many of the staff have already scheduled their days on and their days off. When you take
a close look, it appears that no one has signed up to work Christmas Eve, thanksgiving day,
or Christmas day. You are very concerned, because self-scheduling includes responsibility for
adequate coverage. there are still a few nurses, including yourself, who have not added their
days to the schedule, but even if all of the remaining nurses work all three holidays, it will provide
only scant coverage.
Assignment: What leadership role (if any) should you take in solving this dilemma? should
you ignore the problem and schedule yourself for only one holiday and let your supervisor deal
with the issue? remember, you are a new nurse, both in experience and on this unit. List the
options for decision making available to you and, using rationale to support your decision, plan
a course of action.
NCH/PPD =
Nursing Hours Worked in 24 Hours
Patient Census
FIGURE 17.2 • standard formula for calculating nursing
care hours (NCh) per patient-day (ppd). Copyright
® 2006 Lippincott Williams & Wilkins. instructor’s
resource Cd-rOM to accompany Leadership roles and
Management Functions in Nursing, by Bessie L. Marquis
and Carol J. huston.
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398 UNIT V ROLES AND FUNCTIONS IN STAFFING
PCSs are institution specific and must be modified to reflect the unique staff and patient
population of each health-care organization.
There are several types of PCS measurement tools. The critical indicator PCS uses broad
indicators such as bathing, diet, intravenous fluids and medications, and positioning to
categorize patient care activities. The summative task type requires the nurse to note the
frequency of occurrence of specific activities, treatments, and procedures for each patient. For
example, a summative task–type PCS might ask the nurse whether a patient required nursing
time for teaching, elimination, or hygiene. Both types of PCSs are generally filled out prior
to each shift, although the summative task type typically has more items to fill out than the
critical incident or criterion type.
Once an appropriate PCS is adopted, hours of nursing care must be assigned for each
patient classification. Although an appropriate number of hours of care for each classification
is generally suggested by companies marketing PCSs, each institution is unique and must
determine to what degree that classification system must be adapted for that institution.
QuadraMed Corporation (2013) notes the primary purpose of the acuity system is to have
subjectivity give way to objective data. With this data, organizations can staff according
to documented need rather than perceived convenience, decreasing distrust, fostering
collaboration, and moving finance and patient management toward a common goal.
In addition, Oakes (2012) stresses the importance of organizations correctly interpreting
the acuity data. When robust data inform planning, forecasting, and decision making,
organizations can better understand how nursing workloads contribute to financial efficiency
and productivity. “Most importantly, nurses have the capacity, via an acuity tool, to become
key informers of organizational planning and to demonstrate how much work is required, the
type of work and when it will be required” (Oakes 2012, p. 11).
It is important though to remember that staffing according to a PCS does not always mean
that staffing is adequate or that it will be perceived as adequate. Indeed, it is not uncommon
to have staffing perceived as adequate one day and considered inadequate the next day, even
if there are the same number of patients and staff.
It is not uncommon to have staffing perceived as adequate one day and considered inadequate
the next day, even if there are the same number of patients and staff.
It is clear that PCSs will not solve all staffing problems, as all systems have special features
and faults as well. Although such systems provide a better definition of problems, it is up
to people in the organization to make judgments and use the information obtained by the
system appropriately to solve staffing problems. A sample classification system is illustrated
in Table 17.1.
In addition, the middle-level manager must be alert to internal or external forces affecting
unit needs that may not be reflected in the organization’s patient care classification system.
Examples of such forces could be a sudden increase in nursing or medical students using the
unit, a lower skill level of new graduates, or cultural and language difficulties of recently
hired foreign nurses. The organization’s classification system may prove to be inaccurate,
or the hours allotted for each category or classification of patient may be inaccurate (too
high or too low). This does not imply that unit managers should not be held accountable for
the standard unit of measurement; rather, they must be cognizant of justifiable reasons for
variations.
Some futurists have suggested that eventually workload measurement systems may replace
acuity-based staffing systems or that the two will be used as a hybrid tool for determining
staffing needs. Workload measurement is a technique that evaluates work performance as well
as necessary resource levels. Therefore, it goes beyond patient diagnosis or acuity level and

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Chapter 17 Staffing Needs and Scheduling Policies 399
TABLE 17.1 Patient Care Classification Using Four Levels of Nursing Care Intensity
Area of Care Category 1 Category 2 Category 3 Category 4
Eating Feeds self or needs
little food
Needs some help
in preparing food
tray; may need
encouragement
Cannot feed self but
is able to chew and
swallow
Cannot feed
self and may
have difficulty
swallowing
Grooming almost entirely self-
sufficient
Needs some help
in bathing, oral
hygiene, hair
combing, and so
forth
Unable to do much
for self
Completely
dependent
Excretion Up and to bathroom
alone or almost
alone
Needs some help
in getting up to
bathroom or using
urinal
in bed, needs
bedpan or urinal
placed; may be
able to partially
turn or lift self
Completely
dependent
Comfort self-sufficient Needs some help
with adjusting
position or bed
(e.g., tubes and
iVs)
Cannot turn without
help, get drink,
adjust position of
extremities, and so
forth
Completely
dependent
General health Good—for diagnostic
procedure, simple
treatment, or
surgical procedure
(d&C, biopsy, and
minor fracture)
Mild symptoms—
more than one mild
illness, mild debility,
mild emotional
reaction, and mild
incontinence (not
more than once
per shift)
acute symptoms—
severe emotional
reaction to illness
or surgery, more
than one acute
illness, medical or
surgical problem,
severe or frequent
incontinence
Critically ill—may
have severe
emotional reaction
treatments simple—supervised
ambulation, dangle,
simple dressing,
test procedure
preparation
not requiring
medication,
reinforcement of
surgical dressing,
x-pad, vital signs
once per shift
any category 1
treatment more
than once per shift,
Foley catheter
care, i&O; bladder
irrigations, sitz
bath, compresses,
test procedures
requiring
medications
or follow-ups,
simple enema for
evacuation, vital
signs every 4 hours
any treatment more
than twice per
shift, medicated
iVs, complicated
dressings, sterile
procedures, care
of tracheostomy,
harris flush,
suctioning, tube
feeding, vital signs
more than every
4 hours
any elaborate
or delicate
procedure
requiring two
nurses, vital signs
more often than
every 2 hours
Medications simple, routine,
not needing
preevaluation or
postevaluation;
medications no
more than once
per shift
diabetic, cardiac,
hypotensive,
hypertensive,
diuretic,
anticoagulant
medications, prn
medications, more
than once per
shift, medications
needing
preevaluation or
postevaluation
high amount
of category 2
medications;
control of refractory
diabetes (need to
be monitored more
than every 4 hours)
Extensive category
3 medications;
iVs with frequent,
close observation
and regulation
(Continued )
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400 UNIT V ROLES AND FUNCTIONS IN STAFFING
examines the specific number of care hours needed to meet a given population’s care needs.
Thus, workload measurement systems typically capture census data, care hours, patient acuity,
and patient activities. While complicated, workload measurement systems do hold promise for
more accurately predicting the nursing resources needed to staff hospitals effectively.
Regardless of the workload measurement tool used (NCH/PPD, PCS, workload
measurement system, etc.), the units of workload measurement need to be reviewed
periodically and adjusted as necessary. This is both a leadership role and a management
responsibility.
LEARNING EXERCISE 17.4
Calculating Staffing Needs
You use a pCs to assist you with your daily staffing needs. the following are the hours of
nursing care needed for each acuity level patient per shift:
Category I
Acuity Level
Category II
Acuity Level
Category III
Acuity Level
Category IV
Acuity Level
NCH/PPD needed
for day shift
2.3 2.9 3.4 4.6
NCH/PPD needed
for pm shift
2.0 2.3 2.8 3.4
NCH/PPD needed
for night shift
0.5 1.0 2.0 2.8
When you came on duty this morning, you had the following patients:
One patient in category i acuity level
two patients in category ii acuity level
three patients in category iii acuity level
One patient in category iV acuity level
Note that you must be overstaffed or understaffed by more than half of the hours a person is
working to reduce or add staff. For example, for nurses working 8-hour shifts, the staffing must
be over or under more than 4 hours to delete or add staff.
TABLE 17.1 Patient Care Classification Using Four Levels of Nursing Care Intensity (Continued)
Area of Care Category 1 Category 2 Category 3 Category 4
teaching and
emotional
support
routine follow-up
teaching; patients
with no unusual or
adverse emotional
reactions
initial teaching of
care of ostomies;
new diabetics;
tubes that will be
in place for periods
of time; conditions
requiring major
change in eating,
living, or excretory
practices; patients
with mild adverse
reactions to
their illness (e.g.,
depression and
overly demanding)
More intensive
category 2 items;
teaching of
apprehensive or
mildly resistive
patients; care of
moderately upset
or apprehensive
patients; confused
or disoriented
patients
teaching of
resistive patients,
care and support
of patients with
severe emotional
reaction

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Chapter 17 Staffing Needs and Scheduling Policies 401
THE RELATIONSHIP BETWEEN NURSING CARE HOURS, STAFFING MIX,
AND QUALITY OF CARE
It is difficult to pick up a nursing journal today that does not have at least one article that
speaks to the relationship between NCH, staffing mix, quality of care, and patient outcomes.
This has occurred in response to the “restructuring” and “reengineering” boom that occurred
in many acute care hospitals in the 1990s. Restructuring and reengineering was done to
reduce costs, increase efficiency, decrease waste and duplication, and reshape the way that
care was delivered (Huston, 2014c).
Given that health care is labor intensive, cost cutting under restructuring and reengineering
often included staffing models that reduced RN representation in the staffing mix and
increased the use of unlicensed assistive personnel (UAP). This fairly rapid and dramatic shift
in both RN care hours and staffing mix provided fertile ground for comparative studies that
examined the relationship between NCH, staffing mix, and patient outcomes.
Although early research on NCH, staffing mix, and patient outcomes lacked standardization
in terms of tools used and measures examined, nationwide attention shifted to this issue
and a plethora of better-funded and more-rigorous scientific study followed. For example,
Needleman et al. (2011), Aiken et al. (2010), and McHugh (2013) suggest that as the numbers
of staff increase, the number of adverse events, mortality, and readmission decrease.
The right staffing mix matters as well, as demonstrated by a year-long, multi-institution
research project that examined the impact of staffing on nurse-sensitive patient outcomes.
This study found that higher use of agency, float pool, or overtime nursing hours correlated
with higher patient fall rates (QuadraMed Corporation, 2012). Indeed, a review of the
current literature generally suggests that as RN hours decrease in NCH/PPD, adverse patient
outcomes generally increase, including increased errors and patient falls as well as decreased
patient satisfaction (Huston, 2014b).
However, in 2009, the California HealthCare Foundation released a report on the
California ratios that found no change in the average length of patient stay or any significant
reduction in certain nursing-sensitive adverse events as the result of minimum staffing ratio
implementation (Domrose, 2010). While there is a great deal of speculation as to why the
anticipated improvements did not occur, the study concluded there was no evidence that
mandated ratios improved patient outcomes. Staffing levels then should be considered to
be important—though not the only—factor in safe patient care (Domrose). In addition, it is
important to remember that “it takes a lot of data and years of data to do the kind of analysis
that demonstrates whether or not a policy works” (McHugh as cited in Domrose 2010, p. 27).
Staffing levels should be considered an important—though not the only—factor in safe patient
care
Assignment: Calculate your staffing needs for the day shift. You have on duty one rN and one
licensed vocational nurse (LVN)/licensed professional nurse (LpN) working 8-hour shifts and a
ward clerk for 4 hours. are you understaffed or overstaffed?
if you had the same number of patients but the acuity levels were the following, would your
staffing needs be the same?
two patients in category i acuity level
three patients in category ii acuity level
two patients in category iii acuity level
Zero patients in category iV acuity level
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402 UNIT V ROLES AND FUNCTIONS IN STAFFING
Unit managers must understand the effect that major restructuring and redesign have on their
staffing and scheduling policies as well. As new practice models are introduced, there must
be a simultaneous examination of the existing staff mix and patient care assessments to ensure
that appropriate changes are made in staffing and scheduling policies.
For example, decreasing licensed staff, increasing numbers of UAP, and developing
new practice models have a tremendous impact on patient care assignment methods.
Past practices of relying on part-time staff, responding to staff preferences for work,
and providing a variety of shift lengths and shift rotations may no longer be enough.
Administrative practices also have saved money in the past by sending people home when
there was low census; they have also floated them to other areas to cover other unit needs,
not scheduled staff for consecutive shifts because of staff preferences, and had scheduling
policies that were unreasonably accommodating. Finally, patient assignments in the past
were often made without attention to patient continuity and were assigned by numbers
rather than workload. Some of these past practices benefited staff, and some benefited the
organization, but few of them benefited the patient. Indeed, assigning a different nurse to
care for a patient each day of an already reduced length of stay may contribute to negative
patient outcomes.
Therefore, an honest appraisal of current staffing, scheduling, and assignment policies
is needed at the same time that organizations are restructured and new practice models are
engineered. Changing these policies often has far-reaching consequences, but this must be
done for new models of care to be successfully implemented. For example, if primary nursing
is to be effective, then nurses must work a number of successive days with a client to ensure
that there is time to formulate and evaluate a plan of care. In this example, floating policies
and requests for days off may need to be changed or modified to fit the philosophy of primary
nursing care delivery.
Determining an appropriate skill mix depends on the patient care setting, acuity of patients,
and other factors. There is no national standard to determine whether staffing decisions are
suitable for a given setting. In addition, many of the tools and methods used to determine
staffing have been unreliable and invalid, either in their development or their application.
However, some formulas allow for adjustment for variations in the skill mix of staff. These
formulas are still relatively new but may be a better tool to use when making staffing
decisions. Having an adequate number of knowledgeable, trained nurses is imperative to
attaining desired patient outcomes.
MANAGING A DIVERSE STAFF
Managers must also be cognizant of the need to have an ethnically and culturally diverse staff
to meet the needs of an increasingly diverse patient population. Indeed, national standards
for providing culturally and linguistically appropriate services in health care were released by
the US Department of Health and Human Services (2013) Office of Minority Health. Of the
15 standards put forth, several directly address the need for cultural and linguistic diversity
in staffing. For example, Standard 5 requires that health-care organizations offer language
assistance services, including bilingual staff and interpreter services, at no cost to clients with
limited English proficiency. Standard 7 ensures the competency of this language assistance
by interpreters and bilingual staff and Standard 6 requires that all verbal offers and written
notices regarding patients’ access to these services be available to patients in their preferred
languages.
Managers must clearly understand the unique cultural and linguistic needs represented in their
patient population and try to address these needs through an appropriately diverse staff.

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Chapter 17 Staffing Needs and Scheduling Policies 403
GENERATIONAL CONSIDERATIONS FOR STAFFING
In addition to ethnic and cultural diversity, managers must be alert to how generational
diversity may impact staffing needs. Stokowski (2013) notes that social scientists maintain
that this is the first time in history that four generations of nurses have worked together. In
previous years, earlier retirement from nursing and shorter life spans kept the workforce to
three generations.
Some researchers suggest that the different generations represented in nursing today have
different value systems that may impact staffing (Display 17.5). For example, most experts
identify four generational groups in today’s workforce; the veteran generation (also called
the silent generation or the traditionalist), the baby boomers, generation X, and generation Y
(also called the Millennials).
Generation Year of Birth
silent generation or veteran generation
Baby boomer or boom
Generation X
Generation Y
1925 to 1942
1943 to early 1960s
Early 1960s to early 1980s
Early 80s to 2000
DISPLAY 17.5 Generational Work Groups
The veteran generation is typically recognized as those nurses born between 1925 and
1942. Currently, about 5% of employed nurses belong to this age group (Stokowski, 2013).
Having lived through several international military conflicts (World War II, the Korean War,
and Vietnam) and the Great Depression, they are often risk averse (particularly regarding
personal finances), respectful of authority, supportive of hierarchy, and disciplined (Patterson,
2007). They are also called the silent generation because they tend to support the status quo
rather than protest or push for rapid change. As a result, these nurses are less likely to question
organizational practices and more likely to seek employment in structured settings. Their
work values are traditional and they are often recognized for their loyalty to their employers.
The boom generation (born 1943 to 1960), representing 40% of the current workforce
(Stokowski, 2013), also displays traditional work values; however, they tend to be more
materialistic and thus are willing to work long hours at their jobs in an effort to get ahead.
Indeed, this generation, which includes many of today’s nursing leaders, is more apt than
any other to be called “workaholics.” Yet, many boomers are caring for family members
from both sides. In addition, many boomers volunteer their time to advance environmental,
cultural, or educational causes.
In addition, this generation of workers is often recognized as being more individualistic
as a result of the “permissive parenting” many of this generation experienced growing up,
and constantly being told that their future contained limitless opportunities for achievement
(Patterson, 2007). This individualism often results in greater creativity and thus nurses born
in this generation may be best suited for work that requires flexibility, independent thinking,
and creativity. Yet, it also encourages this generation to challenge rules.
In contrast, “generation Xers” (born between 1961 and 1981), a much smaller cohort than
the baby boomers who preceded them, or the generation Yers who follow them, may lack the
interest in lifetime employment at one place that prior generations have valued, instead valuing
greater work hour flexibility and opportunities for time off. This likely reflects the fact that
many individuals born in this generation had both parents working outside their home as they
were growing up and they want to put more emphasis on family and leisure time in their own
family units. Thus, this generation may be less economically driven than prior generations
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404 UNIT V ROLES AND FUNCTIONS IN STAFFING
and may define success differently than the Veteran generation or the baby boomers. They are,
however, pragmatic, self-reliant, and amenable to change (Patterson, 2007). Forty percent of
the RN workforce belongs to this generational cohort (Stokowski, 2013).
Generation Y, also known as the Millennials (born 1982 to 2000), represents the first
cohort of truly global citizens. They are known for their optimism, self-confidence,
relationship orientation, volunteer mindedness, and social consciousness. They are also
highly sophisticated in their use of technology, which allows them to view the world as a
“smaller, diverse, highly-networked environment in which to work and live” (Patterson,
2007, p. 20). This is why some people call this generation “digital natives.” Generation Y
currently represents only 15% of the nursing workforce, but this number will increase rapidly
over the coming decade (Stokowski, 2013).
Generation Y, however, may demand a different type of organizational culture to meet
their needs. In fact, generation Y nurses may test the patience of their baby-boomer leaders
since they may appear to be brash or inpatient and often come with a sense of entitlement that
can be an affront to older workers. On the other hand, generation Y is known to work together
well in teams, exhibit a high degree of altruism, have a higher ecoawareness, and far greater
multicultural ease than their older coworkers.
Mensik (2007) suggests that although generational diversity poses new management
challenges, it also provides a variety of perspectives and outlooks that enhance workplace
balance and productivity. She suggests that the literature often focuses on differences and
negative attributes between the generations, particularly for generations X and Y and that
a balanced view is needed. For example, the literature repeatedly suggests that generations
X and Y may have less loyalty to their employers than the generations who preceded them,
but Mensik cites current research, which suggests that their commitment to employment
longevity is actually greater than the boomers who precede them.
Mensik (2007) concludes that instead of focusing on generational differences, nurses
should move forward and put their energies into seeking collaboration between the
generations. In addition, patients should benefit from the optimal outcomes that should
occur when all generations of the workforce can work together as a higher performing team.
Anderson (2013) agrees, suggesting that diversity of generations leads to diversity of thought
which can be very valuable to the nurse-manager, staff nurses, and ultimately patients.
Generational diversity, like cultural diversity, should be viewed as a strength in the workforce.
THE IMPACT OF NURSING STAFF SHORTAGES UPON STAFFING
As discussed in Chapter 15, shortages of nurses have always occurred periodically, whether
nationally, regionally, or locally. It has been difficult for the profession as a whole to
accurately predict exactly when and where there will be a short supply of professional nurses,
but all nurse-managers will at some time face a short supply of staff—both RNs and others.
Health-care organizations have used many solutions to combat this problem. Such things
as advanced planning and recruitment have already been discussed. Another long-term
solution to a shortage of staff is cross-training. Cross-training involves giving personnel with
varying educational backgrounds and expertise the skills necessary to take on tasks normally
outside their scope of work and to move between units and function knowledgeably. These
are all good solutions for long-term problem solving and show vision on the part of the
leader-manager.
However, staffing shortages frequently occur on a day-to-day basis. These occur because
of an increase in patient census, an unexpected increase in client needs, or an increase in staff
absenteeism or illness. Health-care organizations have used many methods to deal with an

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Chapter 17 Staffing Needs and Scheduling Policies 405
unexpected short supply of staff. Chief among the solutions are closed-unit staffing, drawing
from a central pool of nurses for additional staff, requesting volunteers to work extra duty,
and mandatory overtime.
Closed-unit staffing occurs when the staff members on a unit make a commitment to
cover all absences and needed extra help themselves in return for not being pulled from the
unit in times of low census. In mandatory overtime, employees are forced to work additional
shifts, often under threat of patient abandonment, should they refuse to do so. Some hospitals
routinely use mandatory overtime in an effort to keep fewer people on the payroll.
A health-care worker who is in an exhausted state represents a risk to public health and
patient safety. While mandatory overtime is neither efficient nor effective in the long term,
it has an even more devastating short-term impact with regard to staff perceptions of a lack
of control and its subsequent impact on mood, motivation, and productivity. Nurses who are
forced to work overtime do so under the stress of competing duties—to their job, their family,
their own health, and their patient’s safety (Huston, 2014b). Clearly, mandatory overtime
should be a last resort, not standard operating procedure because an institution does not have
enough staff.
Regardless of how the manager chooses to deal with an inadequate number of staff, certain
criteria must be met:
• Decisions made must meet state and federal labor laws and organizational policies.
• Staff must not be demoralized or excessively fatigued by frequent or extended overtime
requests.
• Long-term as well as short-term solutions must be sought.
• Patient care must not be jeopardized.
FISCAL AND ETHICAL ACCOUNTABILITY FOR STAFFING
Regardless of inherent difficulties, PCSs and the assignment of NCH remain a method for
controlling the staffing function of management. As long as managers realize that all systems
have weaknesses and as long as they periodically evaluate the system, managers will be
able to initiate needed change. It is crucial, however, for managers to make every effort to
base unit staffing on their organization’s PCS. Nursing care remains labor intensive, and the
manager is fiscally accountable to the organization for appropriate staffing. Accountability
for a prenegotiated budget is a management function.
Growing federal and state budget deficits has resulted in increased pressure for all
health-care organizations to reduce costs. Because personnel budgets are large in health-
care organizations, a small percentage cut in personnel may result in large savings. Thus,
managers must increase staffing when patient acuity rises as well as decrease staffing when
acuity is low; to do otherwise is demoralizing to the unit staff. It is important for managers to
use staff to provide safe and effective care economically.
Fiscal accountability to the organization for staffing is not incompatible with ethical
accountability to patients and staff. The manager’s goal is to stay within a staffing budget and
meet the needs of patients and staff.
Some organizations require only that managers end the fiscal year within their budgeted
NCH and pay less attention to daily or weekly NCH. Shift staffing based on a patient acuity
system does, however, allow for more consistent staffing and is better able to identify
overstaffing and understaffing on a timelier basis. In addition, this is a fairer method of
allocating staff.
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406 UNIT V ROLES AND FUNCTIONS IN STAFFING
The disadvantage of shift-based staffing is that it is time consuming and somewhat
subjective, because acuity or classification systems leave much to be determined by the
person assigning the acuity levels. The greater the degree of objectivity and accuracy in any
system, the longer the time required to make staffing computations. Perhaps the greatest
danger in staffing by acuity is that many organizations are unable to supply the extra staff
when the system shows unit understaffing. However, the same organization may use the
acuity-based staffing system to justify reducing staff on an overstaffed unit. Therefore, a
staffing classification system can be demotivating if used inconsistently or incorrectly.
Employees have the right to expect a reasonable workload. Managers must ensure that
adequate staffing exists to meet the needs of staff and patients. Managers who constantly
expect employees to work extra shifts, stay overtime, and carry unreasonable patient
assignments are not being ethically accountable.
Effective managers, however, do not focus totally on numbers of personnel but look at
all components of productivity. They examine nursing duties, job descriptions, patient care
organization, staffing mix, and staff competencies. Such managers also use every opportunity
to build a productive and cohesive team.
Uncomplaining nursing staff have often put forth superhuman efforts during periods
of short staffing simply because they believed in their supervisor and in the organization.
However, just as often, the opposite has occurred: Nurses on units that were only moderately
understaffed spent an inordinate amount of time and wasted energy complaining about
their plight. The difference between the two examples has much to do with trust that such
conditions are the exception, not the norm; that real solutions and not Band-Aid approaches to
problem solving will be used to plan for the future; that management will work just as hard as
the staff in meeting patient needs; and that the organization’s overriding philosophy is based
on patient interest and not financial gain.
DEVELOPING STAFFING AND SCHEDULING POLICIES
Nurses will be more satisfied in the workplace if staffing and scheduling policies and
procedures are thoughtfully developed, fairly applied, and clearly communicated to all
employees. Personnel policies represent the standard of action that is communicated in
advance so that employees are not caught unaware regarding personnel matters. Written
policies generally provide a means for greater consistency and fairness. In addition to being
standardized, personnel policies should be written in a manner that allows some flexibility. A
leadership challenge for the manager is to develop policies that focus on outcomes rather than
constraints or rules that limit responsiveness to individual employee needs.
Scheduling and staffing policies should be reviewed and updated periodically. When
formulating policies, management must examine its own philosophy and consider prevailing
community practices. Unit-level managers will seldom have complete responsibility for
formulating organizational personnel policies but should have some input as policies are
reviewed. There are, however, nursing department and unit personnel policies that supervisors
develop and implement.
The policies in Display 17.6 should be formalized by the manager and communicated to all
personnel. To ensure that unit-level staffing policies do not conflict with higher level policies,
there should be adequate input from the staff, and they should be developed in collaboration
with personnel and nursing departments. For example, some states have labor laws that
prohibit 12-hour shifts. Other states allow workers to sign away their rights to overtime
pay for shifts greater than 8 or 12 hours. In addition, in organizations with union contracts,
many staffing and scheduling policies are incorporated into the union contract. In such cases,
staffing changes might need to be negotiated at the time of contract renewal.

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Chapter 17 Staffing Needs and Scheduling Policies 407
1. Name of the person responsible for the staffing schedule and the authority of that individual if it
is other than the employee’s immediate supervisor
2. type and length of staffing cycle used
3. rotation policies, if shift rotation is used
4. Fixed shift transfer policies, if fixed shifts are used
5. time and location of schedule posting
6. When shift begins and ends
7. day of week schedule begins
8. Weekend off policy
9. tardiness policy
10. Low census procedures
11. policy for trading days off
12. procedures for days-off requests
13. absenteeism policies
14. policy regarding rotating to other units
15. procedures for vacation time requests
16. procedures for holiday time requests
17. procedures for resolving conflicts regarding requests for days off, holidays, or requested time off
18. Emergency request policies
19. policies and procedures regarding requesting transfer to other units
20. Mandatory overtime policy
DISPLAY 17.6 Unit Checklist of Employee Staffing Policies
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
IN STAFFING AND SCHEDULING
The manager is responsible for providing adequate staffing to meet patient care needs.
The leader assumes an ethical accountability to patients and employees for adequate and
appropriate staffing. The leader-manager then must pay attention to fluctuations in patient
census and workload units to ensure that understaffing or overstaffing is minimized and to
ensure fiscal accountability to the organization.
Using evidence and evidence-based tools in making these staffing decisions is critical
for contemporary nurse leader-managers. Yet, Douglas (2010, p. 55) provides a reasoned
counterpart in her assertion that while the call for “data driven staffing is loud and even
overdue, that the approach to it must be harmonized with the human side as well.” The
end goal then must be the right combination of hard and soft data with the end result being
“highly informed use of data and information with the understanding and wisdom necessary
to achieve optimal outcomes” (Douglas 2010, p. 62).
The prudent leader-manager is also cognizant of the need to have comprehensive scheduling
and staffing policies that are not only fair but also in compliance with organizational policies,
union contracts, and labor laws. When possible, employees should be involved in developing
these staffing and scheduling policies. This helps establish the trust needed to build team
spirit when dealing with temporary staff shortages.
Unit staffing and scheduling policies should be reviewed and revised on a timely basis to
reflect changes in community and national trends as well as contemporary methods of staffing
and scheduling. In addition, the leader should be alert for factors that affect the standard of
productivity and negotiates changes in the standard when appropriate.
The leader also looks for innovative methods to overcome staffing difficulties. Knowing
that staff needs are in part related to work design, the prudent leader-manager looks for
ways to redesign work to reduce staffing needs. When leadership roles are integrated with
management functions, creative staffing and scheduling options can occur.
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408 UNIT V ROLES AND FUNCTIONS IN STAFFING
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
KEY CONCEPTS
l the manager has both a fiscal and an ethical duty to plan for adequate staffing to meet patient care needs.
l innovative and creative methods of staffing and scheduling should be explored to avoid understaffing
and overstaffing as patient census and acuity fluctuate.
l staffing and scheduling policies must not violate labor laws, state or national laws, or union contracts.
l Workload measurement tools include NCh/ppd, pCs, and workload measurement systems. all
workload measurement tools should be periodically reviewed to determine if they are a valid and reliable
tool for measuring staffing needs in a given organization.
l Mandatory overtime should be a last resort, not standard operating procedure because an institution
does not have enough staff.
l research clearly shows that as professional nursing representation in the skill mix increases, patient
outcomes generally improve and adverse incidents decline.
l those with staffing responsibility must remain cognizant of mandatory staffing ratios and comply with
such mandates.
l Managers should attempt to have a diverse staff that will meet the cultural and language needs of the
patient population.
l Fair and uniform staffing and scheduling policies and procedures must be written and communicated to
all staff.
l Existing staffing policies must be examined periodically to determine if they still meet the needs of the
staff and the organization.
LEARNING EXERCISE 17.5
Implementing a New Nursing Care Delivery Model
You are serving on an ad hoc committee to examine ways to improve the continuity of patient
assignments because your unit is thinking about switching from total patient care to a primary
nursing care delivery model. the committee is having a difficult time formulating policies
because you currently have a great number of nurses who work part-time, 2 days on and 2 days
off. in addition, your unit has a census that goes up and down unexpectedly, resulting in nurses
being floated out of the unit often. the committee is committed to providing continuity of care
in the new patient care delivery system.
Assignment: develop several scheduling and staffing policies that have the probability of
increasing continuity of assignment and will not result in a financial liability to the unit. how will
these polices be fairly executed, and do they have the potential to cause staff to leave the unit?
LEARNING EXERCISE 17.6
Making Sound Staffing Decisions
You are the staffing coordinator for a small community hospital. it is now 12:30 pm, and your
staffing plan for the 3 pm to 11 pm shift must be completed no later than 1 pm. (the union contract
stipulates that any “call offs” that must be done for low census must be done at least 2 hours

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Chapter 17 Staffing Needs and Scheduling Policies 409
before the shift begins; otherwise, employees will receive a minimum of 4 hours of pay.) You do,
however, have the prerogative to call off staff for only half a shift (4 hours). if they are needed
for the last half of the shift (7 pm to 11 pm), you must notify them by 5 pm tonight. a local outside
registry is available for supplemental staff; however, their cost is two and a half times that of
your regular staff, so you must use this resource sparingly. Mandatory overtime is also used but
only as a last resort.
the current hospital census is 52 patients, although the Ed is very busy and has 4 possible
patient admissions. there are also two patients with confirmed discharge orders and three
additional potential discharges on the 3 pm to 11 pm shift. all units have just submitted their pCs
calculations for that shift.
You have five units to staff: the iCU, pediatrics, obstetrics (includes labor, delivery, and
postpartum), medical, and surgical departments. the iCU must be staffed with a minimum of a
1:2 nurse–patient ratio. the pediatric unit is generally staffed at a 1:4 nurse–patient ratio and the
medical and surgical departments at a 1:6 ratio. in obstetrics, a 1:2 ratio is used for labor and
delivery, and a 1:6 ratio is used in postpartum. On reviewing the staffing, you note the following:
ICU
Census = 6. Unit capacity = 8. the pCs shows a current patient acuity level requiring 3.2 staff.
One of the potential admissions in the Ed is a patient who will need cardiac monitoring. One
patient, however, will likely be transferred to the medical unit on 3 pm to 11 pm shift. Four rNs
are assigned for that shift.
Pediatrics
Census = 8. Unit capacity = 10. the pCs shows a current acuity level requiring 2.4 staff.
there are two rNs and one CNa assigned for the 3 pm to 11 pm shift. there are no anticipated
discharges or transfers.
Obstetrics
Census = 6. Unit capacity = 8. three women are in active labor, and three women are in the
postpartum unit with their babies. two rNs are assigned to the obstetrics department for the 3 pm
to 11 pm shift. there are no in-house staff on that shift that have been cross-trained for this unit.
Medical Floor
Census = 19. Unit capacity = 24. the pCs shows a current acuity level requiring 4.4 staff.
there are two rNs, one LVN, and two CNa assigned for the 3 pm to 11 pm shift. three of the
potential Ed admissions will come to this floor. two of the potential patient discharges are on
this unit.
Surgical Floor
Census = 13. Unit capacity = 18. the pCs shows a current acuity level requiring 3.6 staff.
Because of sick calls, you have only one rN and two CNas assigned for the 3 pm to 11 pm shift.
Both confirmed patient discharges as well as one of the potential discharges are from this unit.
Assignment: answer the following questions:
1. Which units are overstaffed, and which are understaffed?
2. Of those units that are overstaffed, what will you do with the unneeded staff?
3. how will you staff units that are understaffed? Will outside registry or mandatory overtime
methods be used?
4. how did staffing mix and pCs acuity levels factor into your decisions, if at all?
5. What safeguards can you build into the staffing plan for unanticipated admissions or changes
in patient acuity during the shift?
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410 UNIT V ROLES AND FUNCTIONS IN STAFFING
LEARNING EXERCISE 17.7
Reviewing Pros and Cons of Staffing Solutions
You are serving on a committee to help resolve a chronic problem with short staffing on your
unit, which is a pediatric iCU. Volunteer overtime, cross-training with the regular non–intensive
care pediatric unit, and closed-unit staffing have been suggested as possible solutions.
Assignment: Make a list of the pros and cons of each of these suggestions to bring back to the
committee for review. share your list with group members.
LEARNING EXERCISE 17.8
Choosing a Delivery Care Model and Staffing Pattern
You have been hired as the unit supervisor of the new rehabilitation unit at Memorial hospital.
the hospital decentralizes the responsibility for staffing, but you must adhere to the following
constraints:
1. all staff must be licensed.
2. the ratio of LVNs/LpNs to rNs is 1:1.
3. an rN must always be on duty.
4. Your budgeted NCh/ppd is 8.2.
5. You are not counted into the NCh/ppd, but ward clerks are counted.
6. Your unit capacity is seven patients, and you anticipate a daily average census of six patients.
7. You may use any mode of patient care organization.
Your patients will be chronic, not acute, but will be admitted for an active 2- to 12-week
rehabilitation program. the emphasis will be in returning the patient home with adequate ability
to perform activities of daily living. Many other disciplines, including occupational and physical
therapy, will be part of the rehabilitation team. a waiting list for the beds is anticipated because
this service is needed in your community. You anticipate that most of your patients will have had
cerebrovascular accidents, spinal cord injuries, other problems with neurologic deficits, and
amputations.
You have hired four full-time rNs and two part-time rNs. the part-time rNs would like to have at
least 2 days of work in a 2-week pay period; in return for this work guarantee, they have agreed
to cover for most sick days and vacations and some holidays for your regular rN full-time staff.
You also have hired three full-time LVNs/LpNs and two part-time LVNs/LpNs. however, the part-
time LVNs/LpNs would like to work at least 3 days per week. You have decided not to hire a
ward clerk but to use the pediatric ward clerk for 4 hours each day to assist with various duties.
therefore, you need to calculate the ward clerk’s 4 hours into the total hours worked.
You have researched various types of patient care delivery models (Chapter 14) and staffing
patterns. Your newly hired staff is willing to experiment with any type of patient care delivery
model and staffing pattern that you select.
Assignment: determine which patient care delivery model and staffing pattern you will use.
Explain why and how you made your choice. Next, show a 24-hour and 7-day staffing pattern.
Were you able to create a schedule that adhered to the given constraints? Was this a time-
consuming process?

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Chapter 17 Staffing Needs and Scheduling Policies 411
LEARNING EXERCISE 17.9
Floating Again
You are a new rN, having graduated just 4 months ago from nursing school. When you arrive
for work tonight, you are told that because your unit is experiencing a low census, you must
once again float to another unit. this is the third night in a row that you have been required to
float and the last two nights were to two different units. When you question why it is your turn
to float again, you are told that this is the last night you will work before having 3 days off and
that it makes more sense to have you go than to have someone else who will be working the
next few nights and could provide continuity of care. another nurse says that this is the last
night for her in a 7-day work stretch and that it would not be fair for her to have to float at this
point. in addition, one of the nurses says she has not been cross-trained for the unit needing
staff and another one says that she is there only because she swapped nights with another
nurse as a personal favor and therefore should not have to float. the charge nurse recognizes
your frustration but says that because the current floating policy is not clear, she had to make a
decision and selected you to float. she invites you though to help her create a written floating
policy that is fairer to all.
Assignment: You feel that the lack of a clearly written policy about floating resulted in arbitrary
and unfair treatment and you decide to use your upcoming days off to begin work on a new
policy which comprehensively covers all aspects of floating. Create such a policy. Make sure it
addresses the qualifications necessary to float, as well as how floating will be determined when
employee needs and arguments are conflicting. then have your peers review your floating policy.
do they feel your policy is comprehensive? Clear? safe? Fair?
REFERENCES
Aiken, L, Sloane, D., Cimiotti, J., Clarke, S., Flynn, L.,
Seago, J., … Smith, H. (2010). Implications of the
California nurse staffing mandate for other states.
Health Services Research, 45(4), 904–921.
American Nurses Association. (2013) Safe staffing saves
lives. Retrieved June 9, 2013, from http://www
.safestaffingsaveslives.org/WhatisANADoing/
StateLegislation.aspx
Anderson, L. (2013, January 31). The nurse manager’s guide
to handling a multigenerational workforce. Nurse
Together. Retrieved June 11, 2013, from http://www
.nursetogether.com/the-nurse-managers-guide-to
-handling-a-multigenerational-workforce
Domrose, C. (2010, February 8). The sum of staffing: States
consider the pros and cons of mandating RN staffing
levels. NurseWeek (West), 17(2), 18–19.
Douglas, K. (2010, January–February). The human side of
staffing. Nursing Economic$, 28(1), 55–57, 62.
Estryn-Béhar, M., & Van der Heijden, B. I. (2012). Effects
of extended work shifts on employee fatigue, health,
satisfaction, work/family balance, and patient safety.
Work, 41, 4283–4290.
Geiger-Brown, J., & Trinkoff, A. M. (2010, March). Is it
time to pull the plug on 12-hour shifts? Journal of
Nursing Administration, 40(3), 100–102.
Georgia Nurses Association. (2012). 12-Hour Shifts and
Fatigue. Georgia Nursing, 72(1), 7–8.
Huston, C. (2014a). Mandatory Minimum staffing ratios: Are
they working? In C. Huston (Ed.), Professional issues
in nursing. Philadelphia, PA: Lippincott Williams &
Wilkins 172–187.
Huston, C. (2014b). Mandatory overtime in nursing: How
much? How often? In C. Huston (Ed.), Professional
issues in nursing. Philadelphia, PA: Lippincott
Williams & Wilkins 188–200.
Huston, C. (2014c). Unlicensed assistive personnel and the
registered nurse. In C. Huston (Ed.), Professional
issues in nursing. Philadelphia, PA: Lippincott
Williams & Wilkins 107–120.
McHugh, M. (2013). Hospital nursing and 30-day
readmissions among medicare patients with heart
failure, acute myocardial infarction, and pneumonia.
Medical Care, 51(1), 52–59.
Mensik, J. S. (2007, November). A view on generational
differences from a generation X leader. Journal of
Nursing Administration, 37(11), 483–484.
National Nurses United. (2010–2013). Ratio Basics.
Retrieved June 9, 2013, from http://www
.nationalnursesunited.org/page/-/files/pdf/ratios/
basics-unit-0704
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http://www.nursetogether.com/the-nurse-managers-guide-to-handling-a-multigenerational-workforce

http://www.nationalnursesunited.org/page/-/files/pdf/ratios/basics-unit-0704

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412 UNIT V ROLES AND FUNCTIONS IN STAFFING
Needleman, J., Buerhaus, P., Pankratz, S., Leibson,
C., Stevens, S., & Harris, M. (2011). Nurse
staffing and inpatient hospital mortality.
The New England Journal of Medicine,
364, 1037–1045.
Oakes, R. (2012). Matching care to patient demand. Kai
Tiaki Nursing New Zealand, 18(11), 11.
Patterson, C. K. (2007). The impact of generational
diversity in the workplace. Diversity Factor, 15(3),
17–22.
QuadraMed Corporation. (2012). Nurse staffing and patient
outcomes: Bridging research into evidenced-based
practice. Unpublished internal study of data from
nine hospitals and 49 inpatient units.
QuadraMed Corporation. (2013). White paper. Five
reasons why CFOs should care about staffing
and acuity. Retrieved June 10, 2013, from http://
www.quadramed.com/Solutions—Services/Care
-Management/White-Papers/Five-Reasons-Why
-CFOs-Should-Care-about-Staffing_w.aspx
Stokowski, L. A. (2013, April 11). The 4-generation gap
in nursing. Medscape Nurses News. Retrieved
June 10, 2013, from http://www.medscape.com/
viewarticle/781752_2
US Department of Health and Human Services. (2013, May).
The National CLAS Standards. Retrieved June 8,
2013, from http://minorityhealth.hhs.gov/templates/
browse.aspx?lvl=2&lvlid=15

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http://www.medscape.com/viewarticle/781752_2

http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=15

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Roles and Functions
in Directing
UNIT VI
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414
Creating a Motivating Climate
… how we feel about and enjoy our work is crucial to how we perceive the quality of our lives.
—Jo Manion
… whether you think you can or whether you think you can’t, you’re right.
—Henry Ford
CROSSWALK tHis cHapter addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
QSEN Competency: teamwork and collaboration
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l describe the relationship between motivation and behavior
l differentiate between intrinsic and extrinsic motivation
l recognize the need to create a work environment in which both organizational and individual
needs can be met
l delineate how the work of individual motivation theorists has contributed to the understanding
of what motivates individuals inside and outside the work setting
l recognize the complexity of using incentives and rewards so that they motivate rather than
demotivate
l recognize the need to individualize reward systems for each subordinate
l develop strategies for creating a motivating work environment
l develop increased self-awareness about personal motivation and the need for “self-care” to
remain motivated in a leadership or management role
l identify positive reinforcement techniques that may be used by a manager in an organization
l describe the constraints managers face in creating a climate that will motivate employees
l identify the organization’s responsibility for effective promotions
l describe the advantages and disadvantages of promoting from within an organization versus
recruiting externally for advancement opportunities
18
This unit reviews the fourth phase of the management process: directing. This phase also
may be referred to as coordinating or activating. Regardless of the nomenclature, this is the
“doing” phase of management, requiring the leadership and management skills necessary to
accomplish the goals of the organization. Managers direct the work of their subordinates during
this phase and leaders support them so they can achieve desired outcomes. Components of
the directing phase discussed in this unit include creating a motivating climate, establishing

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Chapter 18 Creating a Motivating Climate 415
organizational communication, managing conflict, facilitating collaboration, negotiating, and
understanding the impact of collective bargaining and employment laws on management.
In planning and organizing, leader-managers attempt to establish an environment that
is conducive to getting work done. In directing, the leader-manager sets those plans into
action. This chapter focuses on creating a motivating climate as a critical element in meeting
employee and organizational goals.
The amount and quality of work accomplished by managers directly reflects their
motivation and that of their subordinates. Why are some managers or employees more
motivated than others? How do demotivated managers affect their subordinates? What can the
manager do to help the employee who is demotivated? The motivational problems frequently
encountered by the manager are complex. To respond to demotivated staff, managers need an
understanding of the relationship between motivation and behavior.
Motivation is the force within the individual that influences or directs behavior. Because
motivation comes from within the person, managers cannot directly motivate subordinates.
The leader can, however, create an environment that maximizes the development of human
potential. Management support, collegial influence, and the interaction of personalities in the
work group can have a synergistic effect on motivation. The leader-manager must identify
those components and strengthen them in hopes of maximizing motivation at the unit level.
All human beings have needs that motivate them. The leader focuses on the needs and
wants of individual workers and uses motivational strategies appropriate for each person and
situation. Leaders should apply techniques, skills, and knowledge of motivational theory to
help workers achieve what they want out of work. At the same time, these individual goals
should complement the goals of the organization. The manager bears primary responsibility for
meeting organizational goals, such as reaching acceptable levels of productivity and quality.
The leader-manager, then, must create a work environment in which both organizational
and individual needs can be met. Adequate tension must be created to maintain productivity
while encouraging subordinates’ job satisfaction. Thus, while the worker is achieving personal
goals, organizational goals are being met. This is not an easy task. The leadership roles and
management functions inherent in creating such an environment are included in Display 18.1.
DISPLAY 18.1 Leadership Roles and Management Functions Associated with Creating
a Motivating Work Climate
LEADERSHIP ROLES
1. recognizes each worker as a unique individual who is motivated by different things.
2. identifies the individual and collective value system of the unit and implements a reward system
that is consistent with those values.
3. Listens attentively to individual and collective work values and attitudes to identify unmet needs
that can cause dissatisfaction.
4. encourages workers to “stretch” themselves in an effort to promote self-growth and self-
actualization.
5. promotes a positive and enthusiastic image to subordinates in the clinical setting.
6. encourages mentoring, sponsorship, and coaching with subordinates.
7. devotes time and energy to create an environment that is supportive and encouraging to the
discouraged individual.
8. is authentic rather than automatic in giving praise and positive reinforcement.
9. develops a unit philosophy that recognizes the unique worth of each employee and promotes
reward systems that make each employee feel successful.
10. demonstrates through actions and words a belief in subordinates that they desire to meet
organizational goals.
11. is self-aware regarding own enthusiasm for work and takes steps to remotivate self as necessary.
(Continued )
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416 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
This chapter examines motivational theories that have guided organizational efforts and
resource distribution for the last 100 years. Special attention is given to the concepts of
intrinsic versus extrinsic motivation and organizational motivation versus self-motivation.
INTRINSIC VERSUS EXTRINSIC MOTIVATION
Motivation involves the action people take to satisfy unmet needs. It is the willingness
to put effort into achieving a goal or reward to decrease the tension caused by the need.
Intrinsic motivation comes from within the person, driving him or her to be productive (see
Display 18.2).
MANAGEMENT FUNCTIONS
1. Uses legitimate authority to provide formal reward systems.
2. Uses positive feedback to reward the individual employee.
3. develops unit goals that integrate organizational and subordinate needs.
4. Maintains a unit environment that eliminates or reduces job dissatisfiers.
5. promotes a unit environment that focuses on employee motivators.
6. creates the tension necessary to maintain productivity while encouraging subordinate job
satisfaction.
7. clearly communicates expectations to subordinates.
8. demonstrates and communicates sincere respect, concern, trust, and a sense of belonging to
subordinates.
9. assigns work duties commensurate with employee abilities and past performance to foster a
sense of accomplishment in subordinates.
10. identifies achievement, affiliation, or power needs of subordinates and develops appropriate
motivational strategies to meet those needs.
DISPLAY 18.2 Intrinsic and Extrinsic Motivation
This does not mean, however, that others cannot influence an individual’s intrinsic
motivation. Parents and peers, for example, often play major roles in shaping a person’s
values about what he or she wants to do and be. Parents who set high but attainable
expectations for their children, and who constantly encourage them in a nonauthoritative
environment, tend to impart strong achievement drives. Cultural background also has an
impact on intrinsic motivation since some cultures value career mobility, job success, and
recognition more than others.
Intrinsic motivation can be and often is impacted by others.
Rewards resulting from extrinsic motivation (which is motivation that is enhanced by
the work environment) occur after the work has been completed. Although all people are
Intrinsic Extrinsic
comes from within the individual comes from outside the individual
Often influenced by family unit and cultural values

rewards and reinforcements are given to
encourage certain behaviors and/or levels of
achievement

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Chapter 18 Creating a Motivating Climate 417
intrinsically motivated to some degree, it is unrealistic for the organization to assume that all
workers have adequate levels of intrinsic motivation to meet organizational goals. Thus, the
organization must provide a climate that stimulates both extrinsic and intrinsic drives.
The intrinsic motivation to achieve is directly related to a person’s level of aspiration. Extrinsic
motivation is motivation enhanced by the job environment or external rewards.
LEARNING EXERCISE 18.1
Thinking About Motivation
think back to when you were a child. What rewards did your parents use to promote good
behavior? Was your behavior more intrinsically or extrinsically motivated? Were strong
achievement drives encouraged and supported by your family? if you have children, what
rewards do you use to influence their behavior? are they the same rewards that your parents
used? Why or why not?
Because people have constant needs and wants, they are always motivated to some extent.
In addition, because all human beings are unique and have different needs, they are motivated
differently. The difference in motivation can be explained in part by our large- and small-
group cultures. For example, because American culture tends to value material goods and
possessions more highly than many other cultures, rewards in this country are frequently tied
to those values.
Because motivation is so complex, the leader faces tremendous challenges in accurately
identifying individual and collective motivators.
Organizations also have cultures and values. Motivators vary among organizations as well as
among units in organizations. Even in similar or nearly identical work environments, large
variations in individual and group motivation often exist. Much research has been undertaken
by behavioral, psychological, and social scientists to develop theories and concepts of
motivation. Economists and engineers have focused on extrinsic fiscal rewards to improve
performance and productivity, whereas human relations scientists have stressed intrinsic
needs for recognition, self-esteem, and self-actualization. To better understand the current
view that both extrinsic and intrinsic rewards are necessary for high productivity and worker
satisfaction, one needs to look at how motivational theory has evolved over time.
MOTIVATIONAL THEORY
Chapter 2 introduced traditional management philosophy, which emphasizes paternalism,
worker subordination, and bureaucracy as a means to predictable but moderate
productivity. In this philosophy, high productivity means greater monetary incentives for
the worker, and workers are viewed as being motivated primarily by economic factors.
This traditional management philosophy is still in use today. Many factory and assembly
line production jobs as well as jobs that use production incentive pay are based on these
principles. The shift from traditional management philosophy to a greater focus on the
human element and worker satisfaction as factors in productivity began during the human
relations era (1930 to 1970).
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418 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
Maslow
Continued focus on human motivation did not occur until Abraham Maslow’s work in the
1950s. Most nurses are familiar with Maslow’s hierarchy of needs and theory of human
motivation. Maslow (1970) believed that people are motivated to satisfy certain needs,
ranging from basic survival to complex psychological needs, and that people seek a higher
need only when the lower needs have been predominantly met. Maslow’s hierarchy of needs
is depicted in Figure 18.1.
Although Maslow’s work helps to explain personal motivation, his early work,
unfortunately, was not applied to motivation in the workplace. His later work, however,
offers much insight into motivation and worker dissatisfaction. In the workplace, Maslow’s
work contributed to the recognition that people are motivated by many needs other than
economic security.
Because of Maslow’s work, managers began to realize that people are complex beings, and
rather than just being motivated by economics, their many needs motivating them at any one
time.
It also became clear that motivation is internalized and that if productivity is to increase,
management must help employees meet lower-level needs. The shifting focus on what
motivates employees has tremendously affected how organizations value workers today.
Skinner
B.F. Skinner was another theorist in this era who contributed to the understanding
of motivation, dissatisfaction, and productivity. Skinner’s (1953) research on operant
conditioning and behavior modification demonstrated that people could be conditioned to
behave in a certain way based on a consistent reward or punishment system. Behavior that is
rewarded will be repeated, and behavior that is punished or goes unrewarded is extinguished.
Skinner’s work continues to be reflected today in the way many managers view and use
discipline and rewards in the work setting.
FIGURE 18.1 • Maslow’s hierarchy of needs. copyright ®
2006 Lippincott Williams & Wilkins. instructor’s resource
cd-rOM to accompany Leadership roles and Management
Functions in Nursing, by Bessie L. Marquis and carol J. Huston.

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Chapter 18 Creating a Motivating Climate 419
Herzberg
Frederick Herzberg (1977) believed that employees can be motivated by the work itself
and that there is an internal or personal need to meet organizational goals. He believed that
separating personal motivators from job dissatisfiers was possible. This distinction between
hygiene or maintenance factors and motivator factors was called the motivation–hygiene
theory or two-factor theory. Display 18.3 lists motivator and hygiene factors identified by
Herzberg.
Herzberg maintained that motivators or job satisfiers are present in work itself; they give
people the desire to work and to do that work well. Hygiene or maintenance factors keep
employees from being dissatisfied or demotivated but do not act as real motivators. It is
important to remember that the opposite of dissatisfaction may not be satisfaction. When
hygiene factors are met, there is a lack of dissatisfaction, not an existence of satisfaction.
Likewise, the absence of motivators does not necessarily cause dissatisfaction.
For example, salary is a hygiene factor. Although it does not motivate in itself, when used
with other motivators such as recognition and advancement, it can be a powerful motivator.
If, however, salary is deficient, employee dissatisfaction can result. Maxfield (2013, para 5)
agrees, noting that “money is much more apt to play the role of de-motivator than motivator,
because it is difficult to stay motivated if you don’t think your pay is fair. But, if you do think
your pay is fair, then you stop thinking about it and its power to motivate fades. Leaders need
to establish fair pay, but they shouldn’t rely on fair pay to motivate.”
Some argue, however, that money can truly be a motivator, as evidenced by people who
work insufferable hours at jobs they truly do not enjoy. Some theorists would argue that
money in this case might be taking the place of some other unconscious need. Some people in
Herzberg’s studies, however, did report job satisfaction solely from hygiene or maintenance
factors. Herzberg asserts that these people are only temporarily satisfied when hygiene
factors are improved, show little interest in the kind and quality of their work, experience
little satisfaction from accomplishments, and tend to show chronic dissatisfaction with other
hygiene factors such as salary, status, and job security.
Herzberg’s work suggests that although the organization must build on hygiene or
maintenance factors, the motivating climate must actively include the employee. The worker
must be given greater responsibilities, challenges, and recognition for work well done. The
reward system must meet both motivation and hygiene needs, and the emphasis given by the
manager should vary with the situation and the employee involved. Although hygiene factors
in themselves do not motivate, they are needed to create an environment that encourages
the worker to move on to higher-level needs. Hygiene factors also combat employee
dissatisfaction and are useful in recruiting an adequate personnel pool.
DISPLAY 18.3 Herzberg’s Motivators and Hygiene Factors
Motivators Hygiene Factors
achievement salary
recognition supervision
Work Job security
responsibility positive working conditions
advancement personal life
possibility for growth interpersonal relationships and peers
company policy
status
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420 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
Vroom
Victor Vroom (1964), another motivational theorist in the human relations era, developed
an expectancy model, which looks at motivation in terms of the person’s valence, or
preferences based on social values. In contrast to operant conditioning, which focuses on
observable behaviors, the expectancy model says that a person’s expectations about his or
her environment or a certain event will influence behavior. In other words, people look at all
actions as having a cause and effect; the effect may be immediate or delayed, but a reward
inherent in the behavior exists to motivate risk taking.
In Vroom’s expectancy model (Fig. 18.2), people make conscious decisions in anticipation
of reward; in operant conditioning, people react in a stimulus–response mode. Managers using
the expectancy model must become personally involved with their employees to understand
better the employees’ values, reward systems, strengths, and willingness to take risks.
McClelland
David McClelland (1971) examined what motives guide a person to action, stating that people
are motivated by three basic needs: achievement, affiliation, and power. Achievement-oriented
people actively focus on improving what is; they transform ideas into action, judiciously and
wisely, taking risks when necessary. In contrast, affiliation-oriented people focus their energies
on families and friends; their overt productivity is less because they view their contribution
to society in a different light from those who are achievement oriented. Research shows that
women generally have greater affiliation needs than men and that nurses generally have high
affiliation needs. Power-oriented people are motivated by the power that can be gained as a
result of a specific action. They want to command attention, get recognition, and control others.
LEARNING EXERCISE 18.2
Identifying Goals and Motivation
List six goals that you hope to accomplish in the next 5 years. identify which goals are most related to
achievement needs, affiliation needs, and power needs. remember that most people are motivated
in part by all three needs, and no one motivational need is better than the others. However, each
person must recognize and understand which basic needs motivate him or her most.
Expectancy
Effort
Performance Reward
Valence
FIGURE 18.2 • Vroom’s expectancy model. copyright ® 2006 Lippincott Williams &
Wilkins. instructor’s resource cd-rOM to accompany Leadership roles and
Management Functions in Nursing, by Bessie L. Marquis and carol J. Huston.

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Chapter 18 Creating a Motivating Climate 421
McClelland theorizes that managers can identify achievement, affiliation, or power needs of
their employees and develop appropriate motivational strategies to meet those needs.
Gellerman
Saul Gellerman (1968), another humanistic motivational theorist, identified several methods
to motivate people positively. One such method, stretching, involves assigning tasks that
are more difficult than what the person is used to doing. Bednarz (2013) agrees, noting
that employees must be challenged to stretch their personal and professional limits. This
includes personal and professional development in areas of vocational knowledge, skills, and
expertise. Stretching should not, however, be a routine or daily activity. All employees need
to have time to rest and regroup after being stretched.
The challenge of “stretching” is to energize people to enjoy the beauty of pushing themselves
beyond what they think they can do.
Another method, participation, entails actively drawing employees into decisions affecting
their work. Gellerman strongly believed that motivation problems usually stem from the way
the organization manages and not from the staff’s unwillingness to work hard. According to
Gellerman, most managers “overmanage”—they make the employee’s job too narrow and fail
to give the employee any decision-making power.
Bednarz (2013) agrees, suggesting that in order to stretch employees, managers must
develop confidence in their abilities. This means allowing employees to experiment
with new ideas and techniques while understanding that, “as people grow through
their experiences, many lessons are best learned through personal mistakes and failure.
Individuals who know they have the liberty to perform their jobs without fear of retribution
if they falter are more motivated and empowered to stretch the limits of their capabilities”
(Bednarz, para 7).
McGregor
Douglas McGregor (1960) examined the importance of a manager’s assumptions about
workers on the intrinsic motivation of the workers. These assumptions, which McGregor
labeled Theory X and Theory Y (depicted in Display 18.4), led to the realization in
management science that how the manager views, and thus treats, the worker will have an
impact on how well the organization functions.
DISPLAY 18.4 McGregor’s Theory X and Theory Y
Theory X Employees Theory Y Employees
avoid work if possible Like and enjoy work
dislike work are self-directed
Must be directed seek responsibility
Have little ambition are imaginative and creative
avoid responsibility Have underutilized intellectual capacity
Need threats to be motivated Need only general supervision
Need close supervision are encouraged to participate in problem solving
are motivated by rewards and punishment
McGregor did not consider Theory X and Theory Y as opposite points on the spectrum but
rather as two points on a continuum extending through all perspectives of people. McGregor
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422 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
believed that people should not be artificially classified as always having Theory X or Theory Y
assumptions about others; instead, most people belong on some point on the continuum.
Likewise, McGregor did not promote either Theory X or Theory Y as being the one superior
management style, although many managers have interpreted Theory Y as being the ultimate
management model. No one style is effective in all situations, at all times, and with all people.
McGregor, without making value judgments, simply stated that in any situation, the manager’s
assumptions about people, whether grounded in fact or not, affect motivation and productivity.
Theory Y is not a “better” management style than Theory X; the style which is “best” depends
on the variables inherent in a given situation.
The work of all these theorists has added greatly to the understanding of what motivates
people in and out of the work setting. Research reveals that motivation is extremely complex
and that there is tremendous variation in what motivates different people. Therefore,
managers must understand what can be done at the unit level to create a climate that allows
the worker to grow, increases motivation and productivity, and eliminates dissatisfiers that
drain energy and promote frustration.
CREATING A MOTIVATING CLIMATE
Because the organization has such an impact on extrinsic motivation, it is important to
examine organizational climates or attitudes that directly influence worker morale and
motivation. For example, organizations frequently overtly or covertly reinforce the image
that each employee is expendable and that individual recognition is in some way detrimental
to the employee and his or her productivity within the organization. Just the opposite is
true, because employees are an organization’s most valuable asset. Nurses who experience
satisfaction stay where they are, contributing to an organization’s retention.
Incentives and Rewards
Many organizations use incentives or rewards to foster a motivating climate. The use of
incentives and rewards for this purpose, however, can be very challenging. Some individuals
erroneously believe that if a small reward results in desired behavior, then a larger reward
will result in even more of the desired behavior. This simply is not true. There appears to be
a perceived threshold beyond which increasing the incentive results in no additional meaning
or weight.
In addition, recent research suggests that offering rewards in defined categories, even
when the categories are meaningless, can increase motivation, since the very act of
segmenting these rewards motivates people to perform better and longer (Wood, 2013). This
occurs because people feel they might “miss out” if they do not obtain a second reward. The
researchers concluded that instead of presenting one big reward, organizations should set up
more small rewards. Even if they are not all that different, people will generally work harder
when different rewards are available (Wood).
Using incentives and rewards to motivate workers can also be complicated by a view of
rewards as competition. When rewards lack consistency, there is greater risk that the reward
itself will become a source of competition and thereby lower morale. An attitude prevails that
“a limited number of awards are available, and an award received by anyone else limits the
chances of my getting one; thus, I cannot support recognition for my peers.” All employees
should be recognized for meeting milestones.
Likewise, rewarding one person’s behavior and not the behavior of another who has
accomplished a similar task at a similar level promotes jealousy and can demotivate. Rewards
and praise should be spontaneous and not relegated to predictable events, such as routine

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Chapter 18 Creating a Motivating Climate 423
annual performance reviews and recognition dinners. Rewards and praise should be given
whenever possible and whenever they are deserved.
If positive reinforcement and rewards are to be used as motivational strategies, then
rewards must represent a genuine accomplishment on the part of the person and should be
somewhat individual in nature. For example, many managers erroneously consider annual
merit pay increases as rewards that motivate employees. Most employees, however, recognize
annual merit pay increases as a universal “given”; thus, this reward has little meaning and
little power to motivate.
Organizations must be cognizant of the need to offer incentives at a level where employees
value them. This requires that the organization and its managers understand employees’
collective values and devise a reward system that is consistent with that value system.
Generational Differences and Motivation
Managers also must be cognizant of an employee’s individual values and attempt to reward
each worker accordingly. The ability to recognize each worker as a unique person who is
motivated differently and then to act upon those differences is a leadership skill.
For example, some researchers have suggested that generational differences exist in terms
of motivational factors and that while relatively stable, an individual’s motives can change
over the life cycle in terms of rank ordering, absolute levels, and motive strength as changes
in life goals and self-concept occur (Inceoglu, Segers, & Bartram, 2012).
In addition, research by Inceoglu et al. (2012) suggest that as people age, a shift in motives
generally occurs. Inceoglu et al. clarify that this does not mean that motivation decreases with
age; rather, that older employees tend to become less motivated by extrinsic job features and
instead become more motivated by intrinsic factors.
Deal et al. (2013) cautions, however, that existing research on generational differences
has rarely considered the effects of managerial level within the organization and that this
seems like an obvious confounding variable since employees at higher levels are typically
older than those at lower levels and since organizational level appears to impact many of
the variables examined in research on generational differences including job satisfaction. In
their survey of 3,440 participants, Deal et al. found that while there was some difference in
work motivation by generation, more of the variance could be explained by managerial level.
Individuals at lower managerial levels had higher levels of external motivation than did those
at higher managerial levels, whereas individuals at higher managerial levels had higher levels
of intrinsic, identified, and introjected (employees believe that they “should” engage in work
activities but have not fully embraced the value of the activities) motivation. These findings
suggest that organizations should look beyond just generational difference when attempting
to understand and improve employee motivation (Examining the Evidence 18.1).
Source: Deal, J. J., Stawiski, S., Graves, L., Gentry, W. A., Weber, T. J., & Ruderman, M. (2013). Motivation at
work: Which matters more: Generation or managerial level? consulting psychology Journal: practice & research,
65(1), 1–16.
The purpose of this study was to investigate whether work motivation differed by generations
or whether differences in work motivation were better explained by managerial level. The study
population was 3,440 individuals (1,723 men and 1,717 women) from more than 200 diffe-
rent organizations, who participated voluntarily in a web-based survey between March 2008
and December 2010. The survey included a series of questions about demographic and lifestyle
characteristics, motivation, work attitudes, and beliefs about leadership.
Examining the Evidence 18.1
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424 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
Clearly, generational considerations are only one aspect that must be considered in
determining how best to individualize reward systems for employees. Astute leader-managers
will consider these generational differences in determining how best to create a motivating
workplace climate but will also consider that any single employee’s motivations may in fact
be very different from their generational cohort.
The Relationship Between the Employee and His or Her Supervisor
In addition, the interpersonal relationship between an employee and his or her supervisor
is critical to the employee’s motivation level. We often forget that the only way to achieve
our goals is through the people who work with us. Therefore, although managers cannot
directly motivate employees, they can create a climate that demonstrates positive regard for
their employees, encourages open communication as well as growth and productivity, and
recognizes achievement.
Results suggested that managerial level better explained work motivation than did generati-
ons. although generation X employees, late Boomers, and early Boomers did differ in exter-
nal and introjected work motivation, there was substantially more variance in work motivation
explained by managerial level. Individuals at lower managerial levels had higher levels of external
motivation than did those at higher managerial levels, whereas individuals at higher managerial
levels had higher levels of intrinsic, identified, and introjected motivation.
The researchers suggested that top-level employees may need less external motivation
because they have already established themselves financially and professionally and are less
concerned with gaining rewards and approval. In contrast, individuals at lower levels may have
had less opportunity to establish themselves, and therefore financial rewards may be more perti-
nent to them. They also may be more concerned about garnering the approval of others in order
to advance their careers. The finding that higher-level managers report more introjected motiva-
tion suggests that compared with professionals, employees at higher levels seem to be motivated
by the need to view themselves as “winners” or feel good about themselves.
These findings suggest that a generation X employee in a senior management position
(e.g., director) might be motivated differently than a generation X employee in a middle
management position and that motivation would have little to do with their generation. This
suggests the organization would be better off designing a reward system around managerial
level, than by generational cohort.
LEARNING EXERCISE 18.3
The Strongest Motivator
identify the greatest motivator in your life at this time. Has it always been the strongest
motivator? could you list the strongest motivator for the significant others in your life? if so, have
you ever used this awareness to motivate those people to do something specific?
STRATEGIES FOR CREATING A MOTIVATING CLIMATE
The leader-manager can do many things to help create an environment that is motivating.
Sometimes, fostering a subordinate’s motivation is as simple as establishing a supportive and
encouraging environment. The cost of this strategy is only the manager’s time and energy.

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Chapter 18 Creating a Motivating Climate 425
Most managers, however, will tell you that recognition, incentives, support for making
progress, and clear goals are also essential to creating motivating work environments.
Research by Amabile and Kramer (2010) in their multiyear study of hundreds of workers
in multiple settings found that making progress toward goals was the most important factor.
When workers sense they are making headway or when they receive support that helps them
to overcome obstacles, their drive to succeed is at its peak. Amabile and Kramer conclude
that high-ranking managers should take care to clarify goals, ensure that worker’s efforts are
supported, and refrain from exerting such intense time pressure that minor glitches are viewed
as crises rather than learning opportunities. They also note that while recognition is important
as a motivational tool, there will be nothing to recognize if workers are not genuinely moving
forward in achieving their goals.
Asbjörnson and Brenner (2010) also offer advice to leader-managers in their assertion
that employees cannot truly be motivated by promotions, bonuses, or threat of demotion.
Instead, they argue that leaders must give employees the desire to engage in work because it
is enjoyable, meaningful, and personally satisfying.
In addition, one of the most powerful, yet frequently overlooked or underused, strategies
the manager can use to create a motivating climate is positive reinforcement, which validates
workers’ effort. Negative feedback makes workers feel as if they are being punished for
trying, and if negative feedback is consistently provided, the person will give up trying.
Maxfield (2013) agrees, suggesting that many hardworking, productive, and dedicated staff
say they do not get the recognition they deserve. If not corrected, this feeling can undermine
their commitment, engagement, and performance.
Biro (2013, para 2) cautions, however, that we have become a society “in which people
expect to be rewarded for drawing breath and taking up space, which makes the job of an
HR pro or business leader tasked with employee retention a difficult one indeed. If many
of your employees expect routine and social praise and “badges,” how can you recognize
extraordinary achievement?” Biro suggests instead to avoid constant praise for average work
and to remember that recognition can be a key tool in employee retention programs only
when it is recognition of extra effort and when it is authentic and not automatic.
Leaders then need a variety of ways to recognize performance and show appreciation.
This ability to individualize reward systems is a cardinal element in a successful motivation–
reward system for an organization. Additional strategies that can be used to create a
motivating climate are outlined in Display 18.5.
DISPLAY 18.5 Strategies to Create a Motivating Climate
1. Have clear expectations for workers, and communicate these expectations effectively.
2. Be fair and consistent when dealing with all employees.
3. Be a firm decision maker using an appropriate decision-making style.
4. develop the concept of teamwork. develop group goals and projects that will build a team spirit.
5. integrate the staff’s needs and wants with the organization’s interests and purpose.
6. Know the uniqueness of each employee. Let each know that you understand his or her uniqueness.
7. remove traditional blocks between the employee and the work to be done.
8. provide experiences that challenge or “stretch” the employee and allow opportunities for growth.
9. When appropriate, request participation and input from all subordinates in decision making.
10. Whenever possible, give subordinates recognition and credit.
11. Be certain that employees understand the reason behind decisions and actions.
12. reward desirable behavior; be consistent in how you handle undesirable behavior.
13. Let employees exercise individual judgment as much as possible.
14. create a trustful and helping relationship with employees.
15. Let employees exercise as much control as possible over their work environment.
16. Be a role model for employees.
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426 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
PROMOTION: A MOTIVATIONAL TOOL
Promotions are reassignments to a position of higher rank. It is normal for promotions to
include a pay raise. Most promotions include increased status, title changes, more authority,
and greater responsibility; therefore, they can be used as a significant motivational tool.
Because of the importance that US society places on promotions, certain guidelines
must accompany promotion selection to ensure that the process is fair, equitable, and
motivating. When position openings occur, they are often posted and filled quickly with
little thought of long-term organizational or employee goals. This frequently results in
negative personnel outcomes. To avoid this, the following elements should be determined
in advance:
• Whether recruitment will be internal or external. There are obvious advantages and
disadvantages to recruiting for promotions from both inside and outside the organization.
Recruiting from within can help to develop employees to fill higher-level positions as
they become vacant. It can also serve as a powerful motivation and recognition tool
since all employees know that opportunities for advancement are possible, and this
encourages them to perform at a higher level.
There are advantages to recruiting from outside the organization, however. When
promotions are filled with people outside the organization, the organization is infused with
people with new ideas. This prevents the stagnation that often occurs when all promotions are
internal. External candidates, however, often cost more in terms of salary than internal ones.
This is because external candidates generally need a financial incentive to leave their current
positions for something else.
Regardless of what the organization decides, the policy should be consistently followed
and communicated to all employees. Some companies recruit from within first and recruit
from outside the organization only if they are unable to find qualified people from among
their own employees.
LEARNING EXERCISE 18.4
Write a Detailed Plan to Motivate—Quickly!
You are the manager of a medical unit in a community hospital. the hospital has faced extreme
budget cuts during the last 5 years as a result of decreased reimbursement. Your unit used to
be a place where nurses wanted to work, and you rarely had openings for long, even though it
was necessary for the hospital to contain costs and shorten nursing care hours per patient-day.
a recent hiring freeze has accelerated worker dissatisfaction in your staff.
in the last week, five of the unit nurses, all excellent long-time employees, have stopped by your
office either in tears, anger, or frustration. their various comments have included, “Working here
is no longer fun,” “i used to love my job,” “i am tired of working with incompetent people,” and
“i am sick to death of calling for supplies that should be stocked on the floor.” You know that
funding will not increase in the near future, but you think that perhaps there are things you could
do to make the situation better for your staff.
Assignment: in examining the strategies for creating a motivating climate and the atmosphere
that supports finding joy in work, decide what you as an individual unit manager can do to
provide a more positive work environment. avoid taking items from the list in display 18.4, but
write a detailed plan that is feasible, that could be implemented fairly quickly, and that would
have the potential to turn this situation around.

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Chapter 18 Creating a Motivating Climate 427
• What the promotion and selection criteria will be. Employees should know in advance
what the criteria for promotion are and what selection method is to be used. Some
organizations use an interview panel as a selection method to promote all employees
beyond the level of charge nurse. Decisions regarding the selection method and
promotion criteria should be justified with rationale. In addition, employees need to
know what place seniority will have in the selection criteria.
• The pool of candidates that exists. When promotions are planned, as in succession
management, there will always be an adequate pool of candidates identified and
prepared to seek higher-level positions. A word of caution must be given regarding the
zeal with which managers urge subordinates to seek promotions. The leader’s role is to
identify and prepare such a pool. It is not the manager’s role to urge the employee to
seek a position in a manner that would lead the employee to think that he or she was
guaranteed the job or to unduly influence him or her in the decision to seek such a job.
When employees actively seek promotions, they are making a commitment to do well in
the new position. When they are pushed into such positions, the commitment to expend the
energy to do the job well may be lacking. In addition, for many reasons, the employee may
not feel ready, either due to personal commitments or because he or she feels inadequately
educated or experienced. Indeed, it is possible to promote an individual beyond his or her
level of capability (known as the Peter Principle). In this case, promotions demotivate that
individual as well as everyone in the organization.
The Peter Principle suggests that individuals often rise “to the level of their incompetence.”
• Handling rejected candidates. All promotion candidates who are rejected must be
notified before the selected candidate is notified. This is common courtesy. They should
be thanked for applying and, when appropriate, encouraged to apply for future position
openings. Sometimes, managers should tell employees which deficiencies kept them
from getting the position. For instance, employees should be told if they lack some
educational component or work experience that would make them a stronger competitor
for future promotions. This can be an effective way of encouraging career development.
• How employee releases are to be handled. Knowledge that the best candidate for the
position currently holds a critical job or difficult position to fill should not influence
decisions regarding promotions. Managers frequently find it difficult to release employees
to another position within the organization. Policies regarding the length of time that a
manager can delay releasing an employee should be written and communicated. On
the other hand, some managers are so good at developing their employees that they
frequently become frustrated because their success at career development results in
constantly losing their staff to other departments. In such cases, higher-level management
should reward such leaders and set release policies that are workable and realistic.
LEARNING EXERCISE 18.5
Why Won’t Beth Apply for the Position?
You have been the evening charge nurse of a large surgical unit for the last 4 years. each year,
you perform a career development conference with all your licensed staff. these sessions
are held separately from the performance appraisal interviews. You have been extremely
pleased with the results of these conferences. two of your licensed vocational nurses/licensed
(Continued)
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428 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
PROMOTING SELF-CARE
Managers can also create a motivating climate by being a positive and enthusiastic role model
in the clinical setting. Indeed Smith-Trudeau (2013) suggests that when managers enjoy their
work and can create fun workplaces, that employee trust, communication, and productivity
increase, leading to lower turnover, higher morale, and a stronger bottom line.
Managers, however, must be internally motivated before they can motivate others. Indeed,
Fernet (2013) suggests that psychological health is a prerequisite for employees to achieve
their full potential. Managers who frequently project unhappiness to subordinates contribute
to low unit morale. A burned-out, tired manager will develop a lethargic and demotivated
staff. Therefore, managers must constantly monitor their own motivational level and do
whatever is necessary to restore their motivation to be role models to staff.
The attitude and energy level of managers directly affect the attitude and productivity of their
employees.
Similarly, when clinicians suffer, so too do patients, since caregivers cannot provide quality
care when they themselves are depleted (Schuster, 2013). Fernet (2013) suggests that when
employees engage in their job for the inherent pleasure and satisfaction they experience
(intrinsic motivation) and/or because they personally endorse the importance or value of
their work (identified regulation), that psychological well-being occurs. In contrast, when
employees perform their job to gain a sense of self-worth or to avoid feelings of anxiety and
guilt and/or because they are pressured by demands, threats, or rewards by an external agent,
negative consequences such as burnout are more likely to occur.
professional nurses are now enrolled in a registered nurse (rN) program. several of the rNs
from your unit have obtained advanced clinical positions, and many have returned to school. as
a result of your encouragement and support, several of the nurses have taken charge positions
on other units. You are proud of your ability to recognize talent and to perform successful
career counseling.
this is the last time that you will be performing career counseling, because you have resigned
your position to return to graduate school. You have encouraged several of the staff to apply
for your position but think that one particular nurse—Beth, a 34-year-old woman—would be
exceptional. she is extremely capable clinically, very mature, well respected by everyone, and
has excellent interpersonal skills. Beth only works 4 days a week but has been invaluable to you
in the 4 years since you have been charge nurse. However, Beth is one of the few nurses who
has never acted on any of your suggestions at previous career-coaching interviews.
Last week, you had another coaching interview with Beth and told her of your plans. You urged
her to apply for your position and told her that you would recommend her to your supervisor,
although you would not be making the final selection. Beth told you that she would think
about it, and today she told you that she does not wish to apply for the position. You are very
disappointed and believe that perhaps you have failed in some way.
Assignment: examine this scenario carefully. Make a list of the possible reasons that Beth
declined the promotion. Be creative. Were the coaching sessions valuable or a waste of your
time? compare your findings with others in the group. after comparison, determine what
influence, if any, personal values had on the development of the lists.

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Chapter 18 Creating a Motivating Climate 429
Van Beek, Hu, Schaufeli, Taris, and Schreurs (2012) agree, noting that employees who
work hard because they are mainly driven or pushed by a strong need to prove themselves and
because they personally value work outcomes often experience burnout. Engaged employees
who work hard because they are mainly pulled by their inherently enjoyable and satisfying
work are more apt to be psychologically healthy.
It is imperative then that discouraged managers acknowledge their own feelings and
seek assistance accordingly. Managers are responsible to themselves and to subordinates
to remain motivated to do the best job possible. Nursing is a stressful profession, and
managers must practice health-seeking behaviors and find social supports when confronted
with stress or else risk burnout as a result. Burnout and other forms of work-related stress
are related to negative organizational outcomes such as illness, absenteeism, turnover,
performance deterioration, decreased productivity, and job dissatisfaction. These outcomes
cost the organization and impede quality of care. “Finding ways to help nurses relax, reflect,
refocus or re-energize then is critical in helping them to prevent or overcome burnout”
(Schuster, 2013, para 3).
Perhaps the most important strategy for avoiding burnout and maintaining a high
motivation level is self-care. For self-care, the manager should seek time off on a regular
basis to meet personal needs, seek recreation, form relationships outside the work setting,
and have fun.
Often, friends and colleagues are essential for emotional support, guidance, and
renewal. A proper diet and exercise are important to maintain physical health as well as
emotional health. Finally, the manager must be able to separate his or her work life and
personal life; the manager should remember that there is life outside of work and that time
should be relished and protected. Ultimately, the decision to practice self-care rests with
each nurse.
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
IN CREATING A MOTIVATING CLIMATE AT WORK
Most human behavior is motivated by a goal that the person wants to achieve. Identifying
employee goals and fostering their attainment allow the leader to create an environment that
encourages employees to reach personal and organizational goals. The motivational strategy
that the leader uses should vary with the situation and the employee involved; it may be
formal or informal. It may also be extrinsic, although because of a limited formal power
base, the leader generally focuses on other aspects of motivation. The leader must listen,
support, and encourage the discouraged employee. However, perhaps the most important
role that the leader has in working with the demotivated employee is that of role model.
Leaders who maintain a positive attitude and high energy levels directly and profoundly
affect the attitude and productivity of their followers.
When creating a motivating climate, the manager uses formal authority to reduce
dissatisfiers at the unit level and to implement a reward system that reflects individual and
collective value systems. This reward system may be formalized, or it may be as informal
as praise. Managers, by virtue of their position, have the ability to motivate subordinates
by “stretching” them intermittently with increasing responsibility and assignments that
they are capable of achieving. The manager’s role, then, is to create the tension necessary
to maintain productivity while encouraging subordinates’ job satisfaction. Therefore,
the success of the motivational strategy is measured by increased productivity and
benefit to the organization and by growth in the person, which motivates him or her to
accomplish again.
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430 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
KEY CONCEPTS
l Because human beings have constant needs and wants, they are always motivated to some extent.
However, what motivates each human being varies significantly.
l Managers cannot intrinsically motivate people, because motivation comes from within the person. the
humanistic manager can, however, create an environment in which the development of human potential
can be maximized.
l Maslow stated that people are motivated to satisfy certain needs, ranging from basic survival to complex
psychological needs, and that people seek a higher need only when the lower needs have been
predominantly met.
l skinner’s research on operant conditioning and behavior modification demonstrates that people can be
conditioned to behave in a certain way based on a consistent reward or punishment system.
l Herzberg maintained that motivators, or job satisfiers, are present in the work itself and encourage
people to want to work and to do that work well. Hygiene or maintenance factors keep the worker from
being dissatisfied or demotivated but do not act as true motivators for the worker.
l Vroom’s expectancy model says that people’s expectations about their environment or a certain event
will influence their behavior.
l Mcclelland’s studies state that all people are motivated by three basic needs: achievement, affiliation,
and power.
l Gellerman states that most managers in organizations overmanage, making the responsibilities too
narrow and failing to give employees any decision-making power or to stretch them often enough.
l McGregor points out the importance of a manager’s assumptions about workers on the intrinsic
motivation of the worker.
l there appears to be a perceived threshold beyond which increasing reward incentives results in no
additional meaning or weight in terms of productivity.
l Offering rewards in defined categories, even when the categories are meaningless, can increase
motivation, since the very act of segmenting these rewards appears to motivate people to perform better
and longer.
l positive reinforcement is one of the most powerful motivators the manager can use and is frequently
overlooked or underused.
l the supervisor or manager’s personal motivation is an important factor affecting staff’s commitment to
duties and morale.
l the success of a motivational strategy is measured by the increased productivity and benefit to the
organization and by the growth in the person, which motivates him or her to accomplish again.
l Because of the importance that american society places on promotions, certain guidelines must
accompany promotion selection to ensure that the process is fair, equitable, and motivating.
l policies regarding promotion should be in writing and communicated to all employees.
l recruitment from within has been shown to have a positive effect on employee motivation, whereas
recruitment from outside the organization allows for new ideas and prevents stagnation.
l it is possible to promote individuals beyond their level of capability. the peter principle, as it is known,
suggests that individuals may rise “to the level of their incompetence.”
l Managers must show their own positive attitude to demonstrate to employees that there is joy in work.

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Chapter 18 Creating a Motivating Climate 431
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
LEARNING EXERCISE 18.6
Create a Plan to Remotivate a New Employee
You are a county public health coordinator. You have grown concerned about the behavior of
one of the new rNs assigned to work in the agency. this new nurse, sally Brown, is a recent
graduate of a local BsN program. she came to work for the agency immediately after her
graduation 6 months ago and for the first few months appeared to be extremely hard working,
knowledgeable, well liked, and highly motivated. recently, though, several small incidents
involved sally. the agency’s medical director became very angry with her over a medication
error that she had made. sally was already feeling badly about the careless error. soon after,
a patient’s husband began disliking sally for no discernible reason and refused sally entrance
to his home to care for his wife. then, 2 weeks ago, a diabetic patient died fairly suddenly
from renal failure, and although no one was to blame, sally thought that if she had been more
observant and skilled in assessment, she would have detected subtle changes in the patient’s
condition sooner.
although you have been supportive of sally, you recognize that she is in danger of becoming
demotivated. Her once-flawless personal appearance now borders on being unkempt, she
is frequently absent from work, and her once-pleasant personality has been exchanged for
withdrawal from her coworkers.
Assignment: Using your knowledge of new role identification, assimilation, and motivational
theory, develop a plan to assist this young nurse. What can you do to provide a climate that
will remotivate her and decrease her job dissatisfaction? explain what you think is happening
to this nurse and the rationale behind your plan, which should be realistic in terms of the time
and energy that you have to spend on one employee. Be sure to identify the responsibilities of
the employee as well.
LEARNING EXERCISE 18.7
A Nursing Officer’s Dilemma
You are the chief Nursing Officer of county Hospital. dr. Martin Jones, a cardiologist, has
approached you about having an icU/ccU nurse make rounds with him each morning on all of
the patients in the hospital with a cardiac-related diagnosis. He believes that this will probably
represent a 90-minute commitment of nursing time daily. He is vague about the nurse’s exact
role or purpose, but you believe that there is great potential for better and more consistent
patient education and care planning.
Beth, one of your finest icU/ccU nurses, agrees to assist dr. Jones. Beth has always wanted to
have an expanded teaching role. However, for various reasons, she has been unable to relocate to
a larger city where there are more opportunities for teaching. You warn Beth that it might be some
time before this role develops into an autonomous position, but she is eager to assist dr. Jones.
the other icU/ccU staff agree to cover Beth’s patients while she is gone, although it is obviously
an extension of an already full patient load.
after 3 weeks of making rounds with dr. Jones, Beth comes to your office. she tearfully reports
that rounds frequently take 2 to 3 hours and that making rounds with dr. Jones amounts to little
(Continued)
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432 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
more than “carrying his charts, picking up his pages, and being a personal handmaiden.” she
has assertively stated her feelings to him and has attempted to demonstrate to dr. Jones how
their allegiance could result in improved patient care. she states that she has not been allowed
any input into patient decisions and is frequently reminded of “her position” and his ability to
have her removed from her job if she does not like being told what to do. she is demoralized
and demotivated. in addition, she believes that her peers resent having to cover her workload
because it is obvious that her role is superficial at best.
You ask Beth if she wants you to assign another nurse to work with dr. Jones, and she says that
she would really like to make it work but does not know what action to take that would improve
the situation.
You call dr. Jones, and he agrees to meet with you at your office when he completes rounds the
following morning. at this visit, dr. Jones confirms Beth’s description of her role but justifies his
desire for the role to continue by saying, “i bring $10 million of business to this hospital every
year in cardiology procedures. the least you can do is provide the nursing assistance i am asking
for. if you are unable to meet this small request, i will be forced to consider taking my practice
to a competitive hospital.” However, after further discussion, he does agree that eventually he
would consider a slightly more expanded role for the nurse after he learns to trust her.
Assignment: do you meet dr. Jones’s request? does it make any difference whether Beth is
the nurse, or can it be someone else? does the revenue that dr. Jones generates supersede
the value of professional nursing practice? should you try to talk Beth into continuing the
position for a while longer? While trying to reach a goal, people must sometimes endure a
difficult path, but at what point does the means not justify the end? Be realistic about what you
would do in this situation. What do you perceive to be the greatest obstacles in implementing
your decision?
LEARNING EXERCISE 18.8
To Work or Not to Work?
You are a nurse in a long-term care facility. the facility barely meets minimum licensing
standards for professional nursing staffing. although agency recruiters have been actively
seeking to hire more licensed staff, pay at the facility for professional staff is less than at local
acute care hospitals and the patient–nurse ratio is significantly higher. there appears to be
little chance of improving the rN staffing mix in your agency in the near future. the nursing
administrator is extremely supportive of the staff’s efforts but can do little to ease the current
workload for licensed staff other than to turn away patients or close the agency. as a result,
all of the nurses on the unit have been working at least 48 hours per week during the last 6
months; many have been working several double shifts and putting in many overtime hours
each pay period.
Morale is deteriorating, and the staff has begun to complain. Most of the licensed staff are
feeling burned out and demotivated. Many have started refusing to work overtime or to take
on extra shifts. You feel a responsibility to the patients, community, and organization and have
continued to work the extra hours but you are exhausted as well.
today is your first evening off in 6 days. at 2 pm, the phone rings, and you suspect that it is the
agency calling you to come in to work. You delay answering while you decide what to do. the
answering machine turns on, and you hear your administrator’s voice. she says that they are
desperate. two new patients were admitted during the day, and the facility is full. she says that

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Chapter 18 Creating a Motivating Climate 433
she appreciates all the hours you have been working but needs you once again, although she
is unable to give you tomorrow off in compensation. You feel conflicting loyalties to the unit,
patients, supervisor, and yourself.
Assignment: decide what you will do. Will you agree to work? Will you return the administrator’s
telephone call or pretend that you are not at home? When do your loyalties to your patients and the
organization end and your loyalties to yourself begin? is the administrator taking advantage of you?
are the other staff being irresponsible? What values have played a part in your decision making?
LEARNING EXERCISE 18.10
Downsizing Panic and Anxiety
as the result of rising costs and shrinking reimbursement, many hospitals downsized their staffs
in an effort to shrink costs. Because the hospital where you are the chief Nursing administrator
is faced with mandatory staffing ratios, it is impossible to cut further staff nurse positions and
meet requirements for state licensing.
therefore, the ceO of the hospital has mandated that management positions be reduced
by 30% throughout the hospital. the ceO has decided that department heads can reduce
management positions by any method they choose as long as it is done in 6 months. Job duties
are to be reassigned among the remaining managers.
this affects you significantly, as nursing has more managers than any other department. it does
not appear that attrition or turnover rates in the next months will be adequate to eliminate the
need for some reassignments, demotions, or termination of your group of 17 managers. this
includes both house supervisors and unit managers.
(Continued)
LEARNING EXERCISE 18.9
Remotivating Oneself
You are a school nurse and have worked in the same school for 2 years. Before that time, you
were a staff nurse at a local hospital working in pediatrics and later for a physician. You have
been an rN for 6 years.
When you began your job, it was exciting. You believed that you were really making a difference
in children’s lives. You started several good health promotion programs and worked hard
upgrading your health aides’ education and training.
several months ago, funding for the school was drastically cut, and several of your favorite
programs were eliminated. You have been depressed about this and lately have been short-
tempered at work. today, one of your best health aides gave you her 2-week notice and said,
“this isn’t a good place to work anymore.” You realize that many of the aides and several of the
schoolteachers have picked up your negative attitude.
there is much that you still love about your job, and you are not sure if the budget problems are
temporary or long term. You go home early today and contemplate what to do.
Assignment: should you stay in this job or leave? if you stay, how can you get remotivated?
can you remotivate yourself if the budget cuts are long term? Make a plan about what to do.
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434 UNIT VI Roles aND FUNCTIoNs IN DIReCTINg
REFERENCES
the news travels rapidly through the hospital grapevine. semi-hysteria prevails, with many
managers consulting you regarding whether their position is in jeopardy and what they can do
to increase the likelihood of their retention. Morale is rapidly plummeting, and relationships are
becoming increasingly competitive rather than cooperative.
Assignment: determine how you will handle this situation. What strategies might you implement
to reduce the immediate anxiety level? What advice can you give to staff who may face either
a layoff or a demotion? is it possible to preserve the morale of your managers in an uncertain
situation such as this?
LEARNING EXERCISE 18.11
Just Getting By
You are a senior student in an adN nursing program. You are also a single mother of three
grade-school aged children, currently living at home with your parents who are retired. Your
recent divorce left you emotionally shattered as well as financially destitute. You work part time
as a waitress at a local coffee shop at night to help buy groceries and pay your educational
expenses, but there is never enough money and you are just trying to do what you can to get by.
Your barely passing grades at school reflect the recent disorganization in your life. in addition,
you feel physically exhausted and increasingly depressed.
today, one of your nursing instructors calls you into her office, noting the drop in your grades,
and expresses concern that “you are not living up to your academic potential.” she encourages
you to try harder because she knows that you had hoped at some point to return to school, and
your current grades would not likely qualify you to do so.
You leave her office, feeling more discouraged than ever. there is already no time in your life for
self-care and doing better in school would require you to either work less or spend less time
with your family, neither of which seems like a plausible alternative to you.
Assignment: decide what you will do. Make sure the expectations you set for yourself are
reasonable. are the expectations intrinsically or extrinsically determined? also identify whether
your plan of action is more driven by achievement, affiliation, or power needs.
Amabile, T. M., & Kramer, S. J. (2010, January–February).
What really motivates workers. Harvard Business
Review, 88, 44–45.
Asbjörnson, K., & Brenner, M. (2010, Winter). Leadership is
a performing art. Leader to Leader, 2010(55), 18–23.
Bednarz, T. F. (2013). Motivation must be personal to
be effective. Leaders to Leader. Retrieved June 12,
2013, from http://blog.majoriumbusinesspress
.com/2013/02/12/motivation-must-be-personal-to-be
-effective/
Biro, (2013, January 13). 5 ways leaders rock
employee recognition. Forbes. Retrieved June
13, 2013, from http://www.forbes.com/sites/
meghanbiro/2013/01/13/5-ways-leaders-rock
-employee-recognition/
Deal, J. J., Stawiski, S., Graves, L., Gentry, W. A., Weber,
T. J., & Ruderman, M. (2013). Motivation at work:
Which matters more: Generation or managerial
level? Consulting Psychology Journal: Practice &
Research, 65(1), 1–16.
Fernet, C. (2013). The role of work motivation in
psycho logical health. Canadian Psychology,
54(1), 72–74
Gellerman, S. W. (1968). Management by motivation. New
York, NY: American Management Association.
Herzberg, F. (1987, September/October). One more time: How
do you motivate employees? HBR Classic. Harvard
Business Review, pp. 5-16. Retrieved Oct. 6, 2013
from http://www.facilitif.eu/user_files/file/herzburg
_article .

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Chapter 18 Creating a Motivating Climate 435
Inceoglu, I., Segers, J., & Bartram, D. (2012). Age-
related differences in work motivation. Journal of
Occupational & Organizational Psychology,
85(2), 300–329.
Maslow, A. (1970). Motivation and personality (2nd ed.).
New York, NY: Harper & Row.
Maxfield, D. (2013, May 14). Motivating without money.
Crucial Skills. Retrieved June 12, 2013, from http://
www.crucialskills.com/2013/05/motivating-without
-money/
McClelland, D. C. (1971). Assessing human motivation.
Morristown, NJ: General Learning Press.
McGregor, D. (1960). The human side of enterprise.
New York, NY: McGraw-Hill.
Schuster, J. L (2013, June 10 ). With nurses at risk
of compassion fatigue, hospitals try to ease their
stress. The Washington Post. Retrieved October 6,
2013 from http://articles.washingtonpost.com/
2013-06-10/national/39865768_1_burnout-intensive-
care-unit-nurses
Skinner, B. F. (1953). Science and human behavior.
New York, NY: Free Press.
Smith-Trudeau, P. (2013). Nurse managers cultivating a fun
culture. Vermont Nurse Connection, 16(2), 3.
van Beek, I., Hu, Q., Schaufeli, W. B., Taris, T. W., &
Schreurs, B. J. (2012). For fun, love, or money:
What drives workaholic, engaged, and burned-
out employees at work? Applied Psychology: An
International Review, 61(1), 30–55.
Vroom, V. (1964). Work and motivation. New York, NY:
John Wiley and Sons.
Wood, J. (2013, June 2). Separating rewards into categories
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http://articles.washingtonpost.com/2013-06-10/national/39865768_1_burnout-intensivecare-unit-nurses

http://psychcentral.com/news/2013/06/02/separating-rewards-into-categories-increases-motivation/55490.html

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436
19
Organizational, Interpersonal, and Group
Communication
… effective communication is the lifeblood of a successful organization. It reinforces the
organization’s vision, connects employees to the business, fosters process improvement, facilitates
change and drives business results by changing employee behavior.
—Watson Wyatt Worldwide
… the difference between the right word and the almost right word is the difference between
lightning and a lightning bug.
—Mark Twain
CROSSWALK This chapTer addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential IV: information management and application of patient care technology
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential V: informatics and health-care technologies
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: patient-centered care
QSEN Competency: Teamwork and collaboration
QSEN Competency: Quality improvement
QSEN Competency: safety
QSEN Competency: informatics
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency: professionalism
AONE Nurse Executive Competency: Business skills
LEARNING OBJECTIVES The learner will:
l identify the relationship between the sender, message, and receiver in any given communication
l differentiate between the internal and external climate in which communication occurs
l identify barriers to effective organizational communication
l describe strategies managers can take to increase the likelihood of clear and complete
organizational communication

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Chapter 19 Organizational, Interpersonal, and Group Communication 437
l choose appropriate communication modes for specific situations and messages
l differentiate among assertive, passive, aggressive, and passive–aggressive communication
l diagram upward, downward, horizontal, and diagonal communication
l recognize isBar (introduction, situation, Background, assessment, and recommendation)
and sBar (situation, Background, assessment, and recommendation) as a structured,
orderly approach in providing accurate, relevant information, in emergent patient situations
as well as routine handoffs
l write in a clear and concise manner using appropriate language for the receiver of the message
l demonstrate listening skills consistent with those outlined in the Grrrr (Greeting, respectful
Listening, review, recommend or request More information, and reward) listening model
l recognize culture and gender as significant variables impacting communication
l recognize the need for confidentiality in sensitive interpersonal, group, or organizational
communication
l describe the opportunities as well as the challenges new technologies pose for communication
in contemporary organizations
l recognize the potential benefits of social media as a communication tool as well as the
potential risks and identify principles for social networking use that minimize those risks
l accurately assess stages of group formation (forming, storming, norming, and performing)
l identify specific group-building and maintenance roles that must be established for groups
to accomplish work
Although some functions of management such as planning, organizing, and controlling can
be reasonably isolated, communication impacts all management activities and cuts across all
phases of the management process. The nurse-leader communicates with clients, colleagues,
superiors, and subordinates. In addition, because nursing practice tends to be group
oriented, interpersonal communication among group members is necessary for continuity
and productivity. One must have excellent interpersonal communication skills then to be an
effective leader-manager. In fact, communication is perhaps the most critical leadership skill.
Organizational communication is even more complex than interpersonal or group
communication, as there are more communication channels, more individuals to communicate
with, more information to transmit, and new technologies, which both complicate and ease
care delivery. Thus, organizational communication is a high-level management function; it
must be systematic, have continuity, and be appropriately integrated into the organizational
structure, encouraging an exchange of views and ideas. Organizational communication is
complex, however, and communication failure often results in a failure to meet organizational
goals. In addition, there are confidentiality risks that must be addressed.
In addition, the leader is responsible for developing a cohesive team to meet organizational
goals. To do this, the leader must articulate issues and concerns so that workers will not
become confused about priorities. The ability to communicate effectively often determines
success as a leader-manager and developing expertise in all aspects of communication is
critical to managerial success. Leadership skills and management functions inherent in
organizational, interpersonal, and group communication are listed in Display 19.1.
DISpLAy 19.1 Leadership Roles and Management Functions Associated with
Organizational, Interpersonal, and Group Communication
LEADERSHIP ROLES
1. Understands and appropriately uses both the formal and informal communication network in
the organization.
2. communicates clearly and precisely in language that others will understand.
3. is sensitive to the internal and external climate of the sender or receiver and uses that aware-
ness in interpreting messages.
(Continued )
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438 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
This chapter examines multiple forms of communication. Barriers to communication in large
organizations and managerial strategies to minimize those difficulties are presented. Channels
and modes of communication are compared, and guidelines are given for managerial selection of
the optimum channel or mode. In addition, assertiveness, nonverbal behavior, and active listening
as interpersonal communication factors are discussed. The chapter also includes a discussion
of how ISBAR (Introduction, Situation, Background, Assessment, and Recommendation)
and SBAR (Situation, Background, Assessment, Recommendation) can be used to provide a
more structured, orderly approach in communicating client data, how technology continues to
alter communication in health-care settings, and the ever-increasing challenge of maintaining
confidentiality in a system where so many people have access to so much information.
THE COMMUNICATION pROCESS
Answers.com (2013, para 1) provides a definition of communication as “the exchange of
thoughts, messages, or information, by speech, signals, writing, or behavior.” Communication
can also occur on at least two levels: verbal and nonverbal. Thus, whenever two or more
people are aware of each other, communication begins.
Communication begins the moment that two or more people become aware of each other’s
presence.
What happens, however, when the thoughts, ideas, and information exchanged do not have
the same meaning for both the sender and the receiver of the message? What if the verbal and
4. appropriately observes and interprets the verbal and nonverbal communication of followers.
5. role models assertive communication and active listening.
6. demonstrates congruency in verbal and nonverbal communication.
7. recognizes status, power, and authority as barriers to manager–subordinate communication
and uses communication strategies to overcome those barriers.
8. role models the use of social networking principles that promote collaboration, shared deci-
sion making, and evidence-based practice, while protecting patient rights and confidentiality.
9. seeks a balance between technological communication options and the need for human touch,
caring, and one-on-one, face-to-face interaction.
10. Maximizes group functioning by keeping group members on course, encouraging the shy,
controlling the garrulous, and protecting the weak.
MANAGEMENT FUNCTIONS
1. Understands and appropriately uses the organization’s formal communication network.
2. determines the appropriate communication mode or combination of modes for optimal distribu-
tion of information in the organizational hierarchy.
3. prepares written communications that are clear and uses language that is appropriate for the
message and the receiver.
4. consults with other departments or disciplines in coordinating overlapping roles and group
efforts.
5. differentiates between “information” and “communication” and appropriately assesses the
need for subordinates to have both.
6. prioritizes and protects client and subordinate confidentiality.
7. ensures that staff and self are trained to appropriately and fully utilize technological
communication tools.
8. establishes a technology-enabled communication infrastructure that leverages the benefits of
social media while minimizing the risks.
9. Uses knowledge of group dynamics for attaining goals and maximizing organizational
communication.

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Chapter 19 Organizational, Interpersonal, and Group Communication 439
nonverbal messages are incongruent? Does communication occur if an idea is transmitted but
not translated into action?
Because communication is so complex, many models exist to explain how organizations
and individuals communicate. Basic elements common to most models are shown in
Figure 19.1. In all communication, there is at least one sender, one receiver, and one message.
There is also a mode or medium through which the message is sent—for example, spoken,
written, or nonverbal.
An internal and an external climate also exist in communication. The internal climate
includes the values, feelings, temperament, and stress levels of the sender and the receiver.
Weather conditions, temperature, timing, and the organizational climate itself are parts of the
external climate. The external climate also includes status, power, and authority as barriers to
manager–subordinate communication (see Display 19.2).
SENDER
MESSAGE
RECEIVER
External
climate
Internal
climate
Written
Nonverbal
Verbal
External
climate
Internal
climate
FIGURE 19.1 • The communication process. copyright ® 2006 Lippincott Williams &
Wilkins. instructor’s resource cd-rOM to accompany Leadership roles and
Management Functions in Nursing, by Bessie L. Marquis and carol J. huston.
DISpLAy 19.2 The Internal and External Climate in Communication
Internal climate includes internal factors such as the values, feelings,
temperament, and stress levels of the sender and the
receiver
External climate includes external factors such as the weather,
temperature, timing, status, power, authority, and the
organizational climate itself
Both the sender and the receiver must be sensitive to the internal and external climate,
because the perception of the message is altered greatly depending upon the climate that
existed at the time the message was sent or received. For example, an insecure manager who
is called to meet with superiors during a period of stringent layoffs will probably view the
message with more trepidation than a manager who is secure in his or her role.
Because each person is different and thus makes decisions and perceives differently,
assessing external climate is usually easier than assessing internal climate. In assessing
internal climate, remember that the human mind perceives only what it expects to
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440 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
perceive. The unexpected is generally ignored or misunderstood. In other words,
receivers cannot communicate if the message is incompatible with their expectations. If
senders want communication to be effective, they need to decide what the receiver will
see or hear.
Effective communication requires the sender to validate what receivers see and hear.
VARIABLES AFFECTING ORGANIZATIONAL COMMUNICATION
Formal organizational structure has an impact on communication. People at lower levels of
the organizational hierarchy are at risk for inadequate communication from higher levels.
This occurs because of the number of levels that communication must filter through in
large organizations. As the number of employees increases (particularly more than 1,000
employees), the quantity of communication generally increases; however, employees may
perceive it as increasingly closed. In large organizations, it is impossible for individual
managers to communicate personally with each person or group involved in organizational
decision making. Not only is spatial distance a factor but the presence of subgroups or
subcultures also affects what messages are transmitted and how they are perceived.
LEARNING EXERCISE 19.1
Large Organization Communication
have you ever been employed in a large organization? Was the communication within that
organization clear and timely? What or who was your primary source of information? Were you
a part of a subgroup or subculture? if so, how did that affect communication?
Gender is also a significant factor in organizational communication, as men and
women communicate and use language differently. Women are generally perceived as
being more relationship oriented than men but this is not always the case. Women are also
characterized as being more collaborative in their communication, whereas men are more
competitive.
Complicating the picture further is the historical need in the health-care industry for
a predominantly male medical profession to closely communicate with a predominantly
female nursing profession. In addition, the majority of health-care administrators continue
to be male. Therefore, male physicians and administrators may feel little incentive to seek
the collaborative approach in communication that female nurses may desire. The quality of
organizational and unit-level communication then continues to be affected by differences in
gender, power, and status.
Differences in gender, power, and status significantly affect the types and quality of
organizational and unit-level communication.
Power and status also impact organizational communication. Garon (2012) notes that
communication problems are commonplace in health-care organizations when health-care
workers believe they cannot speak up or be heard. This then negatively impacts worker
job satisfaction, teamwork, as well as patient safety and limits the ability of organizational
leaders to address the problems that are affecting the ability of the organization to function
and change. The importance of the manager in setting up a culture of open communication
cannot be underestimated (Examining the Evidence 19.1).

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Chapter 19 Organizational, Interpersonal, and Group Communication 441
ORGANIZATIONAL COMMUNICATION STRATEGIES
Although organizational communication is complex, the following strategies increase the
likelihood of clear and complete communication:
• Leader-managers must assess organizational communication. Who communicates with
whom in the organization? Is the communication timely? Does communication within
the formal organization concur with formal lines of authority? Are there conflicts or
disagreements about communication? What modes of communication are used?
• Leader-managers must understand the organization’s structure and recognize who will
be affected by decisions. Both formal and informal communication networks need to be
considered. Formal communication networks follow the formal line of authority in the
organization’s hierarchy. Informal communication networks occur among people at the
same or different levels of the organizational hierarchy but do not represent formal lines
of authority or responsibility.
For example, an informal communication network might occur between a hospital’s
CEO and her daughter, who is a clerk on a medical wing. Although there may be
a significant exchange of information about unit or organizational functioning,
this communication network would not be apparent on the organization chart. It is
imperative, then, that managers be very careful about what they say and to whom until
they have a good understanding of the formal and informal communication networks.
Source: Garon, M. (2012). Speaking up, being heard: Registered nurses’ perceptions of workplace communication.
Journal of Nursing Management, 20(3), 361–371.
This study used a descriptive, qualitative approach, consisting of focus group interviews of
33 registered nurses (RNs), in staff or management positions from a variety of health-care
settings in California, to explore the perceptions of staff RNs and managers regarding their ability
to speak up and be heard in the workplace. Data were analyzed using thematic content analysis.
Study findings were organized into three categories: influences on speaking up, transmission
and reception of a message, and outcomes or results. The influences on the nurses’ decision
to speak up fell into two broad areas: personal and organizational. Personal influences included
cultural background, values, how they were raised, language and education. The organizational
influences consisted of peers, managers, and administrators.
Factors in the work environment that influenced nurses speaking up included peer influences,
manager and administrative influences, and environment or culture. Overall, the strongest theme
in this area and in the study was references to a climate of openness. Staff and managers agree
that the leaders created this climate.
Outcomes of speaking up emerged as the final category. Staff nurses wanted to know that
the issues they brought up were acted upon. Several expressed feelings that—nothing ever chan-
ges—leading them to believe that it was a waste of time and energy to continue to bring up issues.
Findings supported the researcher’s concerns that nurses are still not speaking up, and that
the effects of this are harmful to patients, staff, and organizations. Further changes in health-
care environments are needed to foster effective communication and nurse-managers are in the
ideal place to advance these changes. Study participants stressed the importance of “open door
policies” and listening skills and noted the importance of nurse-managers being able to listen
without blame or criticism, creating environments that encourage nurses to come forward with
their concerns.
Examining the Evidence 19.1
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442 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
• Communication is not a one-way channel. If other departments or disciplines will be
affected by a message, the leader-manager must consult with those areas for feedback
before the communication occurs.
• Communication must be clear, simple, and precise. This requires the sender to adjust
their language as necessary to the target audience.
• Senders should seek feedback regarding whether their communication was accurately
received. One way to do this is to ask the receiver to repeat the communication or
instructions. In addition, the sender should continue follow-up communication in an
effort to determine if the communication is being acted upon. The sender is responsible
for ensuring that the message is understood.
• Multiple communication methods should be used, when possible, if a message is important.
Using a variety of communication methods in combination increases the likelihood that
everyone in the organization who needs to hear the message actually will hear it.
• Managers should not overwhelm subordinates with unnecessary information. Information
is formal, impersonal, and unaffected by emotions, values, expectations, and perceptions.
Communication, on the other hand, involves perception and feeling. It does not depend
on information and may represent shared experiences. In contrast to information sharing,
superiors must continually communicate with subordinates.
Although information and communication are different, they are interdependent.
Most staff need little information about ordering procedures or organizational supply vendors
as long as supplies are adequate and appropriate to meet unit needs. If, however, a vendor is
temporarily unable to meet unit supply needs, the use of supplies by staff becomes an issue
requiring close communication between managers and subordinates. The manager must
communicate with the staff about which supplies will be inadequately stocked and for how
long. The manager also may choose to discuss this inadequacy of resources with the staff to
identify alternative solutions.
Channels of Communication
Because large organizations are so complex, communication channels used by the manager
may be upward, downward, horizontal, diagonal, or through the “grapevine.” In upward
communication, the manager is a subordinate to higher management. Needs and wants are
communicated upward to the next level in the hierarchy. Those at this higher level make
decisions for a greater segment of the organization than do the lower-level managers.
In downward communication, the manager relays information to subordinates. This is
a traditional form of communication in organizations and helps to coordinate activities in
various levels of the hierarchy.
In horizontal communication, managers interact with others on the same hierarchical
level as themselves who are managing different segments of the organization. The need for
horizontal communication increases as departmental interdependence increases.
In diagonal communication, the manager interacts with personnel and managers of
other departments and groups such as physicians, who are not on the same level of the
organizational hierarchy. Although these people have no formal authority over the manager,
this communication is vital to the organization’s functioning. Diagonal communication tends
to be less formal than other types of communication.
The most informal communication network is often called the grapevine. Grapevine
communication flows quickly and haphazardly among people at all hierarchical levels and
usually involves three or four people at a time. Senders have little accountability for the

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Chapter 19 Organizational, Interpersonal, and Group Communication 443
message, and often the message becomes distorted as it speeds along. Given the frequency of
grapevine communication in all organizations, all managers must attempt to better understand
how the grapevine works in their own organization as well as who is contributing to it. The
channels of communication are summarized in Display 19.3.
Grapevine communication is subject to error and distortion because of the speed at which it
passes and because the sender has little formal accountability for the message.
DISpLAy 19.3 Channels of Communication
Upward From subordinate to superior
downward From superior to subordinate
horizontal From peer to peer
diagonal Between individuals at differing hierarchy levels and
job classifications
Grapevine informal, haphazard, and random, usually involving
small groups
LEARNING EXERCISE 19.2
When and How Will You Tell?
assume that you are the project director of a small family planning clinic. You have just received
word that your federal and state funds have been slashed and that the clinic will probably close
in 3 months. although an additional funding source may be found, it is improbable that it will
occur within that time period. The Board of directors informed you that this knowledge is not
to be made public at this time.
You have five full-time employees at the clinic. Because two of these employees are your close
friends, you feel some conflict about withholding this information from them. You are aware
that another clinic in town currently has job openings and that the positions are generally filled
quickly.
Assignment: it is important that you staff the clinic for the next 3 months. When will you notify
the staff of the clinic’s intent to close? Will you communicate the closing to all staff at the same
time? Will you use downward communication? should the grapevine be used to leak news to
employees? When might the grapevine be appropriate to pass on information?
COMMUNICATION MODES
A message’s clarity is greatly affected by the mode of communication used. In general,
the more direct the communication, the greater the probability that it will be clear. The
more people involved in filtering the communication, the greater the chance of distortion.
The manager must evaluate each circumstance individually to determine which mode or
combination of modes is optimal for each situation. The manager uses the following modes
of communication most frequently:
• Written communication. Written messages (including memos, reports, e-mail, and
texting, which will be discussed later in this chapter) allow for documentation.
They may, however, be open to various interpretations and generally consume more
managerial time. Most managers are required to do a considerable amount of this type
of communication and therefore need to be able to write clearly.
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444 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
• Face-to-face communication. Oral communication is rapid but may result in fewer people
receiving the information than necessary. Managers communicate verbally upward and
downward and formally and informally. They also communicate verbally in formal
meetings, with people in peer work groups, and when making formal presentations.
• Telephone communication. A telephone call is rapid and allows the receiver to clarify
the message at the time it is given. It does not, however, allow the receipt of nonverbal
messages for either the sender or receiver of the message. Accents may be difficult
to understand as well in a multicultural workforce. Because managers today use the
telephone so much, it has become an important communication tool, but it does have
limits as an effective communication device.
• Nonverbal communication. Nonverbal communication includes facial expression, body
movements, and gestures and is commonly referred to as body language. Nonverbal
communication is considered more reliable than verbal communication because it conveys
the emotional part of the message. There is significant danger, however, in misinterpreting
nonverbal messages if they are not assessed in context with the verbal message. Nonverbal
communication occurs any time managers are seen (e.g., messages are transmitted to
subordinates every time the manager communicates verbally or just walks down a hallway).
ELEMENTS OF NONVERBAL COMMUNICATION
Much of our communication occurs through nonverbal channels that must be examined
in the context of the verbal content. Generally, if verbal and nonverbal messages are
incongruent, the receiver will believe the nonverbal message. Because nonverbal behavior
can be and frequently is misinterpreted, receivers must validate perceptions with senders. The
incongruence between verbal and nonverbal leads to many communication problems.
Because nonverbal communication indicates the emotional component of the message, it is
generally considered more reliable than verbal communication.
Silence can also be used as a means of nonverbal communication. This supports the old adage
that even silence can be deafening. The following section identifies other nonverbal clues that
can occur with or without verbal communication.
Space
The study of how space and territory affect communication is called proxemics (Loo, n.d.).
All of us have an invisible zone of psychological comfort that acts as a buffer against
unwanted touching and attacks. The degree of space we require depends on who we are
talking to as well as the situation we are in (Loo). It also varies according to cultural norms.
Some cultures require greater space between the sender and the receiver than others. In the
United States, between 0 and 18 inches of space is typically considered appropriate only for
intimate relationships; between 18 inches and 4 feet is appropriate for personal interactions;
between 4 and 12 feet is common for social exchanges; and more than 12 feet is a public
distance (Loo). Most Americans claim a territorial personal space of about 4 feet.
Proxemics, then, may contribute to the message being sent. Distance may imply a lack
of trust or warmth, whereas inadequate space, as defined by cultural norms, may make
people feel threatened or intimidated. Likewise, the manager who sits beside employees
during performance appraisals sends a different message than the manager who speaks to the
employee from the opposite side of a large and formal desk. In this case, distance increases
power and status on the part of the manager; however, the receptivity to distance and the
message that it implies varies with the culture of the receiver.

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Chapter 19 Organizational, Interpersonal, and Group Communication 445
Environment
The area where communication takes place is an important part of the communication process.
Communication that takes place in a superior’s office is generally taken more seriously than
that which occurs in the cafeteria.
Appearance
Much is communicated by our clothing, hairstyle, use of cosmetics, and attractiveness.
Care should be exercised, however, to be sure that organizational policies regarding desired
appearance are both culturally and gender sensitive.
Eye Contact
Decker (2013) suggests that eye contact over the last 10 to 15 years has plummeted as a result
of individuals looking down at their smart devices when they are supposedly communicating
with other people. Decker says “if you don’t have eye communication, you flat out don’t have
communication” (para 2). That is because this nonverbal clue is associated with sincerity.
Eye contact invites interaction and emotional connection. Likewise, breaking eye contact
suggests that the interaction is about to cease. It signals to your listeners that you are not
interested in them and that you are not engaged in the conversation (Decker). Blinking,
staring, or looking away when speaking also makes it difficult to connect with others
emotionally. However, one must always remember, that like space, the presence or absence
of eye contact is strongly influenced by cultural standards.
Posture
Posture and the way that you control the other parts of your body are also extremely important
as part of nonverbal communication. For example, Cherry (2013) suggests that sitting up
straight may indicate that a person is focused and paying attention to what’s going on. Sitting
with the body hunched forward, on the other hand, can imply that the person is bored or
indifferent. Crossing arms across one’s chest may suggest defensiveness or aggressiveness.
Moreover, the weight of a message is increased if the sender faces the receiver; stands or sits
appropriately close; and, with head erect, leans toward the receiver.
Gestures
A message accented with appropriate gestures takes on added emphasis. Too much gesturing
can, however, be distracting. For example, hand movement can emphasize or detract from the
message. Gestures also have a cultural meaning. Some cultures are more tactile than others.
Indeed, the use of touch is one gesture that often sends messages that are misinterpreted by
receivers from different cultures.
Facial Expression and Timing
Effective communication requires a facial expression that agrees with your message. Staff
perceive managers who present a pleasant and open expression as approachable. Likewise, a
nurse’s facial expression can greatly affect how and what clients are willing to relate. On the
other hand, hesitation often diminishes the effect of your statement or implies untruthfulness.
Vocal Expression
Vocal clues such as tone, volume, and inflection add to the message being transmitted.
Tentative statements sound more like questions than statements, leading listeners to think that
you are unsure of yourself, and speaking quickly may be interpreted as being nervous. The
goal, then, should always be to convey confidence and clarity.
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446 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
All nurses must be sensitive to nonverbal clues and their importance in communication.
This is especially true for nursing leaders. Effective leaders make sure that both verbal and
nonverbal communications agree.
Effective leaders are congruent in their verbal and nonverbal communication so that followers
are clear about the messages they receive.
Likewise, leaders are sensitive to nonverbal and verbal messages from followers and look
for inconsistencies that may indicate unresolved problems or needs. Often, organizational
difficulties can be prevented because leaders recognize the nonverbal communication of
subordinates and take appropriate and timely action.
VERBAL COMMUNICATION SKILLS
Highly developed verbal communication skills are critical for the leader-manager. Ibe
(2013) notes the inability to communicate needs or to challenge other people’s ideas can
cause tension in relationships, leading to stress, anxiety, or even depression. Assertive
communication, on the other hand, reduces this type of stress, improves productivity, and
contributes to a healthy workforce.
Assertive communication is a way of communicating that allows people to express
themselves in direct, honest, and appropriate ways that do not infringe on another person’s
rights. A person’s position is expressed clearly and firmly by using “I” statements as well as
direct eye contact and a calm voice. In addition, assertive communication always requires
that verbal and nonverbal messages be congruent. To be successful in the directing phase of
management, the leader must have well-developed skills in assertive communication.
There are many misconceptions about assertive communication. The first is that all
communication is either assertive or passive. Actually, at least four possibilities for
communication exist: passive, aggressive, indirectly aggressive or passive–aggressive, or
assertive. Passive communication occurs when a person suffers in silence although he or she
may feel strongly about the issue. Thus, passive communicators avoid conflict, often at the
risk of bottling up feelings which may lead to an eventual explosion (Ibe, 2013).
Aggressive communication is generally direct, threatening, and condescending. It infringes
on another person’s rights and intrudes into that person’s personal space. This behavior is also
oriented toward “winning at all costs” or demonstrating self-excellence. Thus, it is a bullying
type of communication and a form of dominance (Atlanta Black Star, 2013). Thomson (2013)
suggests that payoffs to being an aggressive communicator are that you often get others to
do what you want because they are afraid to stand up to you. The problem, however, is that
this communication style typically creates enemies, leads to unstable relationships, and the
feelings of power and self-confidence it creates can erode quickly if someone does stand up
to you (Thomson).
Passive–aggressive communication is an aggressive message presented in a passive way.
It generally involves limited verbal exchange (often with incongruent nonverbal behavior) by
a person who feels strongly about a situation. This person feigns withdrawal in an effort to
manipulate the situation. For example, the passive–aggressive communication may say yes
when they want to say no or be sarcastic or complain about others behind their backs (Mayo
Clinic Staff, 2011). Over time, this type of behavior damages relationships and undercuts
mutual respect (Mayo Clinic Staff).
The second misconception is that those who communicate or behave assertively get
everything they want. This is untrue. Being assertive involves both rights and responsibilities.
The third misconception about assertiveness is that it is unfeminine. Although the role of
women in society in general has undergone tremendous change in the last 100 years, some

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Chapter 19 Organizational, Interpersonal, and Group Communication 447
individuals continue to find great difficulty in accepting that both female and male nurses
play assertive, active, decision-making role. Assertive communication involves conveying a
message that insists on being heard.
An assertive communication model helps people to unlearn common self-deprecating
speech patterns that signal insecurity and a lack of confidence. The nursing profession must
be more assertive in its need to be heard. Eventually, a form of peer pressure can emerge that
reshapes others and results in an assertive nursing voice.
Assertive communication is not rude or insensitive behavior, rather, it is having an informed
voice that insists on being heard.
A fourth misconception is that the terms assertive and aggressive are synonymous. To be
assertive is to not be aggressive, although some cultures find the distinction blurred. Even
when faced with someone else’s aggression, the assertive communicator does not become
aggressive. When under attack by an aggressive person, an assertive person can do several
things:
• Reflect. Reflect the speaker’s message back to him or her. Focus on the affective
components of the aggressor’s message. This helps the aggressor to evaluate whether
the intensity of his or her feelings is appropriate to the specific situation or event. For
example, assume that an employee enters a manager’s office and begins complaining
about a newly posted staff schedule. The employee is obviously angry and defensive.
The manager might use reflection by stating, “I understand that you are very upset about
your schedule. This is an important issue, and we need to talk about it.”
• Repeat the assertive message. Repeated assertions focus on the message’s objective
content. They are especially effective when the aggressor overgeneralizes or seems
fixated on a repetitive line of thinking. For example, if a manager requests that an angry
employee step into his or her office to discuss a problem, and the employee continues
his or her tirade in the hallway, the manager might say, “I am willing to discuss this issue
with you in my office. The hallway is not the appropriate place for this discussion.”
• Point out the implicit assumptions. This involves listening closely and letting the
aggressor know that you have heard him or her. In these situations, managers might
repeat major points or identify key assumptions to show that they are following the
employee’s line of reasoning.
• Restate the message by using assertive language. Rephrasing the aggressor’s language
will defuse the emotion. Paraphrasing helps the aggressor to focus more on the cognitive
part of the message. The manager might use restating by changing a “you” message to
an “I” message.
• Question. When the aggressor uses nonverbal clues to be aggressive, the assertive person
can put this behavior in the form of a question as an effective means of helping the other
person become aware of an unwarranted reaction. For example, the desperate, angry
employee may imply threats about quitting or transferring to another unit. The manager
could appropriately confront the employee about his or her implied threat to see if it is
real or simply a reflection of the employee’s frustration.
As in nonverbal communication, the verbal communication skills of the leader-manager in a
multicultural workplace require cultural sensitivity.
Even when dealing with staff from the same cultural background, assertive communication
requires administrative skill to decide whether to speak face-to-face, send an electronic or
paper memo, telephone, or not to communicate about a particular matter at all.
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448 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
SBAR and ISBAR as Verbal Communication Tools
Accrediting bodies and organizations dedicated to improving the quality of health care have
directed health-care organizations to identify and implement strategies for improving and
standardizing professional communication. Indeed, the 2007 Joint Commission’s Annual
Report on Quality and Safety identified inadequate communication between care providers or
between care providers and patients/families as a consistent root cause of sentinel events (an
unexpected occurrence involving death or serious physical or psychological injury, or the risk
thereof) (Jordan, 2009). SBAR (Situation, Background, Assessment, and Recommendation)
and ISBAR (adds identification as first step) are strategies that have been developed to address
this problem.
SBAR, first used in the Navy to standardize important and urgent communication in
nuclear submarines and further developed by Kaiser Permanente, is an easy-to-remember
tool that provides a structured, orderly approach in providing accurate, relevant information,
in emergent patient situations as well as routine handoffs (Display 19.4). Handoffs (verbal
exchange of information, which occurs between two or more health-care providers about a
patient’s condition, treatment plan, care needs, etc.) typically occur both at change of shift
and when patients are transferred to different units. Using SBAR helps health-care providers
avoid long narrative descriptions and ensures that facts, which are essential for the proper
assessment of the patient’s needs, are passed on (Jordan, 2009). Clearly, SBAR has great
potential for reducing communication errors, thus increasing patient safety.
Some health-care organizations have chosen to include an introduction step (ISBAR) to
SBAR because they feel it is important that the clinicians start off with an introduction if they
do not actively know the person they are speaking with during a patient handoff or over the
phone (ISBAR, 2013). This step includes an introduction of the person doing the handoff,
their role in the patient’s care, and the unit they are calling from if the handoff occurs over
the phone (ISBAR).
LEARNING EXERCISE 19.3
Handoff with ISBAR
Today you were assigned to provide total patient care for Mr. dixon. he is a 73-year-old male
who was admitted for a total knee replacement 2 days ago. Today, the bloody output from
Mr. dixon’s Jackson pratt drains increased dramatically and the incision site appears to be
reddened, swollen, and hot. he has required iV pain medication every 3 to 4 hours, which
reduces his pain from a level 6 to 8 out of 10 to a level of 2 to 3. he is refusing to use his
continuous passive motion machine because he says it is too painful. he is also nauseated and
DISpLAy 19.4 SBAR as a Communication Tool
s situation introduce yourself and the patient and briefly state the issue that you
want to discuss (generally the patient’s condition)
B Background describe the background or context (patient’s diagnosis, admission
date, medical diagnosis, and treatment to date)
a assessment summarize the patient’s condition and state what you think the
problem is
r recommendation identify any new treatments or changes ordered and provide opinions
or recommendations for further action

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Chapter 19 Organizational, Interpersonal, and Group Communication 449
LISTENING SKILLS
Research shows that most people hear or actually retain only a small amount of the information
given to them. In fact, communication failure is a common root cause of medical error. It is
important then that the leader-manager approaches listening as an opportunity to learn.
To become better listeners, leaders must first become aware of how their own experiences,
values, attitudes, and biases affect how they receive and perceive messages. Second, they must
overcome the information and communication overload inherent in the middle-management
role. It is easy for overwhelmed managers to stop listening actively to the many subordinates
who need and demand their time simultaneously.
Finally, the leader must continually work to improve listening skills by giving time and
attention to the message sender. The leader’s primary purpose is to receive the message being
sent rather than forming a response before the transmission of the message is complete.
The leader who actively listens gives genuine time and attention to the sender, focusing on
verbal and nonverbal communication.
Boynton (2009) suggests that using a listening model such as GRRRR (Greeting, Respectful
Listening, Review, Recommend or Request More Information, and Reward) is especially helpful
in organizations where disruptive behavior, toxic environments, and power struggles interfere
with listening (see Display 19.5). In the Greeting stage, a simple respectful greeting is offered
to establish a professional dialogue. Next, participants demonstrate Respectful Listening by
giving each other time to think and transmit critical information without interrupting. Review
occurs when the speaker summarizes the information he has conveyed to make sure that the
message was understood correctly. Once the speaker is finished conveying this summary and
the other party has validated or clarified it, the listener has enough information to Recommend
or Request More Information. The communication exchange ends when both parties Reward
each other by recognizing and thanking each other for a collaborative exchange. GRRRR
can be used regardless of the relative rank and status of the participants since maintaining
structured communication is even more vital when power differences exist (Boynton, 2009).
refused his lunch today. his bowel sounds are diminished. Mr. dixon’s wife is at the bedside and
shares with you that the patient does not normally complain, so she is worried that something
might be wrong. Mr. dixon’s surgeon is not expected to see this patient until later this evening,
after the close of his private practice.
Assignment: Use isBar to prepare your handoff report for the next shift. Then share what
you have prepared with a peer. ask them to critique whether you communicated all vital patient
information and whether your assessment and recommendations were appropriate for the situation.
DISpLAy 19.5 GRRR (Boynton, 2009) as a Listening Tool
G Greeting Offer greetings and establish positive environment
r respectful listening Listen without interrupting and pause to allow others to think
r review summarize message to make sure it was heard accurately
r recommend or request more
information
seek additional information as necessary
r reward recognize that a collaborative exchange has occurred by
offering thanks
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450 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
WRITTEN COMMUNICATION WITHIN THE ORGANIZATION
Although communication may take many forms, written communication is used most often
in large organizations. The written communication issued by the manager reflects greatly on
both the manager and the organization. Thus, the manager must be able to write clearly and
professionally and to use understandable language. Many types of written communication
are used in organizations. Organizational policy, procedures, events, and change may be
announced in writing. Job descriptions, performance appraisals, and letters of reference are
also forms of written communication.
Often, though, the written communication used most by managers in their daily work life
is the memo. Perkins and Brizee (2013) suggest that business memos have a twofold purpose:
They bring attention to problems and they solve problems. Thus, it is important to choose the
audience of a memo wisely and to ensure that everyone on the distribution list of the memo
LEARNING EXERCISE 19.4
Practice Your Listening Skills
Assignment: Form small groups. assign a group leader and have that person quickly read the
following brief telephone transcript to group members. Group members should be told to take
whatever notes they would need to report the conversation to their unit manager. Group members
should not be allowed to read this exercise, only listen. The group leader should read the
transcript only once and then ask group members the questions at the end of the call transcript.
Caller: hi, my name is Joe Merlisch and i was a patient at the med center last week on 3 east….
room 211 or 213, i’m not sure. dr Trenweth took care of me—did surgery on my left knee. My
hearing aids disappeared when i was there and Lori told me that the hospital would take care
of getting them replaced, but no one has ever called me. My son seth says that Medicare won’t
replace them without me paying another $850 deductible and my private insurance says they
won’t cover it at all. i think it’s a problem with that “donut hole” in Medicare—isn’t that what they
call it? They were the Medihearing brand and they cost me $1700 when i bought them. i need
to get them replaced because i have 60% hearing loss in my right and 70% in my left. You guys
don’t know what it’s like when you can’t hear anything anyone is saying to you. My wife, Nora
is mad at me all the time because she thinks i’m just ignoring her and i just don’t hear her. Now
you guys want me to drive the 70 miles back to the hospital to look in your lost and found and
see if my hearing aids are there. Well,…. i’m not going to and i need someone to fix this. Why
don’t you drive out here and show me what you’ve got in that lost and found? i’ve talked to at
least 10 people today and everyone just keeps shunting me from person to person. isn’t there
anyone there who can fix this for me? What kind of hospital are you anyway?
The group leader should then ask group members to test their listening skills by writing down
answers to the following questions:
What is the patient’s name?
What is the patient’s wife’s name?
What is the doctor’s name?
What was lost?
When was this item lost?
What room was the patient in at the hospital?
how much did the lost hearing aids cost?
What brand were the hearing aids?
how far is it from the patient’s home to the hospital?
how many people have this people spoken to today already?

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Chapter 19 Organizational, Interpersonal, and Group Communication 451
actually needs to read it. Typically, memos should be sent to only a small-to-moderate number
of people. In addition, memos should not be used for highly sensitive messages, which are
better communicated face-to-face or by telephone (Perkins and Brizee).
Perkins and Brizee (2013) suggest that business memos should be comprised of the
following components:
• Header (includes the to, from, date, and subject lines): one-eighth of the memo
• Opening, context, and task (includes the purpose of the memo, the context and problem,
and the specific assignment or task): one-fourth of the memo
• Summary, discussion segment (the details that support your ideas or plan): one-half of
the memo
• Closing segment, necessary attachments (the action that you want your reader to take
and a notation about what attachments are included): one-eighth of the memo
In addition, because writing is a learned skill that improves with practice, Writing Help
Central (n.d.) suggests the following in writing professional correspondence:
• Keep your message short and concise. Less than one page is always preferred. Use
bullets to highlight key points.
• Use the first paragraph to express the context or purpose of the memo and to introduce
the problem. In next paragraphs, address what has been done or needs to be done to
address the problem at hand.
• Add a conclusion to summarize the memo, clarify what the reader is expected to do, and
to address any attachments that are a part of the memo.
• Focus on the recipient’s needs. Make sure that your communication addresses the
recipient’s expectations and what he or she needs to know.
• Use simple language so that the message is clear. Keep paragraphs to less than three or
four sentences.
• Review the message and revise as needed. Almost all important communication requires
several drafts. Always reread the written communication before sending it. Look for areas
that might be misunderstood. Pay attention to tone. Have all of the key points been made?
• Use spelling and grammar checks to be sure that the communication looks professional.
Remember that your document is a direct reflection of you, and even the most important
message will likely be ignored if the communication is perceived as unprofessional.
LEARNING EXERCISE 19.5
Revising a Formal Business Letter
read the following formal business letter and assess the quality of the writing. rewrite the letter
so that it is clearly written and professional in nature. Be prepared to read your letter to the class.
Mrs. Joan Watkins
October 19, 2013
Brownie Troop 407
anywhere, Usa 00000
dear Mrs. Watkins:
i am the official public relations coordinator for county hospital and serve as correspondence
officer for requests from public service groups. We have more than 100 requests such as yours
(Continued )
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452 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
THE IMpACT OF TECHNOLOGy ON CONTEMpORARy ORGANIZATIONAL
COMMUNICATION
Technology has dramatically changed how nurses communicate and perform their work.
Younger generations of nurses, who grew up using computers, cell phones, and instant
messaging, recognize that technology has given us the potential for instant information access
and exchange. These nurses approach and accept technology as an adjunct to their nursing
cognizance and do not question its presence or use.
The Internet
Nurses are increasingly using the Internet as both a communication tool and an information
source. As a communication tool, the Internet provides access to e-mail, file transfer protocol,
and the World Wide Web. As an information source, the Internet allows nurses to access the
latest research and best practice information so that their care can be evidence based.
The growth of the Internet as an information source for all types of information, including
health, is expected to continue to grow exponentially. Gobry (2011) points out the Internet
as a sector now produces about 3% of the US gross domestic product, more than agriculture
or energy, and representing more than 20% of the economic growth in this country for the
past 5 years.
Hospital Information Systems and Intranets
The use of hospital information system configurations such as stand-alone systems, online
interactive systems, networked systems, and integrative systems has also increased. Some
organizations have created internal electronic data repositories as a way of cataloging internal
reference materials, such as policy and procedure manuals. This increases the likelihood that staff
will be able to find such resources when they need them and that they are as up to date as possible.
In such a system, references are typically converted to the portable document format and launched
electronically via an intranet (internal networks, not normally accessible from the Internet) that
allow workers and departments to share files, use Web sites, and collaborate (Huston, 2014).
Wireless, Local Area Networking
The use of wireless, local area networking (WLAN) is also growing. WLAN uses spread-
spectrum radio frequency modulation technology instead of hardwired systems or paper-based
every year, so i have a very busy job! You are welcome to come and visit our hospital anytime.
My assistant told me you called yesterday and wondered whether we provide tours. There is no
charge for our tours. My assistant also told me the average age of your Brownies is 8 years, so
it might be most appropriate to have them visit our NicU, picU, and ed. please tell the girls
about the units in advance so they’ll be better prepared for what they will see. The philosophy at
our hospital promotes community involvement, so this is one way we attempt to meet this goal.
i’ll be sure to arrange to have a nursing manager escort the group on your tour. please call when
you have a date and time in mind. i was a Brownie myself when i was 7 years old, so i think this
is a terrific idea on your part.
sincerely,
ima Verbose, MsN
public relations coordinator
county hospital

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Chapter 19 Organizational, Interpersonal, and Group Communication 453
records and allows caregivers to access, update, and transmit critical patient and treatment
information when hardwiring is impractical or impossible (Huston, 2014).
Social Media and Organizational Communication
It is clear that the telecommunication technology growth experienced in the late 20th century
is continuing to proliferate even more rapidly in the 21st century. This advancing technology
may help to balance the constraints being placed on other patient care resources. Technologies
such as social networking, texting, e-mail, and the intranet are increasing the potential for
effective and efficient communication throughout the organization.
Ferguson (2013) suggests that social media, including web and mobile-based technology
platforms such as Twitter, YouTube, Facebook, and wiki platforms, will form the next
technological wave in health-care communication, replacing commonly used pagers, which
are limited to unidirectional communication. Indeed, social media can be used as a means
of gathering, sharing, and disseminating best practices and new ideas, and it provides for
instantaneous communication to virtually limitless audiences.
Yet, many health-care organizations are slow to embrace these new technologies as
communication tools. For example, some organizations ban or discourage the use of smart
phones, afraid that “health professionals will idle their days away on social media or breach
confidentiality” (Ferguson, 2013, para 4). This limits the ability of staff to improve care
delivery, and overall quality and safety through access to information and decision support.
Piscotty et al. (2013) agree, suggesting that nurses often find workarounds to circumvent such
restrictions anyway, such as increased use of their personal smartphones or use of Internet
access designated for patients and visitors.
In addition, Ferguson (2013, para 8) notes that Google remains blocked by server
administrators on many desktop PCs at nurse’s stations “while the bedside nurse must
hurriedly access his/her hardcopy drug handbook that is a few years out-of-date, attempting
to provide the most up-to-date research-inspired, evidence-based, care.” Ferguson suggests
that Internet access to search tools such as Google Scholar at the point of care could prove
helpful in the uptake of evidence-based care. He also suggests that if nurses can be trusted
with administering controlled drugs, the day-to-day management of hospitals, and with
highly confidential data, that they should be able to be trusted with the Internet at point-of-
care delivery.
Ferguson (2013) goes on to note that while some nurses have been reprimanded for
making comments online about patient care and posting inappropriate photos of themselves or
patients, maintaining patient confidentiality and ethical practice has always been considered a
foundational component of nursing professionalism. He concludes that while there are risks
to the use of social media, prohibition is folly and futile. “Rather than blocking this innovative
communication tool, we need to learn how to manage it, risks and all, and most importantly,
leverage the benefits from increased communication, dissemination, and potential for shared
decision making” (Ferguson, 2013, para 11).
Piscotty et al. (2013) agree, noting that social media can improve provider-to-provider
communication and coordination of patient care, facilitating the quick transfer of information.
In addition, professional networks can provide forums to share and obtain information, pose
questions, and connect with others who have similar professional interests. The resulting
quick dissemination and acquisition of clinical knowledge has the potential for rapid
translation of up-to-date information into practice.
Piscotty et al. (2013) warn though that social media does have the potential to cause
distractions and interruptions. The distraction may occur because of the device notifying
the nurse via sound or vibration that a message has been received. Additionally, there may
also be a mental distraction imposed by knowledge that a message is waiting and an urge
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454 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
to view the message. In addition, social media misuse may violate patient rights and has
been implicated in boundary violations of patients by nurses and nursing students, including
blogging about specific patients and posting actual pictures of patients or body parts on
Facebook. These actions have led the American Nurses Association (2011) and the National
Council of State Boards of Nursing (2011) to establish the Principles for Social Networking
shown in Display 19.6.
Balancing Technology and the Human Element
However, even the most advanced communication technology cannot replace the human
judgment needed by leaders and managers to use that technology appropriately. Examples
of the type of communication challenges that managers face in such a rapidly evolving
technological society include the following:
• Determining which technological advances can and should be used at each level of the
organizational hierarchy to promote efficiency and effectiveness of communication
• Assessing the need for and providing workers with adequate training to appropriately
and fully utilize the technological communication tools that may become available to
them
• Balancing cost and benefits
• Aligning communication technology with the organizational mission
• Finding a balance between technological communication options and the need for
human touch, caring, and one-on-one, face-to-face interaction (Huston, 2014; Huston,
2013).
Even the most advanced communication technology cannot replace the human judgment needed
by leaders and managers to use that technology appropriately.
COMMUNICATION, CONFIDENTIALITy, AND HEALTH INSURANCE pORTABILITy
AND ACCOUNTABILITy ACT
Nurses have a duty to maintain confidential information revealed to them by their patients.
This confidentiality can be breached legally only when one provider must share information
about a patient so that another provider can assume care. In other words, there must be a
DISpLAy 19.6 American Nurses Association/National Council of State Boards of Nursing
Principles for Social Networking
1. Nurses must not transmit or place online individually identifiable patient information.
2. Nurses must observe ethically prescribed professional patient–nurse boundaries.
3. Nurses should understand that patients, colleagues, institutions, and employers may view post-
ings.
4. Nurses should take advantage of privacy settings and seek to separate personal and profes-
sional information online.
5. Nurses should bring content that could harm a patient’s privacy, rights, or welfare to the attention
of appropriate authorities.
6. Nurses should participate in developing institutional policies governing online conduct.
Sources: American Nurses Association. (2011, September). principles for social networking and the nurse. Silver Spring,
MD: Author; National Council of State Boards of Nursing. (2011, August). White paper: a nurses’ guide to the use of social
media. Chicago, IL: Author. Retrieved June 16, 2013, from http://www.nursingworld.org/FunctionalMenuCategories/
AboutANA/Social-Media/Social-Networking-Principles-Toolkit/6-Tips-for-Nurses-Using-Social-Media-Poster

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Chapter 19 Organizational, Interpersonal, and Group Communication 455
legitimate professional need to know. The same level of confidentiality that is required to
protect patient rights is expected regarding sensitive personal communications between
managers and subordinates.
Confidentiality can be breached legally only when one provider must share information about
a patient so that another provider can assume care.
The 1996 Health Insurance Portability and Accountability Act (HIPAA) calls for strict
protections and privacy of medical information. Enactment of HIPAA requires putting in
place mechanisms and accountabilities to protect patients’ privacy. Violations of HIPAA can
result in significant fines for a facility. There is an ethical duty to maintain confidentiality as
well.
Protecting confidentiality and privacy of personal or patient information becomes even
more difficult as a result of increased electronic communication because the information
available by electronic communication is typically easier to access than traditional
information-retrieval methods and because computerized databases are unable to distinguish
whether the user has a legitimate right to such information. For example, the federal
government has mandated computerized patient records, and many health-care organizations
are beginning to implement this mandate. Unfortunately, the discussion and determination of
who in the organization should have access to what information are often inadequate before
such hardware is put in place, and great potential exists for violations of confidentiality.
Clearly, any nurse-manager working with clinical information systems has a responsibility to
see that confidentiality is maintained and that any breaches in confidentially are dealt with
swiftly and appropriately.
LEARNING EXERCISE 19.6
When Personal and Professional Obligations Conflict
You are an rN employed by an insurance company that provides workers’ compensation
coverage for large companies. Your job requires that you do routine health screening on new
employees to identify personal and job-related behaviors that may place these clients at risk for
injury or illness and then to counsel them appropriately regarding risk reduction.
One of the areas that you assess during your patient history is high-risk sexual behavior. One of
the clients you saw today expressed concern that he might be positive for hiV because a former
girlfriend, with whom he had unprotected sex, recently tested positive for hiV. he tells you that
he is afraid to be tested “because i don’t want to know if i have it.” he seems firm on his refusal
to be tested. You go ahead and provide him information about hiV testing and what he can do
in the future to prevent transmission of the virus to himself and others.
Later that evening, you are having dinner with your 26-year-old sister, and she reveals that she
has a “new love” in her life. When she tells you his name and where he works, you immediately
recognize him as the client you counseled in the office today.
Assignment: What will you do with the information you have about this client’s possible hiV
exposure? Will you share it with your sister? What are the legal and ethical ramifications inherent
in violating this patient’s confidentiality? What are the conflicting personal and professional
obligations? Would your action be the same if a casual acquaintance revealed to you that this
client was her new boyfriend? Be as honest as possible in your analysis.
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456 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Electronic Health Records
Even health records have changed as a result of technology. The electronic health record (EHR) is
a digital record of a patient’s health history that may be made up of records from many locations
and/or sources, such as hospitals, providers, clinics, and public health agencies (Huston, 2014).
For example, an EHR might include immunization status, allergies, patient demographics,
laboratory test and radiology results, advanced directives, current medications taken, and current
health-care appointments. The EHR is available 24 hours a day, 7 days a week, and has built in
safeguards to assure patient health information confidentiality and security.
In January 2004, President George Bush set a goal that most Americans would have an
EHR by 2014. This goal was endorsed by President Barack Obama and supported financially
with $30 billion in stimulus funds to support hospital implementation over the next few years.
As a result, this optional improvement has become a near-mandatory initiative (Haughom,
Kriz, & McMillan, 2011).
Many federal programs currently exist to support EHR adoption, including those
around meaningful use (capturing the right data that can improve patient outcomes); the
implementation of electronic information exchange; consumer e-health; and workforce
training (Centers for Medicare and Medicaid Services, 2010; Take 5 with a Nurse Leader,
2012). The process, however, to make such system-wide changes is not easy and resistance is
high. Nor is it cheap. Many challenges continue to exist in understanding and demonstrating
meaningful use, capturing the relevant data electronically as part of clinical workflows, and
not having the appropriate certified technology (Miliard, 2012).
Meaningful use refers to capturing the right data to improve patient outcomes.
In addition, most hospitals and health systems continue to doubt their ability to meet new
mandated EHR standards, with only 48% of health-care leaders in a recent survey feeling
confident in their organization’s readiness to meet Stage 1 meaningful use requirements
(Miliard). Thirty-nine percent said they were somewhat confident; 3% said they were not
confident at all; and 10% indicated that they did not know their level of readiness. Even with
these concerns, nearly three-quarters (71%) of hospital and health system leaders said they
are more than 50% of the way to completing EHR system adoption (Miliard).
GROUP COMMUNICATION
Managers must communicate with large and small groups as well as with individual
employees. Because a group communicates differently than individuals do, it is essential that
the manager has an understanding of group dynamics, including the sequence that each group
must go through before work can be accomplished. Tuckman and Jensen (1977), building on
the work of earlier management theorists, labeled these stages forming, storming, norming,
and performing.
When people are introduced into work groups, they must go through a process of meeting
each other: the forming stage. Here, interpersonal relationships are formed, expectations are
defined, and directions are given. They then progress through a stage where there is much
competition and attempts at the establishment of individual identities: the storming stage.
Individuals in the storming stage begin to feel comfortable enough with each other to disagree
and if managed appropriately, this discourse can lead to increased trust, positive competition,
and effective bargaining (Forming, Storming, Norming, Performing, 2009). Next, the group
begins to establish rules and design its work: the norming stage. Sometimes, norming never
occurs because no one takes the time to agree on and enforce ground rules and processes
(Forming, Storming, Norming, and Performing). Finally, during the performing stage, the
work actually gets done. Table 19.1 summarizes each stage.

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Chapter 19 Organizational, Interpersonal, and Group Communication 457
Some experts suggest, however, that there is another phase: termination or closure. In this
phase, the leader guides members to summarize, express feelings, and come to closure. A
celebration at the end of committee work is a good way to conclude group effort.
Because a group’s work develops over time, the addition of new members to a committee
typically result in a return to the forming stage, often slowing productivity. In addition, some
developmental stages will be performed again or delayed if new members join a group.
Therefore, it is important when assigning members to a committee to select those who can
remain until the work is finished or until their appointment time is over.
GROUp DyNAMICS
In addition to forming, storming, and norming, two other functions of groups are necessary
for work to be performed. One has to do with the task or the purpose of the group, and the
other has to do with the maintenance of the group or support functions. Managers should
understand how groups carry out their specific tasks and roles.
Group Task Roles
There are 11 tasks that each group performs. A member may perform several tasks, but for
the work of the group to be accomplished, all of the necessary tasks will be carried out either
by members or by the leader. These roles or tasks follow:
1. Initiator. Contributor who proposes or suggests group goals or redefines the problem.
There may be more than one initiator during the group’s lifetime.
2. Information seeker. Searches for a factual basis for the group’s work.
3. Information giver. Offers an opinion of what the group’s view of pertinent values
should be.
4. Opinion seeker. Seeks opinions that clarify or reflect the value of other members’
suggestions.
5. Elaborator. Gives examples or extends meanings of suggestions given and how they
could work.
TABLE 19.1 Stages of Group Process
Group
Development
Stage
Group Process Task Process
Forming Testing occurs to identify boundaries
of interpersonal behaviors, establish
dependency relationships with leaders
and other members, and determine
what is acceptable behavior
Testing occurs to identify the tasks,
appropriate rules, and methods suited
to the task’s performance
storming resistance to group influence is evident
as members polarize into subgroups;
conflict ensues and members rebel
against demands imposed by the leader
resistance to task requirements and
the differences surface regarding
demands imposed by the task
Norming consensus evolves as group cohesion
develops; conflict and resistance are
overcome
cooperation develops as differences
are expressed and resolved
performing interpersonal structure focuses on task
and its completion; roles become
flexible and functional; energies are
directed to task performance
problems are solved as the task
performance improves; constructive
efforts are undertaken to complete
task; more of group energies are
available for the task
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458 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
6. Coordinator. Clarifies and coordinates ideas, suggestions, and activities of the group.
7. Orienter. Summarizes decisions and actions, identifies and questions departures from
predetermined goals.
8. Evaluator. Questions group accomplishments and compares them with a standard.
9. Energizer. Stimulates and prods the group to act and raises the level of its actions.
10. Procedural technician. Facilitates group action by arranging the environment.
11. Recorder. Records the group’s activities and accomplishments.
B. T. Chapman suggests a different taxonomy for labeling the roles that are often held by
individuals in groups, particularly in terms of having productive meetings (Urseny, 2007).
Chapman suggests that there must always be someone in charge who can act as the group
facilitator. In addition, there must be a minutes keeper, time keeper, next agenda person, and
action plan keeper. These roles are further defined in Display 19.7.
l Facilitator: creates the final meeting agenda and estimates the time for each agenda item. runs
the meeting and gives notice when a decision is to be made or when future action is needed.
l Minutes keeper: records the meeting’s minutes but does not take down every word. records
directions given, decisions, or actions made and approved by the group.
l Time keeper: Keeps the group on schedule by tracking the time allotted for each issue on the
agenda. seeks agreement from the group before allowing discussion on an issue to go over the
predesignated time limit.
l Next agenda person: records issues for the next meeting and helps to create the following agen-
da. includes on the next agenda who is responsible for what issue and the time that should be
allowed for discussion.
l action plan keeper: records decisions for action in two ways; 30 days or long term. if something
must be done before the next meeting, it goes on the 30-day list. More complex projects go on the
long-term list, which is reviewed at each meeting.
Source: Urseny, L. (2007, January 26). Sticking to the agenda. chico enterprise record, Section E, 4E.
DISpLAy 19.7 B. T. Chapman’s Group Roles Taxonomy for Productive Meetings
Group Building and Maintenance Roles
Group task roles contribute to the work to be done; group-building roles provide for the care
and maintenance of the group. Examples of group-building roles include the following:
• Encourager. Accepts and praises all contributions, viewpoints, and ideas with warmth
and solidarity.
• Harmonizer. Mediates, harmonizes, and resolves conflict.
• Compromiser. Yields his or her position in a conflict situation.
• Gatekeeper. Promotes open communication and facilitates participation by all members.
• Standard setter. Expresses or evaluates standards to evaluate group process.
• Group commentator. Records group process and provides feedback to the group.
• Follower. Accepts the group’s ideas and listens to discussion and decisions.
Organizations need to have a mix of members—enough people to carry out the work and
also people who are good at team building. One group may perform more than one function
and group-building role.
Individual Roles of Group Members
Group members also carry out roles that serve their own needs. Group leaders must be able
to manage member roles so that individuals do not disrupt group productivity. The goal,

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Chapter 19 Organizational, Interpersonal, and Group Communication 459
however, should be management and not suppression. Not every group member has a need
that results in the use of one of these roles. The eight individual roles follow:
• Aggressor. Expresses disapproval of others’ values or feelings through jokes, verbal
attacks, or envy.
• Blocker. Persists in expressing negative points of view and resurrects dead issues.
• Recognition seeker. Works to focus positive attention on himself or herself.
• Self-confessor. Uses the group setting as a forum for personal expression.
• Playboy. Remains uninvolved and demonstrates cynicism, nonchalance, or horseplay.
• Dominator. Attempts to control and manipulate the group.
• Help seeker. Uses expressions of personal insecurity, confusion, or self-deprecation to
manipulate sympathy from members.
• Special interest pleader. Cloaks personal prejudices or biases by ostensibly speaking for
others.
Managers must be well grounded in group dynamics and group roles because of the need to
facilitate group communication and productivity within the organization.
While managers must understand group dynamics and roles to facilitate communication
and productivity, leaders tend to make an even greater impact on group effectiveness.
Dynamic leaders inspire followers toward participative management by how they work and
communicate in groups. Leaders keep group members on course, draw out the shy, politely
cut off the garrulous, and protect the weak.
LEARNING EXERCISE 19.7
Identifying Group Stages and Roles
compile a list of the various groups with which you are currently involved. describe the stage of
each one. did it take longer for some of your groups to get to the performing stage than others?
if membership in the group changed, describe what happened to the productivity level. can you
identify which individuals in the group are fulfilling group task roles? Group maintenance and
building roles? individual roles?
INTEGRATING LEADERSHIp AND MANAGEMENT IN ORGANIZATIONAL,
INTERpERSONAL, AND GROUp COMMUNICATION
Communication is critical to successful leadership and management. A manager has the
formal authority and responsibility to communicate with many people in the organization.
Cultural diversity and rapidly flourishing communication technologies also add to the
complexity of this organizational communication. Because of this complexity, the manager
must understand each unique situation well enough to be able to select the most appropriate
internal communication network or channel.
After selecting a communication channel, the manager faces an even greater challenge in
communicating the message clearly, either verbally or in writing, in a language appropriate
for the message and the receiver. To select the most appropriate communication mode for
a specific message, the manager must determine what should be told, to whom, and when.
Because communication is a learned skill, managers can improve their written and verbal
communication with repetition.
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460 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
The interpersonal communication skills are more reflective of the leadership role.
Sensitivity to verbal and nonverbal communication; recognition of status, power, and
authority as barriers to manager–subordinate communication; and consistent use of
assertiveness techniques are all leadership skills. Nurse-leaders who are perceptive and
sensitive to the environment and people around them have a keen understanding of how the
unit is functioning at any time and are able to intervene appropriately when problems arise.
Through consistent verbal and nonverbal communication, the nurse-leader is able to be a role
model for subordinates.
The integrated leader-manager also uses groups to facilitate communication. Group work
is a tool for increasing productivity. All members of work groups should be assisted with role
clarification and productive group dynamics.
Organizational communication requires both management functions and leadership
skills. Management functions in communication ensure productivity and continuity through
appropriate sharing of information. Leadership skills ensure appraisal and intervention in
meeting expressed and tacit human resource needs. Leadership skills in communication also
allow the leader-manager to clarify organizational goals and direct subordinates in reaching
those goals. Communication within the organization would fail if both leadership skills and
management functions were not present.
KEY CONCEPTS
l communication forms the core of management activities and cuts across all phases of the management
process. it is also the core of the nurse–patient, nurse–nurse, and nurse–physician relationship.
l depending on the manager’s position in the hierarchy, the overwhelming majority of managerial time is
often directed at some type of organizational communication; thus, organizational communication is a
high-level management function.
l Because most managerial communication time is spent speaking and listening, managers must have
excellent interpersonal communication skills.
l communication in large organizations is particularly difficult due to their complexity and size.
l Managers must understand the structure of the organization and recognize whom their decisions will
affect. Both formal and informal communication networks need to be considered.
l The clarity of the message is significantly affected by the mode of communication used. in general, the
more direct the communication, the greater the probability of clear communication. The more people
involved in filtering the communication, the greater the chance of distortion.
l Written communication is used most often in large organizations.
l a manager’s written communication reflects greatly on both the manager and the organization. Thus,
managers must be able to write clearly and professionally and use understandable language.
l The incongruence between verbal and nonverbal messages is the most significant barrier to effective
interpersonal communication.
l effective leaders are congruent in their verbal and nonverbal communication so that followers are clear
about the messages they receive. Likewise, leaders are sensitive to nonverbal and verbal messages from
followers and look for inconsistencies that may indicate unresolved problems or needs.
l To be successful in the directing phase of management, the leader must have well-developed skills in
assertive communication.
l sBar and isBar provide structured, orderly approaches to provide accurate, relevant information, in
emergent patient situations as well as routine handoffs.
l Most people hear or retain only a small amount of the information given to them.
l active listening is an interpersonal communication skill that improves with practice.

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Chapter 19 Organizational, Interpersonal, and Group Communication 461
ADDITIONAL LEARNING EXERCISES AND AppLICATIONS
l Using a listening model such as GRRRR (Greeting, respectful Listening, review, recommend or
request More information, and reward) is especially helpful in organizations where disruptive behavior,
toxic environments, and power struggles interfere with listening.
l adding new members to an established group disrupts productivity and group development.
l Group members perform certain important tasks that facilitate work.
l Group members also perform roles that assist with group-building activities.
l some group members will perform roles to meet their individual needs.
l rapidly flourishing communication technologies have great potential to increase the efficiency and
effectiveness of organizational communication. They also, however, pose increasing challenges to patient
confidentiality.
LEARNING EXERCISE 19.8
Writing a Memo
You are a school nurse. in the last 2 weeks, nine cases of head lice have been reported in four
different classrooms. The potential for spread is high, and both the teachers and parents are
growing anxious.
Assignment: compose a memo for distribution to the teachers. Your goals are to inform,
reassure, and direct future inquiries.
LEARNING EXERCISE 19.9
Identifying and Rephrasing Nonassertive Responses
decide if the following responses are an example of assertive, aggressive, passive–aggressive,
or passive behavior. change those that you identify as aggressive, passive–aggressive, or
passive into assertive responses.
Situation Response
1. a coworker withdraws instead of saying
what is on his mind. You say:
“i guess you are uncomfortable talking
about what’s bothering you. it would be
better if you talked to me.”
2. This is the third time in 2 weeks that
your coworker has asked for a ride home
because her car is not working. You say:
“You’re taking advantage of me, and i
won’t stand for it. it’s your responsibility
to get your car fixed.”
3. an attendant at a gas station neglected to
replace your gas cap. You return to inquire
about it. You say:
“One of the guys here forgot to put my
gas cap back on! i want it found now, or
you’ll buy me a new one.”
4. You would like to have a turn at being in
charge on your shift. You say to your head
nurse:
“do you think that, ah, you could see your
way clear to letting me be in charge once
in a while?”
(Continued )
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462 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Situation Response
5. a committee meeting is being established.
The proposed time is convenient for other
people but not for you. The time makes
it impossible for you to attend meetings
regularly. When you are asked about the
time, you say:
“Well, i guess it’s OK. i’m not going to be
able to attend very much, but it fits into
everyone else’s schedule.”
6. in a conversation, a doctor suddenly asks,
“What do you women libbers want anyway?”
You respond:
“Fairness and equality.”
7. an employee makes a lot of mistakes in his
work. You say:
“You’re a lazy and sloppy worker!”
8. You are the only woman in a meeting with
seven men. at the beginning of the meeting,
the chair asks you to be the secretary. You
respond:
“No. i’m sick and tired of being the
secretary just because i’m the only
woman in the group.”
9. a physician asks to borrow your stethoscope.
You say:
“Well, i guess so. One of you doctors
walked off with mine last week, and this
new one cost me $65. Be sure you return
it, OK?”
10. You are interpreting the i&O sheet for a
physician, and he interrupts you. You say:
“You could understand this if you’d stop
interrupting me and listen.”
LEARNING EXERCISE 19.10
Memo to Chief Executive Officer Leads to Miscommunication
carol White, the coordinator for the multidisciplinary mental health outpatient services of a
150-bed psychiatric hospital, feels frustrated because the hospital is very centralized. she
believes that this keeps the hospital’s therapists and nurse-managers from being as effective
as they could if they had more authority. Therefore, she has worked out a plan to decentralize
her department, giving the therapists and nurse-managers more control and new titles. she
sent her new plan to ceO Joe short and has just received this memo in return.
dear Ms. White:
The Board of directors and i met to review your plan and think it is a good one. in fact, we have
been thinking along the same lines for quite some time now. i’m sure you must have heard of
our plans. Because we recently contracted with a physician’s group to cover our crisis center,
we believe this would be a good time to decentralize in other ways. We suggest that your new
substance abuse coordinator report directly to the new chief of mental health. in addition, we
believe your new director of the suicide prevention center should report directly to the chief of
mental health. he then will report to me.
i am pleased that we are both moving in the same direction and have the same goals. We will
be setting up meetings in the future to iron out the small details.
sincerely,
Joe short, ceO

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Chapter 19 Organizational, Interpersonal, and Group Communication 463
Assignment: how and why did carol’s plan go astray? how did her mode of communication
affect the outcome? could the outcome have been prevented? What communication mode
would have been most appropriate for carol to use in sharing her plan with Joe? What should
be her plan now? explain your rationale.
LEARNING EXERCISE 19.11
Writing a Letter of Reference
Unit managers are frequently asked to write letters of reference for employees who have been
terminated. The information used in writing these letters comes from performance evaluations,
personal interviews with staff and patients, evidence of continuing education, and personal
observations. assume that you are a unit manager and that you have collected the following
information on Mary doe, an rN who worked at your facility for 3 months before abruptly
resigning with 48 hours’ notice.
Performance Evaluation
Three-month evaluation scant.
● The following criteria were marked “competent”: amount of work accomplished,
relationships with patients and coworkers, work habits, and basic skills.
● The following criteria were identified as “needing improvement”: quality of work,
communication skills, and leadership skills.
● No criteria were marked unsatisfactory or outstanding.
● Narrative comments were limited to the following: “has a bit of a chip on her shoulder,”
“works independently a lot,” and “assessment skills improving.”
Interviews with Staff
● coworker rN Judy: “she was OK. she was a little strange—she belonged to some kind of
traveling religious cult. in fact, i think that’s why she left her job.”
● coworker licensed vocational nurse (LVN)/licensed professional nurse (LpN) Lisa: “Mary
was great. she got all her work done. i never had to help her with her meds or am care. she
took her turn at floating, which is more than i can say for some of the other rNs.”
● coworker rN John: “When i was the charge nurse, i found i needed to seek Mary out to
find out what was going on with her patients. it made me real uncomfortable.”
● coworker LVN/LpN Joe: “Mary hated it here—she never felt like she belonged. The charge
nurse was always hassling her about little things, and it really seemed unfair.”
Patient Comments
● “she helped me with my bath and got all my pills on time. she was a good nurse.”
● “i don’t remember her.”
● “she was so busy—i appreciated how efficient she was at how she did her job.”
● “i remember Mary. she told me she really liked older people. i wish she had had more time
to sit down and talk to me.”
Notes from Personnel File
Twenty-four years old. Graduated from 3-year diploma school 2 years ago. has worked in
three jobs since that time.
(Continued )
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464 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Continuing Education
current cpr card. No other continuing education completed at this facility.
Assignment: Mary doe’s prospective employer has requested a letter of reference to
accompany Mary’s application to become a hospice nurse/counselor. No form has been
provided, so you must determine an appropriate format. decide which information you should
include in your letter and which should be omitted. Will you weigh some information more heavily
than other information? Would you make any recommendations about Mary doe’s suitability for
the hospice job? Be prepared to read your letter aloud to the class, and justify your rationale for
the content that you included.
LEARNING EXERCISE 19.12
Bringing a Group Together
You are the evening charge nurse of a medical unit. The staff on your unit has voiced displeasure
in how requests for days off are handled. Your manager has given you the task of forming a
committee and reviewing the present policy regarding requests for days off on the unit. On
your committee are four LVNs, three certified nursing assistants, and five rNs. all shifts are
represented. There are three men among the group members, and there is a fairly broad range
of ethnic and cultural groups.
Tomorrow will be your fourth meeting, and you are becoming a bit frustrated because the
meetings do not seem to be accomplishing much to reach the objectives that the group was
charged to meet. The objective was to develop a fair method to handle special requested days
off that were not part of the normal rotation.
On your first meeting, you spent time getting to know the members and identified the objective.
Various committee members contacted other hospitals, and others did a literature search to
determine how other institutions handled this matter. during the second meeting, this material
was reviewed by all members. at the last meeting, the group was very contentious. in fact,
several raised their voices. Others sat quietly, and some seemed to pout. Only the three men
could agree upon anything. One LVN thought that the rNs were overly represented. One rN
thought that the policy for day-off requests should be separated into three different policies—one
for each classification. You are not sure how to bring this committee together or what, if any,
action you should take.
Assignment: review the section in this chapter about how groups work. Write a one-page
essay on what is happening in the group, and answer the following questions. should you add
members to the committee? does your group have too many task members and not enough
team-building members? What should be your role in getting the group to perform its task?
What could be some strategies you could use that would perhaps bring the group together?
REFERENCES
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MD: Author.
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June 14, 2013, from http://www.answers.com/topic/
communication
Atlanta Black Star (2013, March 22). Effective
communication is neither too passive nor too
aggressive. Retrieved June 16, 2013, from http://
atlantablackstar.com/2013/03/22/effective
-communication-is-neither-too-passive-nor-too
-aggressive/

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Chapter 19 Organizational, Interpersonal, and Group Communication 465
Boynton, B. (2009, November–December). How to improve
your listening skills. American Nurse Today, 4(9),
50–51.
Centers for Medicare and Medicaid Services. (2010).
Medicare & Medicaid EHR incentive program.
Retrieved May 4, 2013, from https://www.cms
.gov/Regulations-and-Guidance/Legislation/
EHRIncentivePrograms/downloads/MU_Stage1
_ReqOverview
Cherry, K. (2013). Understanding body language. About.com
Psychology. Retrieved June 16, 2013, from http://
psychology.about.com/od/nonverbalcommunication/
ss/understanding-body-language_7.htm
Decker , B. (2013, May 30). Decline of eye contact – and
how you can correct it. Decker Communications.
Retrieved June 16, 2013 from http://decker.com/blog/
tag/eye-contact/
Ferguson, K. (2013, March 14). It’s time for the nursing
profession to leverage social media. Journal of
Advanced Nursing, 69 (4), 745–747. Retrieved
June 16, 2013, from http://onlinelibrary.wiley.com/
doi/10.1111/jan.12036/full
Forming, Storming, Norming, Performing: Four-Stage
Evolution of a Top Team. (2009, December). Clinical
Trials Administrator, 7(12), 140–141.
Garon, M. (2012). Speaking up, being heard:
Registered nurses’ perceptions of workplace
communication. Journal of Nursing Management,
20(3), 361–371.
Gobry, P-E. (2011, May 24). The internet is 20% of
economic growth. Business Insider. Retrieved June
13, 2013, from http://www.businessinsider.com/
mckinsey-report-internet-economy-2011-5
Haughom, J., Kriz, S., & McMillan, D. (2011). Overcoming
barriers to EHR adoption. Healthcare Financial
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Huston, C. J. (2013, May 31). The impact of emerging
technology on nursing care: Warp speed ahead.
The Online Journal of Issues in Nursing, 18(2),
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TableofContents/Vol-18-2013/No2-May-2013/
Impact-of-Emerging-Technology.html.aspx
Huston, C. J. (2014). Technology in the health care
workplace: Benefits, limitations, and challenges.
In Professional issues in nursing: Challenges and
opportunities (3rd ed.). Philadelphia, PA: Lippincott
Williams & Wilkins 214–227.
Ibe, P. (2013, May 19). Assertive communication for a
healthy workplace. 3 Plus International. Retrieved
June 16, 2013, from http://3plusinternational
.com/2013/05/assertive-communication/
ISBAR: Adding an Extra Step in Handoff Communication.
(2013). StrategiesforNurse Managers.com. Retrieved
June 16, 2013, from http://www
.strategiesfornursemanagers.com/ce_detail/222773.cfm
Jordan, K. W. (2009, February 17). SBAR: A communication
formula for patient safety. Boston.com. Retrieved
February 19, 2010, from http://www.boston.com/jobs/
healthcare/oncall/articles/2009/02/17/perspective/
Loo, T. (n.d.) How to communicate using space. Retrieved
June 13, 2013, from http://hodu.com/space.shtml
Mayo Clinic Staff (2011, June 11). Stress management.
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Miliard, M. (2012, April 24). Meaningful use still a
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.healthcareitnews.com/news/meaningful-use-still
-challenge-despite-strides-say-hospitals
National Council of State Boards of Nursing. (2011,
August). White Paper: A nurses’ guide to the use
of social media. Chicago, IL: Author. Retrieved
June 16, 2013 from http://www.nursingworld.org/
FunctionalMenuCategories/AboutANA/Social-Media/
Social-Networking-Principles-Toolkit/6-Tips-for
-Nurses-Using-Social-Media-Poster
Perkins, C., & Brizee, A. (2013, March 10). Audience
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.purdue.edu/owl/resource/590/1/
Piscotty, R., Voepel-Lewis, T, Lee, S.H., Annis-Emeott,
A., Lee, E, & Kalisch, B. (2013, May). To tweet or
not to tweet? Nurses, social media, and patient care.
Nursing Management, 44 (5), 52–53.
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.org/index.php/2012/10/05/take-5-with-a-nurse-leader/
Thomson, B. (2013). Are you an aggressive communicator?
Southeast Psych. Retrieved June 16, 2013, from
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-an-aggressive-communicator/
Tuckman, B. W., & Jensen, M. A. C. (1977). Stages of
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Urseny, L. (2007, January 26). Sticking to the agenda. Chico
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https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/MU_Stage1_ReqOverview

http://psychology.about.com/od/nonverbalcommunication/ss/understanding-body-language_7.htm

http://decker.com/blog/tag/eye-contact/

http://onlinelibrary.wiley.com/doi/10.1111/jan.12036/full

http://www.businessinsider.com/mckinsey-report-internet-economy-2011-5

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Emerging-Technology.html.aspx

http://3plusinternational.com/2013/05/assertive-communication/

http://www.strategiesfornursemanagers.com/ce_detail/222773.cfm

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466
20
Delegation
… Delegation is primarily about entrusting your authority to others.
—Raphael M. Barishansky
… at its most basic, delegation is empowering one person to act for another.
—Susanne A. Quallich
CROSSWALK thiS chApteR AddReSSeS:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: patient-centered care
QSEN Competency: teamwork and collaboration
QSEN Competency: Safety
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency II: A knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: professionalism
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l identify specific strategies that increase the likelihood of effective delegation
l recognize delegation as a learned skill imperative to professional nursing practice
l delegate tasks using appropriate priority setting and use of personnel in vicarious situations
l differentiate between tasks that should and should not be delegated
l identify common causes of underdelegation, overdelegation, and improper delegation as well
as strategies to overcome these delegation errors
l recognize the need to give adequate information and authority to complete delegated tasks
l identify factors that must be considered when determining what tasks can be safely
delegated to subordinates
l discuss how the role of the registered nurse as delegator has changed with the increased
use of nursing assistive personnel and unlicensed assistive personnel
l determine whether delegation to an unlicensed worker is appropriate in a given situation,
using a decision tree developed by the National council of State Boards of Nursing
(NcSBN) or a State Board of Nursing
l identify leadership strategies that can be used to reduce subordinate resistance to delegation

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Chapter 20 Delegation 467
l describe cultural phenomena that must be considered when delegating to a multicultural
staff or in encouraging multicultural staff to delegate
l describe actions the manager can take to reduce the liability of supervision, particularly when
delegating tasks
Delegation has long been a function of registered nursing, although the scope of delegation
and the tasks being delegated have changed dramatically the past two decades. Delegation
can be defined simply as getting work done through others or as directing the performance of
one or more people to accomplish organizational goals. Huston (2009) defines delegation as
giving someone else the authority to complete a task or action on your behalf. Similarly, the
North Carolina Nursing Administrative Code defines delegation as a “transfer or hand-off to
a competent individual, the authority to perform a task/activity in a specific setting/situation”
(Winstead, 2013, p. 9).
Even more complex definitions of delegation, supervision, and assignment have been
created by the American Nurses Association (ANA) and the National Council of State Boards
of Nursing (NCSBN) in response to the emerging complexity of delegation in today’s health-
care arena, where increasing numbers of unlicensed and relatively untrained workers provide
direct patient care. Historically, the ANA and the NCSBN defined delegation differently,
with the ANA defining delegation as the transfer of responsibility for the performance of
a task from one person to another and the NCSBN defining delegation as transferring to a
competent individual the authority to perform a selected nursing task in a selected situation
(Huston, 2014).
Both groups have come together, however, to issue a Joint Statement on Delegation,
intended to support nurses in using delegation safely and effectively (Does Your Staff
Understand Delegation, 2009). In addition, both suggest that delegation is a skill that must be
taught and practiced for proficiency.
Experts also agree that delegation is an essential element of the directing phase of the
management process because much of the work accomplished by managers (first-, middle-,
and top-level managers) occurs not only through their own efforts but also through those of
their subordinates. Frequently, there is too much work to be accomplished by one person.
In these situations, delegation often becomes synonymous with productivity and is not an
option—but a necessity. Tredgold (2013, para 6) agrees, noting that “often people want to be
great leaders, but don’t want to delegate, even refuse to delegate, but this is a self defeating
trait. We end up becoming occupied doing stuff, rather than getting as much stuff done as is
possible.”
There are many good reasons for delegating. Sometimes, managers must delegate
routine tasks so they are free to handle problems that are more complex or require a higher
level of expertise. Managers may delegate work if someone else is better prepared or has
greater expertise or knowledge about how to solve a problem. Delegation can also be used
to provide learning or “stretching” opportunities for subordinates. Subordinates who are
not delegated enough responsibility may become bored, nonproductive, and ineffective.
Thus, in delegating, the leader-manager contributes to employees’ personal and professional
development.
The mark of a great leader is when he or she can recognize the excellent performance of
someone else and allow others to shine for their accomplishments.
The leadership roles and management functions inherent in delegation are shown in
Display 20.1.
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468 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
DISPLAY 20.1 Leadership Roles and Management Functions Associated with Delegation
LEADERSHIP ROLES
1. Functions as a role model, supporter, and resource person in delegating tasks to subordinates.
2. encourages followers to use delegation as a time management strategy and team-building tool.
3. Assists followers in identifying situations appropriate for delegation.
4. communicates clearly when delegating tasks.
5. Maintains patient safety as a minimum criterion in determining the most appropriate person to
carry out a delegated task.
6. plans ahead and delegates proactively, rather than waiting until time urgency is present and
crisis responses are required.
7. conveys a feeling of confidence and encouragement to the individual who has taken on a
delegated task.
8. is an informed and active participant in the development of local, state, and national guidelines
for unlicensed assistive personnel (UAp)/nursing assistive personnel (NAp) scope of practice.
9. is sensitive to how cultural phenomena affect transcultural delegation.
10. Uses delegation as a means for stretching and empowering workers to learn new skills and be
successful.
11. Works to establish a culture of mutual trust, teamwork, and open communication so that
delegation becomes a strategy health-care workers feel comfortable using to achieve organiza-
tional, patient, and personal goals.
MANAGEMENT FUNCTIONS
1. creates job descriptions and scope of practice statements for all personnel, including NAp, that
conform to national, state, and professional recommendations for ensuring safe patient care.
2. is knowledgeable regarding legal liabilities of subordinate supervision.
3. Accurately assesses subordinates’ capabilities and motivation when delegating.
4. delegates a level of authority necessary to complete delegated tasks.
5. Shares accountability for delegated tasks.
6. consciously attempts to see the subordinate’s perspective to reduce the likelihood of resis-
tance in delegation.
7. develops and implements a periodic review process for all delegated tasks.
8. Avoids overburdening subordinates by giving them permission to refuse delegated tasks.
9. provides recognition or reward for the completion of delegated tasks.
10. provides formal education and training opportunities on delegation principles for staff.
DELEGATING EFFECTIVELY
Delegation is not easy. It requires you to trust somebody else to perform a task that you
believe to be important. It also takes effort: you have to explain how you do a particular task,
train somebody else to do it, and then monitor that person. Yet, it is also absolutely critical to
managerial productivity and efficiency. The following strategies will increase the likelihood of
successful and effective delegation (Display 20.2). Each of these strategies is detailed below.
DISPLAY 20.2 Strategies for Successful Delegation
plan ahead.
identify necessary skill and education levels to complete the delegated task.
Select capable personnel.
communicate goals clearly.
empower the delegate.
Set deadlines and monitor progress.
Monitor the role and provide guidance.
evaluate performance.
Reward accomplishment.

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Chapter 20 Delegation 469
Plan Ahead
Plan ahead when identifying tasks to be accomplished. Always make an attempt to delegate
before you become overwhelmed. In addition, always be sure to carefully assess the situation
before delegating and to clearly delineate the desired outcomes.
Identify Necessary Skills and Education Levels
Identify the skill or educational level necessary to complete the job. Often, legal and licensing
statutes such as the Nurse Practice Act (NPA) determine this. Anderson (2013) notes that
professional nurses work with a variety of different types of caregivers but the scope of
practice for the RN is typically defined by the Board of Nursing in each state. The challenge
is that the RN must also understand the scope of practice of others on the nursing team who
are providing patient care.
Nurses then must be aware of their state NPA essential elements regarding delegation,
including the following:
• The state’s NPA definition of delegation
• Items that cannot be delegated
• Items that cannot be routinely delegated
• Guidelines for RNs about tasks that can be delegated
• A description of professional nursing practice
• A description of licensed vocational nurse (LVN)/licensed professional nurse (LPN)
nursing practice and unlicensed nursing roles
• The degree of supervision required to complete a task
• The guidelines for lowering delegation risks
• Warnings about inappropriate delegation
• If there is a restricted use of the word “nurse” to licensed staff
In addition, the manager should know the official job description expectations for each
worker classification in the organization, as they may be more restrictive than the state
NPA.
Select Capable Personnel
Identify which individuals can complete the job in terms of capability and time to do so.
Remember that it is a leadership role to stretch new and capable employees who want
opportunities to learn and grow. Also, look for employees who are innovative and willing to
take risks. It is also important that the person to whom the task is being delegated considers
the task to be important.
This does not suggest, however, that skill and expertise are not needed. Leader-
managers should always ask the individuals to whom they are delegating if they
are capable of completing the delegated task and validate this perception by direct
observation.
Communicate Goals Clearly
The goals for delegation should always be clearly communicated. This includes
identifying any limitations or qualifications that are being imposed on the delegated task.
Knox (2013) notes that the delegator must communicate specifically what, how, and by
when delegated tasks are to be accomplished. This communication should also include
the purpose and goal of the task, any limitations for task completion, and the expectations
for reporting.
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470 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Empower the Delegate
Delegate the authority and the responsibility necessary to complete the task. Nothing is more
frustrating to a creative and productive employee than not having the resources or authority
to carry out a well-developed plan.
Set Deadlines and Monitor Progress
Set time lines, and monitor how the task is being accomplished through informal but regularly
scheduled meetings. This shows an interest on the part of the nurse-leader, provides for a
periodic review of progress, and encourages ongoing communication to clarify any questions
or misconceptions. Knox (2013) agrees, suggesting that the RN must monitor and evaluate
both the patient and the staff’s performance of delegated tasks and be prepared to intervene on
behalf of the patient as necessary. In doing so, the leader-manager provides staff feedback to
increase competency in task performance. In addition, this keeps the delegated task before the
subordinate and the manager so that both share accountability for its completion. Although the
final responsibility belongs to the delegator, the subordinate doing the task accepts responsibility
for completing it appropriately and is accountable to the person who delegated the task.
Responsibility is shared when a task is delegated.
Model the Role and Provide Guidance
The leader-manager should convey a feeling of confidence and encouragement to the
individual who has taken on a delegated task. If the worker is having difficulty carrying out
the delegated task, the leader-manager should be available as a role model and resource in
identifying alternative solutions. Leaders should encourage employees, however, to attempt
to solve problems themselves first, although they should always be willing to answer
questions about the task or to clarify desired outcomes as necessary.
Finding a balance between providing guidance and allowing others to best determine
how to accomplish a delegated task, however, is sometimes difficult. Although the desired
end product should be specified, it is important to give the subordinate feedback and an
appropriate degree of autonomy in deciding exactly how the work can be accomplished.
Reassuming the delegated task should be a manager’s last resort, because this action
fosters a sense of failure in the employee and demotivates rather than motivates. Delegation is
useless if the manager is unwilling to allow divergence in problem solving and thus re-does all
work that has been delegated. However, the manager may need to delegate work previously
assigned to an employee so that the employee has time to do the newly assigned task.
Evaluate Performance
Evaluate the delegation experience after the task has been completed. Include positive and
negative aspects of how the person completed the task. Were the outcomes achieved? Ask
the individual you delegated to, what you could have done differently to facilitate their
completion of the delegated tasks. This shared reflection encourages the development of a
mutually trusting and productive relationship between delegators and subordinates.
Reward Accomplishment
Be sure to appropriately reward a successfully completed task. Leaders are often measured by
the successes of those on their teams. Therefore, the more recognition team members receive,
the more recognition will be given to their leader.
The right to delegate and the ability to provide formal rewards for successful completion of
delegated tasks are a reflection of the legitimate authority inherent in the management role.

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Chapter 20 Delegation 471
Delegation is a high-level skill essential to the manager that improves with practice. As
managers gain the maturity and self-confidence needed to delegate wisely, they increase their
impact and power both within and outside the organization. Subordinates gain self-esteem
and increased job satisfaction from the responsibility and authority given to them, and the
organization moves a step closer toward achieving its goals.
COMMON DELEGATION ERRORS
Delegation is not intuitive for most people; instead, it is a critical leadership skill that must
be learned. Frequent mistakes made by managers in delegating include underdelegating,
overdelegating, and improper delegating (Display 20.3).
LEARNING EXERCISE 20.1
Difficulty in Delegation
is it difficult for you to delegate to others? if so, do you know why? Are you more apt to
underdelegate, overdelegate, or delegate improperly? think back to the last thing you
delegated. Was this delegation successful? What safeguards can you build in to decrease this
delegation error?
DISPLAY 20.3 Common Delegating Errors
Underdelegating
Overdelegating
improper delegating
Underdelegating
Underdelegating frequently stems from the individual’s false assumption that delegation
may be interpreted as a lack of ability on his or her part to do the job correctly or completely.
Delegation does not need to limit the individual’s control, prestige, and power; rather,
delegation can extend their influence and capability by increasing what can be accomplished.
In fact, delegation can be empowering, both to the person delegating and to the person being
delegated to.
Another cause of underdelegating is the individual’s desire to complete the whole job
personally due to a lack of trust in the subordinates; some nurses believe that he or she needs
the experience or that he or she can do it better and faster than anyone else, and indeed—
sometimes, this is the case. Case (2013) agrees, noting that many RNs find it difficult to
transfer authority. This is especially the case for individuals who are new to delegation since
they often feel as though they must give up control (Delegating, n.d.). It may be frightening
to allow a team member to complete a task for which you are ultimately responsible.
Communicating frequently with those to whom you’ve delegated to check the progress of
the task can help decrease this fear and should give the delegator some sense of control
(Delegating, n.d).
It may be unnerving to allow a team member to complete a task for which you are ultimately
responsible.
Other individuals underdelegate because there is not enough time to delegate It takes time to
delegate because the delegator must adequately explain the task or teach their team member
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472 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
the skills necessary to complete the delegated task. The problem is paradoxical because one of
the main benefits of delegation is saving time (Delegating, n.d.). Case (2013) states, however,
that delegators should always remember that time spent in training another to do a job can be
repaid 10-fold in the future. In addition to increased productivity, delegation can also provide
the opportunity for subordinates to experience feelings of accomplishment and enrichment.
Nurses also may underdelegate because they lack experience in the job or in delegation
itself. Other nurses refuse to delegate because they have an excessive need to control or be
perfect. The leader-manager who accepts nothing less than perfection limits the opportunities
available for subordinate growth and often wastes time redoing delegated tasks.
In addition, some individuals underdelegate because they fail to anticipate the help they
will need. In an ideal situation, the best time to delegate is before you become overwhelmed
(Huston, 2009). While crises happen that require you to reorganize your priorities, more often
than not you can foresee hectic or challenging times. For example, waiting until the end of
your shift to delegate the tasks you didn’t have time to finish is unfair to the person you’re
delegating to, and that individual is likely to resent your request (Huston).
Finally, some novice managers emerging from the clinical nurse role underdelegate because
they find it difficult to assume the manager role. This occurs, in part, because the nurses have
been rewarded in the past for their clinical expertise and not their management skills. As
managers come to understand and accept the need for the hierarchical responsibilities of
delegation, they become more productive and develop more positive staff relationships.
Overdelegating
In contrast to underdelegating, which overburdens the manager, some managers overdelegate,
burdening their subordinates. Some managers overdelegate because they are poor managers
of time, spending most of it just trying to get organized. Others overdelegate because they
feel insecure in their ability to perform a task.
It is critical that the manager is sensitive to the workload constraints of his or her staff.
Staff should always have the right to refuse a delegated task. The servant leader always asks
the person they want to delegate to, if they have time to help, instead of just assuming that
their needs are greater than those of the staff member. Managers also must be careful not to
overdelegate to exceptionally competent employees, because they may become overworked
and tired, which can decrease their productivity.
Improper Delegating
Improper delegation includes such things as delegating at the wrong time, to the wrong
person, or for the wrong reason. It also may include delegating tasks and responsibilities that
are beyond the capability of the person to whom they are being delegated or that should be
done by someone with greater expertise, training, or authority.
Knox (2013) emphasizes that one of the most important aspects of delegation is determining
if a task should be delegated. To do this, she suggests the nurse make an assessment of the patient
or a group of patients and determine what activities can be delegated to a specific member of
the health-care team. In addition, Knox notes that the decision to delegate a task must match
the staff’s competency and level of supervision available. Finally, Knox notes that appropriate
delegation must include a consideration of who is the most appropriate person is to delegate to.
Delegating decision making without providing adequate information is another example
of improper delegation. If the manager requires a higher quality than satisficing, this must be
made clear at the time of the delegation. Not everything that is delegated needs to be handled
in a maximizing mode. Almost all of these delegation errors could be avoided if the five rights
of delegation, identified by the American Nurses Association (ANA) and the National Council
of State Boards of Nursing (NCSBN) (n.d.), were followed. These are shown in Display 20.4.

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Chapter 20 Delegation 473
l Right task
One that is delegable for a specific patient
l Right circumstances
Appropriate patient setting, available resources, and other relevant factors considered
l Right person
Right person is delegating the right task to the right person to be performed on the right person.
l Right direction/communication
clear, concise description of the task, including its objective, limits, and expectations
l Right level of supervision
Appropriate monitoring, evaluation, intervention, as needed, and feedback
Source: American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) (n.d.).
Joint statement on delegation. Retrieved June 17, 2013, from https://www.ncsbn.org/Delegation_joint_statement
_ NCSBN-ANA
DISPLAY 20.4 The Five Rights of Delegation
DELEGATION AS A FUNCTION OF PROFESSIONAL NURSING
With the restructuring of care delivery models, RNs at all levels are increasingly being
expected to make assignments for and supervise the work of different levels of employees. To
increase the likelihood that the increased delegation required in today’s restructured health-
care organizations does not result in an unsafe work environment, organizations should take
appropriate action. Huston (2014) suggests that (a) organizations must have a clearly defined
structure where RNs are recognized as leaders of the health-care team, (b) job descriptions
clearly define the roles and responsibilities of all, (c) educational programs are developed
to help personnel learn roles and responsibilities of each other’s roles, and (d) adequate
programs are developed to foster leadership and delegation.
RNs asked to assume the role of supervisor and delegator need preparation to assume these
leadership tasks, including instruction in personnel supervision and delegation principles.
Repeated education programs on delegation principles and role clarity are necessary to
demonstrate consistency in delegating appropriate role activities and to begin to feel
confident in delegating because in many cases, nurses who are well prepared to provide care
for patients may not be well prepared to be a delegator.
The RN, although well trained in the role of direct care provider, may not be adequately prepared
for the role of delegator.
In addition, nursing schools and health-care organizations need to do a better job of
preparing professional RNs for the delegator role. This includes educating them about the
NPA governing the scope of practice in their state; basic principles of delegating to the right
person, at the right time, and for the right reason; and actions that must be undertaken when
work is delegated in an inappropriate or unsafe manner. Knox (2013, para 5) states that
“knowledge of state practice acts and agency directives are essential when making decisions
about what patient care tasks can be delegated.”
Finally, health-care organizations need to assure that new nurses are supported in their
early efforts to delegate and that these skills are not learned by trial and error. Instead, leaders
must create workplace cultures where teamwork, mutual respect, and open communication
are valued, and where nurses believe they can delegate without fearing they will be perceived
as lazy or incompetent (Examining the Evidence 20.1).
Nurses must believe they can delegate without fearing they will be perceived as lazy or
incompetent.
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474 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Delegating to Unlicensed Assistive Personnel
In an effort to contain spiraling health-care costs, many health-care providers in the 1990s
chose to eliminate RN positions or to replace licensed professional nurses with UAP or
NAP. (In 2007, the ANA stopped using the term UAP and replaced it with NAP, suggesting
that many NAPs are now licensed or formally recognized in some manner.) Both UAP and
NAP include but are not limited to nurse extenders, care partners, nurse’s aides, orderlies,
assistants, attendants, health care assistants, and technicians (Huston, 2014).
Almost all RNs in acute care institutions and long-term care facilities are currently
involved in some capacity with the assignment, delegation, and supervision of the NAP in
the delivery of nursing care. The primary argument for utilizing NAP in acute care settings is
cost (although nursing shortages are a contributing factor). NAP can free professional nurses
from tasks and assignments (specifically, non-nursing functions) that can be completed by
less extensively trained personnel at a lower cost.
LEARNING EXERCISE 20.2
Assessing Nurses’ Comfort with Delegation
informally survey nurses in the agency in which you work or do clinical practicums. how many
of them have received formal education on delegation principles? how comfortable do these
nurses feel in determining what should be delegated to whom? how comfortable do you feel in
delegating work to other members of the health-care team?
Source: Kærnested, B., & Bragadóttir, H. (2012). Delegation of registered nurses revisited: Attitudes towards dele-
gation and preparedness to delegate effectively. Nordic Journal of Nursing Research & clinical Studies/Vård i Norden,
32(1), 10–15.
The descriptive, correlational study surveyed 71 RNs working in five medical acute care inpatient
units at a university hospital in Iceland to determine the attitudes of these nurses toward dele-
gation and their preparedness to delegate effectively. In addition, the study sought to determine
whether attitude and preparedness to delegate were related to age, experience, education in
delegation, workload, and job satisfaction.
Overall, participants showed a relatively positive attitude toward delegation, although there
was potential for improvement. The majority of participants reported they do delegate, but noted
that they still spent a large amount of time on tasks that could be done by others. One out of
four participants agreed wholly or moderately that staff lacked the necessary commitment and
experience to complete delegated tasks in a satisfactory manner and that it was easier for them
to just do it themselves. In addition, just over 45% of participants suggested they were always,
often, or sometimes worried that staff would regard them as lazy for delegating tasks. This was
especially true for younger nurses (<30 years old). While novice nurses stated they understood basic delegation principles, they also felt they lacked the skills to delegate effectively and they suggested that much of what they knew about delegation had been learned through trial and error on the job. Participants with less than 5 years of experience believed they would delegate more if they were more confident about delegating. The researchers concluded that the results signified to some extent, a lack of trust, teamwork, and communication in nursing delegation. They noted that effective delegation by registered nurses (RNs) needs constant attention within educational programs as well as in health-care settings, regardless of the time and economic situation within which health care is practiced. The researchers suggest this will not occur solely by educating RNs about who and what can be dele- gated; instead, it must be done by teaching, practicing, and nurturing mutual trust and effective communication within nursing teams. Examining the Evidence 20.1 free ebooks ==> www.ebook777.com
Chapter 20 Delegation 475
Assuming the role of delegator and supervisor to NAP, however, increases the scope
of liability for the RN. Although nurses are not automatically held liable for all acts of
negligence on the part of those they supervise, they may be held liable if they were negligent
in the supervision of those employees at the time they committed the negligent acts. Liability
is based on a supervisor’s failure to determine which patient needs could safely be assigned
to a subordinate or for failing to closely monitor a subordinate who requires such supervision.
In delegating, the RN needs to know well the skills of the person to whom work is delegated.
The liability of supervision is discussed in Chapter 5.
In assigning tasks to NAP, the RN must be aware of the job description, knowledge base, and
demonstrated skills of each person.
In addition, RNs should recognize that although the Omnibus Budget Reconciliation Act of
1987 established regulations for the education and certification of nurse’s aides (minimum of
75 hours of theory and practice and successful completion of an examination in both areas),
no federal or community standards have been established for training the more broadly
defined NAP (Huston, 2014). Some standards and guidelines are now required for the
preparation and use of NAP in certified home health agencies and skilled nursing facilities,
but there are no required education standards or guidelines for the use of NAP in acute care
hospitals that cross state lines and jurisdictions.
The UAP has no license to lose for “exceeding scope of practice” and nationally established
standards for scope of practice do not exist for UAP.
This does not imply that all NAPs are uneducated and unprepared for the roles they have been
asked to fill. Indeed, NAP educational levels vary from less than a high school graduate to
those holding advanced degrees. It merely suggests that the RN, in delegating to NAP, must
carefully assess what skills and knowledge that each NAP has or risk-increased personal
liability for the failure to do so (Huston, 2014).
Unfortunately, many institutions do not have distinct job descriptions for NAP that clearly
define their scope of practice. While some institutions limit the scope of practice for NAP to
non-nursing functions, other organizations allow NAP to perform many skills traditionally
reserved for the licensed nurse. Some NAPs have little background in health care and only
rudimentary training. Yet they may be allowed to insert catheters, read electrocardiograms,
suction tracheostomy tubes, change sterile dressings, and perform other traditional nursing
functions (Huston, 2014). This is because some agencies interpret regulations broadly,
allowing NAP a broader scope of practice than that advocated by professional nursing
associations or State Boards of Nursing. Few states use the ANA or NCSBN definitions
for delegation, supervision, or assignment. Most states, however, reported no standardized
curriculum in place for NAP employed in acute care hospitals (Huston, 2014).
Some State Boards of Nursing, in an effort to more clearly define the scope of practice
for NAP, have issued task lists. Training of the NAP is not based on the notion that such
individuals will be performing activities independently. Task lists, however, suggest no need
for delegation, as NAP already have a list of nursing activities that he or she may perform
without waiting for the delegation process. But what happens when the condition of a client
changes? Are NAP with fewer than 75 hours of training astute enough to recognize that there
has been a change in the client’s condition and alert the RN?
In addition, in the late 1990s, the NCSBN established a decision tree for delegation, which
includes a step-by-step analysis nurses can use to decide whether a task should be delegated.
Many State Boards of Nursing have also adopted decision trees that are posted on their Web
sites. See Figure 20.1 for an example of the decision tree created by the Kentucky Board of
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476 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Is the task within the scope
of practice for a licensed
nurse?
Cannot delegate to UAP.
RN to complete assessment,
then proceed with
consideration of delegation.
Do not delegate.
Do not delegate.
The UAP is responsible for accepting only those
delegated acts for which they are competent to perform.
Only the implementation of a task/activity may be
delegated. Assessment, planning, evaluation, and
nursing judgment cannot be delegated.
Yes
The nurse shall provide supervision of a delegated nursing task. The
degree of supervision required determined by the delegator after an
evaluation including the following:
• The stability and acuity of the client’s condition
• The training and competency of the delegatee
• The complexity of the nursing task being delegated
Proceed with delegation.
Approved: 2009
Revised: 2/2010
Is the task consistent with the criteria for delegation to UAP? Must
meet all the following criteria:
• A task that a reasonable and prudent nurse would find is
within the scope of sound nursing judgment and practice to
delegate.
• A task that, in the opinion of the delegating nurse, can be
competently and safely performed by the delegatee without
compromising the client’s welfare.
• A task shall not require the delegatee to exercise
independent nursing judgment or intervention.
• The delegator shall be responsible for assuring that the
delegated task is performed in a competent manner by the
delegatee.
RN assessment of client’s nursing care
needs complete?
Is the RN/LPN competent to make delegation
decision? Nurse is accountable for the
decision to delegate, to assure the delegated
task is appropriate, and to adhere to the
criteria for delegation.
No
No
No
No
Yes
Yes
Yes
Yes
Do not delegate.No
FIGURE 20.1 • KBN decision tree for delegation to unlicensed assistive personnel (UAp).
Source: Kentucky Board of Nursing. (2010). decision tree for delegation to unlicensed assistive personnel
(UAp). Retrieved June 17, 2013, from http://kbn.ky.gov/NR/rdonlyres/E1591ED0-5C3E-425C-ACE6
-396268CE1774/0/DecisionTreeforDelegationtoUAP (Reprinted with permission of the Kentucky
Board of Nursing).

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Chapter 20 Delegation 477
Registered Nursing (2010) to guide nurses in delegating to unlicensed workers. In addition,
Display 20.5 suggests criteria developed by the North Carolina Board of Registered Nursing
(2013) that may be helpful in determining what tasks can safely be delegated to UAP.
New decision trees created by the NCSBN and State Boards of Nursing guide RNs in
determining what can safely be delegated to unlicensed workers.
DISPLAY 20.5 Criteria for Delegation to an Unlicensed Assistive Personnel
The North Carolina Board of Registered Nursing (2013) suggests that tasks should be delegated
to UAP only if they meet ALL of the following criteria:
1. Frequently recur in the daily care of a client or group of clients
2. Are performed according to an established (standardized) sequence of steps
3. involve little or no modification from one client-care situation to another
4. May be performed with a predictable outcome
5. do not inherently involve ongoing assessment, interpretation, or decision making which cannot
be logically separated from the procedure(s) itself
6. do not endanger the health or well-being of clients
7. Are allowed by agency policy/procedures
Source: North Carolina Board of Nursing (2013). delegation: Non-nursing functions. position Statement for
RN and LpN practice. Retrieved June 18, 2013, from http://allnurses.com/north-carolina-nursing/north-carolina
-board-465130.html
It is critical that the RN never loses sight of his or her ultimate responsibility for ensuring
that patients receive appropriate, high-quality care. This means that while NAP may complete
non-nursing functions such as bathing, vital signs, and the measurement and recording of intake
and output, it is the RN who must analyze that information and then use the nursing process
to see that desired patient outcomes are achieved. This is consistent with delegation principles
suggested by the ANA, which note that while RNs may delegate tasks and elements of care,
they cannot delegate the nursing process (Is It OK to Delegate? 2012). Only RNs have the
formal authority to practice nursing, and activities that rely on the nursing process or require
specialized skill, expert knowledge, or professional judgment should never be delegated.
Case (2013, para 11) agrees, noting that “while nursing tasks may be delegated, the
licensed nurse’s generalist knowledge of patient care indicates that the practice-pervasive
functions of assessment, evaluation and nursing judgment must not be delegated.” This
includes such skills as the initial and ongoing assessment of patients, administering treatments
and medications ordered by a licensed prescriber, initiating and coordinating the plan of
care, teaching and counseling patients, promoting and maintaining health, and teaching and
supervising students (Case).
It is the RN who bears the legal liability for allowing UAP to perform tasks that should be
accomplished only by a licensed health-care professional.
The outcomes associated with the increased use of NAP are not yet known. An increasing
number of studies suggest a direct link between decreased RN staffing and declines in patient
outcomes. Some of these declines in patient outcomes noted in the literature include an increased
incidence of patient falls, nosocomial infections, and medication errors (Huston, 2014).
Certainly, at some point, given the increasing complexity of health care and the increasing
acuity of patient illnesses, there is a maximum representation of NAP in the staffing mix that
should not be breached. Until those levels are determined, RNs can expect a continued increase
in the utilization of NAP. To protect their patients and their professional license, RNs must
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478 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
continue to seek current information regarding national efforts to standardize the scope of
practice for NAP and professional guidelines regarding what can be safely delegated to the NAP.
Subordinate Resistance to Delegation
Resistance is a common response by subordinates to delegation. One of the most common
causes of subordinate resistance to, or refusal of, delegated tasks is the failure of the
delegator to see the subordinate’s perspective. Workloads assigned to NAP are generally
highly challenging, both physically and mentally. In addition, NAPs frequently must adapt
rapidly to changing priorities, often imposed on him or her by more than one delegator. If
the subordinate is truly overwhelmed, additional delegation of tasks is inappropriate, and the
RN should reexamine the necessity of completing the delegated task personally or finding
someone else who is able to complete the task.
The leader-manager should always attempt to see the delegated task from the perspective of
the individual being delegated to.
Some subordinates resist delegation simply because they believe that they are incapable
of completing the delegated task. If the employee is capable but lacks self-confidence, the
astute leader may be able to use performance coaching to empower the subordinate and
build self-confidence levels. If, however, the employee is truly at high risk for failure, the
appropriateness of the delegation must be questioned and a task more appropriate to that
employee’s ability level should be delegated.
Another cause of subordinate resistance to delegation is an inherent resistance to authority.
Some subordinates simply need to “test the water” and determine what the consequences are
of not completing delegated tasks. In this case, the delegator must be calm but assertive about
his or her expectations and provide explicit work guidelines, if necessary, to maintain an
appropriate authority power gap. It is an ongoing leadership challenge to instill a team spirit
between delegators and their subordinates.
Finally, resistance to delegation may be occurring because tasks are overdelegated in
terms of specificity. All subordinates need to believe that there is some room for creativity
and independent thinking in delegated tasks. Failure to allow for this human need results in
disinterested subordinates who fail to internalize responsibility and accountability for the
delegated task. When delegating to NAP, the RN should try to mix routine and boring tasks with
more challenging and rewarding assignments. An additional strategy is to provide NAP with
consistent, constructive feedback, both positive and negative, to foster growth and self-esteem.
When subordinates resist delegation, the delegator may be tempted to avoid confrontation
and simply do the delegated task independently. This is seldom appropriate. Instead, the
delegator must ascertain why the delegated task was not accomplished and take appropriate
action to eliminate these restraining forces.
LEARNING EXERCISE 20.3
Dealing with Resistance to Delegation
You are the team leader for 10 patients. An experienced LVN/LpN and nurse’s aide are also
assigned to the team. it is an extremely busy day, and there is a great deal of work to be done.
Several times today, you have found the LVN/LpN taking long breaks in the lounge or chatting
socially at the front desk, despite the unmet needs of many patients. On those occasions, you
have clearly delegated work tasks and time lines to her. Several hours later, you follow up on
the delegated tasks and find that they were not completed. When you seek out the LVN/LpN,

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Chapter 20 Delegation 479
DELEGATING TO A TRANSCULTURAL WORK TEAM
The increasing diversity of both the workforce and the client populations being served has
ramifications for delegation. Challenges in delegation are seen for both the culturally diverse
delegatee and the delegator. For example, numerous studies have shown that nurses from an
Asian background may require more time to develop delegation skills since assertiveness
and asking for help from others may violate values that are culturally bound (NMC Says
Asian Nurses, 2012). Wong (2012) agrees, noting that assertiveness is more highly valued
in American culture than many other cultures and that this can be a challenge to nurses from
other cultural backgrounds who are expected to delegate work.
According to Giger and Davidhizar (2008), there are six cultural phenomena that must be
considered when working with staff from a culturally diverse background: communication,
space, social organization, time, environmental control, and biologic variations.
Communication, the first of the cultural phenomena, is greatly affected by cultural
diversity in the workforce because dialect, volume, use of touch, context of speech, and
kinesics such as gestures, stance, and eye movement all influence how messages are sent
and received. For example, delegation delivered in a softer tone may be perceived as less
important than delegation received in a loud tone, even if the delegated tasks have equal
importance. Similarly, a manager may make an inappropriate assumption about a person’s
inability to carry out an important delegated task if that person represents a culture that values
softer speech and more passive behavior.
Space is the second cultural phenomenon influencing delegation. Space refers to the
distance and intimacy techniques that are used when relating verbally or nonverbally to
others. It is important that the delegator recognizes the personal space needs of each staff
member and acts accordingly. If these space needs are not recognized and respected, the
likelihood that a delegated task will be heard and followed through on appropriately will be
reduced.
The third cultural phenomenon, social organization, refers to the importance of a group
or unit in providing social support in a person’s life. For many cultures, the family unit is
the most important social organization. In some cultures, the duty to family always takes
precedence over the needs of the organization. In other cultures, this values ranking is less
clear, and the employee may experience great intrapersonal conflict in prioritizing delegated
work tasks and obligations to the family unit. It is important, then, that the delegator is aware
that employees’ values differ and is sensitive in delegating critical tasks to employees who
are experiencing stress in the family unit.
Time is the fourth cultural phenomenon affecting delegation. Cultural groups can be past,
present, or future oriented. Past-oriented cultures are interested in preserving the past and
maintaining tradition. Present-oriented cultures focus on maintaining the status quo and on
daily operations. Future-oriented cultures focus on goals to be achieved and are more visionary
in their approach to problems. For example, strategic planning might best be delegated to a
person from a future-oriented culture, although the leader-manager should always be alert for
opportunities to create new insight and stretching opportunities for subordinates.
you find that she went to lunch without telling you or the aide. You are furious at her apparent
disregard for your authority.
Assignment: What are possible causes of the LVN/LpN’s failure to follow up on delegated
tasks? how will you deal with this LVN/LpN? What goal serves as the basis for your actions?
Justify your choice with rationale.
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480 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Environmental control, the fifth cultural phenomenon, refers to the person’s perception
of control over his or her environment (internal locus of control). Some cultures believe
more strongly in fate, luck, or chance than other cultures, and this may affect how a person
approaches and carries out a delegated task. The person who believes that he or she has an
internal locus of control is more likely to be creative and autonomous in decision making.
The final phenomenon, biological variations, refers to the biopsychosocial differences
between racial and ethnic groups, such as susceptibility to disease and physiologic differences.
Display 20.6 provides a summary of considerations when delegating to a transcultural work team.
DISPLAY 20.6 Cultural Phenomena to Consider When Delegating to a Transcultural Team
communication: especially dialect, volume, use of touch, and eye contact
Space: interpersonal space differs between cultures
Social organization: Family unit of primary importance in some cultures
time: cultures tend to be past, present, or future oriented
environmental control: cultures often have either internal or external locus of control
Biological variations: Susceptibility to diseases (e.g., tay-Sachs) and physiologic differences (e.g.,
height and skin color)
LEARNING EXERCISE 20.4
Cultural Considerations in Delegation
You are a new charge nurse working on a surgical unit and have one of the recently hired Filipino
travel nurses working on your unit. this is the end of her second week of orientation on the unit.
She also received a month of classroom orientation and enculturation when she was first hired.
today, you assign her as one of your team leaders, responsible for a team of LVN/LpNs and
certified nursing assistants. She has been working with another team leader for more than a
week, but this is her first day to have the team to herself.
You check with her several times during the morning to see how things are going. She speaks
shyly without making eye contact and says that “everything is okay.” At about noon, one of the
LVN/LpNs comes to you and says that the new nurse has not delegated tasks appropriately
and is trying to do too much of the work herself. in addition, some of the other members of the
team find her unsmiling behavior and lack of eye contact unsettling.
Assignment: do you feel that you made an appropriate assignment? Since things do not seem
to be going well, what should you do now? in a small group, develop a plan of action with the
following goals: (a) ensure that patient care is accomplished safely, (b) build self-esteem in the
Filipino nurse, and (c) be a cultural bridge to staff.
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
IN DELEGATION
The right to delegate and the ability to provide formal rewards for successful completion of
delegated tasks reflect the legitimate authority inherent in the management role. Delegation
provides a means of increasing unit productivity. It is also a managerial tool for subordinate
accomplishment and enrichment.
Delegation, however, is not easy. It requires high-level management skills since effective
delegation involves selecting the right person for the right reason, and at the right time and
assessing the qualifications, availability, and experience of individuals being delegated to

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Chapter 20 Delegation 481
(Huston, 2009). Novice managers often make delegation errors such as delegating too late,
not delegating enough, delegating to the wrong person or for the wrong reason, and failing to
provide appropriate supervision and guidance of delegated tasks.
Delegation also requires highly developed leadership skills such as sensitivity to
subordinates’ capabilities and needs, the ability to communicate clearly and directly, the
willingness to support and encourage subordinates in carrying out delegated tasks, and the
vision to see how delegation might result in increased personal growth for subordinates as
well as increased unit productivity.
With the increased use of NAP in patient care, the need for nurses to have highly
developed delegation skills has never been greater. The challenge continues to be using NAP
only to provide personal care needs or nursing tasks that do not require the skill and judgment
of the RN. With increasing patient loads and the current nursing shortage, many health-care
organizations and the RNs who work within them are tempted to allow NAP to perform tasks
that should be limited to professional nursing practice. Nurses must remember, however,
that the responsibility for assuring that patients are protected and that NAP do not exceed
their scope of practice, ultimately falls to the RN. When UAPs are allowed to encroach into
professional nursing care, patients are placed at risk (Huston, 2014).
Using delegation skills appropriately will help to reduce the personal liability associated
with supervising and delegating to NAP. It will also ensure that clients’ needs are met and
their safety is not jeopardized.
KEY CONCEPTS
l professional nursing organizations and regulatory bodies are actively engaged in clarifying the scope of
practice for unlicensed workers and delegation parameters for RNs.
l delegation is not an option for the manager—it is a necessity.
l delegation should be used for assigning routine tasks and tasks for which the manager does not have
time. it is also appropriate as a tool for problem solving, changes in the manager’s own job emphasis,
and building capability in subordinates.
l in delegation, managers must clearly communicate what they want to be done, including the purpose
for doing so. Limitations or qualifications that have been imposed should be delineated. Although the
manager should specify the end product desired, it is important that the subordinate has an appropriate
degree of autonomy in deciding how the work is to be accomplished.
l Managers must delegate the authority and the responsibility necessary to complete the task.
l RNs who are asked to assume the role of supervisor and delegator need preparation to assume these
leadership tasks.
l Assuming the role of delegator and supervisor to the NAp increases the scope of liability for the RN.
l Although the Omnibus Budget Reconciliation Act of 1987 established regulations for the education and
certification of “nurse’s aides” (minimum of 75 hours of theory and practice and successful completion
of an examination in both areas), no federal or community standards have been established for training
the more broadly defined NAp.
l the RN always bears the ultimate responsibility for ensuring that the nursing care provided by his or her
team members meets or exceeds minimum safety standards.
l When subordinates resist delegation, the delegator must ascertain why the delegated task was not
accomplished and take appropriate action to remove these restraining forces.
l transcultural sensitivity in delegation is needed to create a productive multicultural work team.
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482 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
LEARNING EXERCISE 20.5
Need for Immediate Delegation
You are the charge nurse on the 7 am to 3 pm shift in an oncology unit. immediately after report
in the morning, you are overwhelmed by the following information:
● the nursing aide reports that Mrs. Jones has become comatose and is moribund. Although
this is not unexpected, her family members are not present, and you know that they would like
to be notified immediately.
● there are three patients who need 0730 insulin administration. One of these patients had a
0600 blood sugar of 400.
● Mr. Johnson inadvertently pulled out his central line catheter when he was turning over in bed.
his wife just notified the ward clerk by the call-light system and states that she is applying
pressure to the site.
● the public toilet is overflowing, and urine and feces are pouring out rapidly.
● Breakfast trays arrived 15 minutes ago, and patients are using their call lights to ask why they
do not yet have their breakfast.
● the medical director of the unit has just discovered that one of her patients has not been
started on a chemotherapeutic drug that she ordered 3 days ago. She is furious and demands
to speak to you immediately.
Assignment: the other RNs are all very busy with their patients, but you have the following
people to whom you may delegate: yourself, a ward clerk, and an iV-certified LVN/LpN. decide
who should do what and in what priority. Justify your decision.
LEARNING EXERCISE 20.6
Issues with Delegating Discipline
You are the supervisor of the oncology unit. One of your closest friends and colleagues is
paula, the supervisor of the medical unit. Frequently, you cover for each other in the event of
absence or emergency. today, paula stops at your office to let you know that she will be gone for
7 days to attend a management workshop on the east coast. She asks that you check on the
unit during her absence. She also asks that you pay particularly close attention to Mary Jones,
an employee on her unit. She states that Mary, who has worked at the hospital for 4 years, has
been counseled repeatedly about her unexcused absences from work and has recently received
a written reprimand specifying that she will be terminated if there is another unexcused absence.
paula anticipates that Mary may attempt to break the rules during her absence. She asks that
you follow through on this disciplinary plan in the event that Mary again takes an unexcused
absence. her instructions to you are to terminate Mary if she fails to show up for work this week
for any reason.
When you arrive at work the next day, you find that Mary called in sick 20 minutes after the shift
was to begin. the hospital’s policy is that employees are to notify the staffing office of illness
no less than 2 hours before the beginning of their shift. When you attempt to contact Mary by
telephone at home, there is no answer.

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Chapter 20 Delegation 483
Later in the day, you finally reach Mary and ask that she come in to your office early the next
morning to speak about her inadequate notice of sick time. Mary arrives 45 minutes late the next
morning. You are already agitated and angry with her. You inform her that she is to be terminated
for any rule broken during paula’s absence and that this action is being taken in accord with the
disciplinary contract that had been established earlier.
Mary is furious. She states that you have no right to fire her because you are not her “real boss”
and that paula should face her herself. She goes on to say that “paula told me that the disciplinary
contract was just a way of formalizing that we had talked and that i shouldn’t take it too seriously.”
Mary also says, “Besides, i didn’t get sick until i was getting ready for work. the hospital rules
state that i have 12 sick days each year.” Although you feel certain that paula was very clear about
her position in reviewing the disciplinary contract with Mary, you begin to feel uncomfortable with
being placed in the position of having to take such serious corrective action without having been
involved in prior disciplinary review sessions. You are, however, also aware that this employee
has been breaking rules for some time and that this is just one in a succession of absences. You
also know that paula is counting on you to provide consistency of leadership in her absence.
Assignment: discuss how you will handle the situation. Was it appropriate for paula to
delegate this responsibility to you? is it appropriate for one manager to carry out another
manager’s disciplinary plan? does it matter that a written disciplinary contract had already been
established?
LEARNING EXERCISE 20.7
How Will You Plan This Busy Morning?
You are a staff nurse who functions as a modular leader on a general medical–surgical unit. the
group for which you are responsible is assigned patients in Rooms 401 through 409, with a
maximum capacity of 13 patients.
in your unit, a modular type of patient care organization is employed, using a combination of
licensed and unlicensed staff. each module consists of one RN, one LVN/LpN, and one NAp.
the LVN/LpN is iV certified and can maintain and start iVs but cannot hang piggybacks or give
iV push medications. the LVN/LpN may give all other medications except iV medications. the
RN gives all iV medications. the NAp, with the assistance of his or her modular team members,
generally bathes and feeds patients and provides other care that does not require a license.
the RN, as modular leader, divides up the workload at the beginning of the shift between the
three modular team members. in addition, he or she acts as a teacher and resource person for
the other members of the module.
today is Wednesday. You have one LVN/LpN and one NAp assigned to work with you—LVN
Franklin and NAp Martinez. LVN Franklin is 26 years old and the mother of four preschool
children. her husband is a city bus driver. NAp Martinez is 53 years old and a grandmother with
no children living at home. her husband died 2 years ago. She says that work keeps her “happy.”
the patient roster this morning is as follows:
Room Patient Age Diagnosis Condition Acuity Level
401 Mrs. Jones 33 Mastectomy for
breast cA
2 days postop/fair ii
402 Mrs. Redford 55 Back pain—pelvic Good i
(Continued)
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484 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Room Patient Age Diagnosis Condition Acuity Level
403 Mrs. Worley 46 cholecystectomy 2 d postop/good iii
404–1 Mrs. Smith 83 parkinson’s, cVd,
hypertension
Fair ii
404–2 Mrs. dewey 26 pid Good—home today i
405–1 Mr. Arthur 71 Metastatic cA poor—semi-comatose/
chemotherapy
iV
405–2 Mr. Vines 34 possible peptic
ulcer
Good—UGi today iii
406–1 Vacant
406–2 Miss Brown 24 dilatation and
curettage
to OR this am iii
407–1 Mrs. West 41 Myocardial infarction
heparin lock from
yesterday/telemetry
Fair/icU iii
408–1 Mr. Niles 21 Open reduction
femur (MVA)
Fair/3 d postop iii
408–2 Mr. Ford 44 Gastrectomy Fair/1 d postop iii
409 Mrs. Land 42 depression Fair/barium enema
today
iii
Additional information about patients:
● Mr. Niles is depressed because he believes that his football career is over.
● there have been problems with Mr. Ford’s iV and his nasogastric tube. Both will need to be
replaced today.
● Mrs. Worley requires frequent changes (every 2 to 3 hours) of the dressings at the
laparoscopy site owing to a high volume of serous drainage.
● Mrs. Jones will need instructions regarding her postoperative activities and has begun to talk
about her prognosis.
● Mrs. Land began to talk with you yesterday about her husband’s recent death.
● the preparation for the barium enema will result in Mrs. Land’s having frequent toileting needs
today.
● Mrs. Smith requires assistance with feeding at mealtime.
● Mr. Arthur is no longer able to turn himself in bed.
● Mr. Vines states that being in the same room with a critically ill patient upsets him, and he has
asked to be moved to a new room.
Assignment: how will you make out your assignments this morning? Assign these patients to
the LVN/LpN, NAp, and yourself. Be sure to include assessments, procedures, and basic care
needs. What will you do if a patient is admitted to your team? explain the rationale for all your
patient assignments. Refer to the sample acuity levels provided to assist in determining patient
needs and staffing.

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Chapter 20 Delegation 485
LEARNING EXERCISE 20.8
Evaluating Staffing Safeguards
interview a middle- or top-level manager of a local health-care agency. determine the staffing
mix at his or her agency. Are there minimum hiring criteria for the NAp? Are there written
guidelines for determining tasks appropriate for NAp delegation? What educational or training
opportunities on delegation are made available to staff who must delegate work assignments
on a regular basis?
On the basis of your interview results, write an essay evaluating whether you believe there are
adequate safeguards in place at that agency to protect the licensed staff, unlicensed staff, and
clients. Would you feel comfortable working in such a facility?
LEARNING EXERCISE 20.9
Deciding Delegation Using the Nurse Practice Act
Which of the following tasks would you be willing to delegate to an NAp? Use your state’s
NpA or a decision tree created by the NcSBN or a state Board of Nursing, as a reference for
this case. discuss your answers in small groups. did you all agree? if not, what factors were
significant in your differences?
1. Uncomplicated wet-to-dry dressing change on a patient 3 days post-hip replacement
2. every 2-hour checks on a patient with soft wrist restraints to assess circulation, movement,
and comfort
3. cooling measures for a patient with a temperature of 104°F
4. calculation of iV credits, clearing iV pumps, and completing shift intake/output totals
5. completing phlebotomy for daily drawing of blood
6. holding pressure on the insertion site of a femoral line that has just been removed
7. educating a patient about components of a soft diet
8. conducting guaiac stool tests for occult blood
9. performing electrocardiographic testing
10. Feeding a patient with swallowing precautions (high risk of choking post-cardiovascular
accident
11. Oral suctioning
12. tracheostomy care
13. Ostomy care
LEARNING EXERCISE 20.10
Reflecting on Negative Delegation Experiences
Write a one-page essay about one of the following situations you have experienced:
● A supervisor asked you to complete a task you believed was beyond your capability
● A supervisor delegated a task to you but failed to give you adequate authority to carry out the
task
● A supervisor gave such explicit directions on how to complete a delegated task that you felt
demoralized
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486 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
REFERENCES
American Nurses Association (ANA) and the National
Council of State Boards of Nursing (NCSBN). (n.d.).
Joint statement on delegation. Retrieved June 17,
2013, from https://www.ncsbn.org/Delegation_joint
_statement_NCSBN-ANA
Anderson, L. (2013, February 10). Understanding the different
scope of nursing practice. nursetogether.com. Retrieved
June 19, 2013, from http://www.nursetogether.com/
understanding-the-different-scope-of-nursin
Case, B. (2013). Delegation skills. Advance for Nurses.
Retrieved June 20, 2013, from http://nursing
.advanceweb.com/Article/Delegation-Skills.aspx
Delegating. Leadership Skills Training. (n.d.). Park/
Scholarships. Retrieved June 20, 2013, from http://
www.ncsu.edu/project/parkprgrd/PSTrainingModules/
delegating/del12frame.htm
Does Your Staff Understand Delegation? (2009, January).
OR Manager, 25(1), 21–23.
Giger, J., & Davidhizar, R. (2008). Transcultural nursing:
Assessment and intervention (5th ed.). St Louis, MO:
Mosby Year Book.
Huston, C. (2009, March). 10 tips for successful delegation:
Improve patient care and save time by recognizing
when to delegate and learning how to do it wisely.
Nursing, 39(3), 54–56.
Huston, C. (2014). Professional issues in nursing: Challenges
and opportunities (3rd ed.). Unlicensed assistive
personnel and the registered nurse (chapter 7).
Philadelphia, PA: Lippincott Williams & Wilkins
107–120.
Is It OK to Delegate? (2012, December 3). American
Nurse. Retrieved June 18, 2013, from http://www
.theamericannurse.org/index.php/2012/12/03/is-it
-ok-to-delegate/
Kærnested, B., & Bragadóttir, H. (2012). Delegation
of registered nurses revisited: Attitudes towards
delegation and preparedness to delegate effectively.
Nordic Journal of Nursing Research & Clinical
Studies/Vård I Norden, 32(1), 10–15.
Kentucky Board of Nursing. (2010). Decision tree for delegation
to unlicensed assistive personnel (UAP). Retrieved
June 17, 2013, from http://kbn.ky.gov/NR/rdonlyres/
E1591ED0-5C3E-425C-ACE6-396268CE1774/0/
DecisionTreeforDelegationtoUAP
Knox, C. (2013, January 3). The five rights of delegation.
Essentials of Correctional Nursing. Retrieved June
19, 2013, from http://essentialsofcorrectionalnursing
.com/2013/01/03/a-case-example-the-five-rights-of
-delegation/
NMC Says Asian Nurses. (2012). NMC says Asian nurses
may need support with delegating work. Nursing
Standard, 26(26), 5.
North Carolina Board of Nursing. (2013). Delegation: Non-
nursing functions. Position Statement for RN and
LPN Practice. Retrieved June 18, 2013, from http://
allnurses.com/north-carolina-nursing/north-carolina
-board-465130.html
Tredgold, G. (2013, May 30). Why delegation is important.
Leadership Principles. Retrieved June 18, 2013, from
http://www.leadership-principles.com/2013/05/30/
why-delegation-is-important/
Winstead, J. V. (2013, winter). Delegation: What are the
nurse’s responsibilities? Nursing Bulletin. Official
Bulletin of the North Carolina Board of Nursing (pp.
8–16). Retrieved June 18, 2013, from http://www
.ncbon.com/WorkArea/linkit.aspx?LinkIdentifier=id
&ItemID=3240
Wong, M. (2012, August 2). Do foreign nurses lack
cultural competency? Healthecareers.com. Retrieved
June 20, 2013, from http://www.healthecareers
.com/article/do-foreign-nurses-lack-cultural
-competency/170789

https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA

http://www.nursetogether.com/understanding-the-different-scope-of-nursin

http://www.ncsu.edu/project/parkprgrd/PSTrainingModules/delegating/del12frame.htm

http://www.theamericannurse.org/index.php/2012/12/03/is-it-ok-to-delegate/

http://kbn.ky.gov/NR/rdonlyres/E1591ED0-5C3E-425C-ACE6-396268CE1774/0/DecisionTreeforDelegationtoUAP

http://essentialsofcorrectionalnursing.com/2013/01/03/a-case-example-the-five-rights-of-delegation/

http://allnurses.com/north-carolina-nursing/north-carolina-board-465130.html

http://www.leadership-principles.com/2013/05/30/why-delegation-is-important/

http://www.ncbon.com/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=3240

http://www.healthecareers.com/article/do-foreign-nurses-lack-cultural-competency/170789

http://nursing.advanceweb.com/Article/Delegation-Skills.aspx

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487
21
Effective Conflict Resolution and Negotiation
… getting good players is EASY. Gettin‘ ’em to play together is the hard part.
—Casey Stengel
… negotiation in the classic diplomatic sense assumes parties more anxious to agree than to
disagree.
—Dean Acheson
CROSSWALK thiS ChApter ADDreSSeS:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential VIII: professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: teamwork and collaboration
QSEN Competency: Safety
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: professionalism
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l differentiate between qualitative and quantitative conflict and between intrapersonal and
interpersonal conflict
l identify the stages of conflict
l describe manifestations of workplace violence, incivility, bullying, and mobbing as well as
strategies that might be used to immediately confront and intervene
l seek win–win conflict resolution outcomes whenever possible
l identify the functional and dysfunctional results of various methods of conflict resolution
l select appropriate conflict resolution strategies to solve various conflict situations
l identify the components of effective collaboration
l describe strategies that can be used before, during, and after negotiation to increase the
likelihood that desired outcomes will be achieved
l identify effective ways to counter commonly used tactics in conflict negotiation
l describe how alternative dispute resolution might be used to resolve conflicts when
negotiation has not been successful
l recognize the challenges as well as rewards in seeking consensus to address group conflict
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488 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Stanton (2013) notes that health care is delivered by people working in both large and small
organizations and that each worker is part of many groups, both formal and informal. Being
able to work well with other people, within and across departmental and other organizational
boundaries, is essential to efficiency and effectiveness in patient care. Yet, dynamic
environments, characterized by interactions among many people, within a defined setting, are
always conducive to conflict (Stanton, 2013).
Conflict is generally defined as the internal or external discord that results from
differences in ideas, values, or feelings between two or more people. Because managers
have interpersonal relationships with people having a variety of different values, beliefs,
backgrounds, and goals, conflict is an expected outcome. Conflict is also created when there
are differences in economic and professional values and when there is competition among
professionals. Scarce resources, restructuring, and poorly defined role expectations also are
frequent sources of conflict in organizations.
Openly acknowledging that conflict is a naturally occurring and expected phenomenon
in organizations reflects a tremendous shift from how sociologists viewed conflict a century
ago. The current sociological view is that organizational conflict should be neither avoided
nor encouraged but managed. The leader’s role is to create a work environment where conflict
may be used as a conduit for growth, innovation, and productivity. When organizational
conflict becomes dysfunctional, the manager must recognize it in its early stages and actively
intervene so that subordinates’ motivation and organizational productivity are not adversely
affected.
Conflict is neither good nor bad, and it can produce growth or destruction, depending on how it
is managed.
Conflict resolution, or problem solving, appears to be learned less frequently through
developmental experiences; rather, it requires a conscious learning effort. Thus, the skills
necessary to manage conflict effectively can be learned.
This chapter presents an overview of growth-producing versus dysfunctional conflict in
organizations. The history of conflict management, categories of conflict, the conflict process
itself, and strategies for successful conflict resolution are discussed. Incivility, workplace
violence, bullying, and mobbing are presented as threats to safety as well as patient care and
negotiation as a conflict resolution strategy is emphasized. Leadership skills and management
functions necessary for conflict resolution at the unit level are outlined in Display 21.1.
DISpLAy 21.1 Leadership Roles and Management Functions Associated with Conflict
Resolution
LEADERSHIP ROLES
1. is self-aware and conscientiously works to resolve intrapersonal conflict.
2. Addresses conflict as soon as it is perceived and before it becomes felt or manifest.
3. immediately confronts and intervenes when incivility, bullying, and mobbing occur.
4. Seeks a win–win solution to conflict whenever feasible.
5. Lessens the perceptual differences that exist between conflicting parties and broadens the
parties’ understanding about the problems.
6. Assists subordinates in identifying alternative conflict resolutions.
7. recognizes and accepts individual differences in team members.
8. Uses assertive communication skills to increase persuasiveness and foster open communication.
9. role models honest and collaborative negotiation efforts.
10. encourages consensus building when group support is needed to resolve conflicts.

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Chapter 21 Effective Conflict Resolution and Negotiation 489
THE HISTORy OF CONFLICT MANAGEMENT
Early in the 20th century, conflict was considered to be an indication of poor organizational
management, was deemed destructive, and was avoided at all costs. When conflict occurred,
it was ignored, denied, or dealt with immediately and harshly. The theorists of this era
believed that conflict could be avoided if employees were taught the one right way to do
things and if expressed employee dissatisfaction was met swiftly with disapproval.
In the mid-20th century, when organizations recognized that worker satisfaction and
feedback were important, conflict was accepted passively and perceived as normal and
expected. Attention centered on teaching managers how to resolve conflict rather than
how to prevent it. Although conflict was considered to be primarily dysfunctional, it was
believed that conflict and cooperation could happen simultaneously. The interactionist
theorists of the 1970s, however, recognized conflict as a necessity and actively encouraged
organizations to promote conflict as a means of producing growth. From this, one can
infer that some conflict is desired, although its extent is difficult to know. Perhaps
more important than the quantification of conflict is the impact this conflict has on the
organization.
Some level of conflict in an organization appears desirable, although the optimum level for a
specific person or unit at a given time is difficult to determine.
Too little conflict results in organizational stasis. Too much conflict reduces the organization’s
effectiveness and eventually immobilizes its employees (Fig. 21.1). With few formal
instruments to assess whether the level of conflict in an organization is too high or too
low, the responsibility for determining and creating an appropriate level of conflict on the
individual unit often falls to the leader-manager.
Conflict also has a qualitative nature. A person may be totally overwhelmed in one conflict
situation yet can handle several simultaneous conflicts at a later time. The difference is in the
quality or significance of that conflict to the person experiencing it. Although quantitative
and qualitative conflicts produce distress at the time they occur, they can lead to growth,
energy, and creativity by generating new ideas and solutions. If handled inappropriately,
quantitative and qualitative conflicts can lead to demoralization, decreased motivation, and
lowered productivity.
MANAGEMENT FUNCTIONS
1. Creates a work environment that minimizes the antecedent conditions for conflict.
2. establishes a workplace culture that has zero tolerance for incivility, bullying, mobbing, and
violence.
3. Appropriately uses legitimate authority in a competing approach when a quick or unpopular
decision needs to be made.
4. When appropriate, formally facilitates conflict resolution among team members.
5. Accepts mutual responsibility for reaching predetermined supraordinate goals.
6. Obtains needed unit resources through effective negotiation strategies.
7. Compromises unit needs only when the need is not critical to unit functioning and when higher
management gives up something of equal value.
8. is adequately prepared to negotiate for unit resources, including the advance determination of
a bottom line and possible trade-offs.
9. Addresses the need for closure and follow-up to negotiation.
10. pursues alternative dispute resolution (ADr) when conflicts cannot be resolved using
traditional conflict management strategies.
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490 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Nursing managers can no longer afford to respond to conflict traditionally (i.e., to avoid
or suppress it), because this is nonproductive. In an era of shrinking health-care dollars, it has
become increasingly important for managers to confront and manage conflict appropriately.
The ability to understand and deal with conflict appropriately is a critical leadership skill.
FIGURE 21.1 • the relationship between organizational conflict and effectiveness.
Copyright ® 2006 Lippincott Williams & Wilkins. instructor’s resource CD-rOM to
Accompany Leadership roles and Management Functions in Nursing, by Bessie L.
Marquis and Carol J. huston.
LEARNING EXERCISE 21.1
Thinking and Writing About Conflict
Do you generally view conflict positively or negatively?
Does conflict affect you more cognitively, emotionally, or physically?
how was conflict expressed in the home in which you grew up?
Does the way that you handle conflict mirror that of your role models as a child?
Do you believe that you have too much or too little conflict in your life?
Do you feel like you have control over the issues that are now causing conflict in your life?
Assignment: Write a one-page essay, answering one of the questions above.
CATEGORIES OF CONFLICT: INTERGROup, INTRApERSONAL,
AND INTERpERSONAL
There are three primary categories of conflict: intergroup, intrapersonal, and interpersonal
(Fig. 21.2). Intergroup conflict occurs between two or more groups of people, departments,
and organizations. An example of intergroup conflict might be two political affiliations with

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Chapter 21 Effective Conflict Resolution and Negotiation 491
widely differing or contradictory beliefs or nurses experiencing intergroup conflict with
family and work issues.
Intrapersonal conflict occurs within the person. It involves an internal struggle to clarify
contradictory values or wants. Stacey, Johnston, Stickley, and Diamond (2011) suggest that
the values nurses hold when they enter the profession generally remain intact; however,
workplace constraints and resistance may prevent the nurse from applying those values. This
then affects the capacity of the nurse to work with people in distress and can lead to high
levels of stress and job attrition.
For managers, intrapersonal conflict may result from the multiple areas of responsibility
associated with the management role. Managers’ responsibilities to the organization,
subordinates, consumers, the profession, and themselves sometimes conflict, and that conflict
may be internalized. Being self-aware and conscientiously working to resolve intrapersonal
conflict as soon as it is first felt is essential to the leader’s physical and mental health.
Interpersonal conflict happens between two or more people with differing values, goals, and
beliefs and may be closely linked with bullying, incivility, and mobbing. Bullying is defined
by Townsend (2012) as repeated, offensive, abusive, intimidating, or insulting behaviors;
abuse of power; or unfair sanctions that make recipients feel humiliated, vulnerable, or
threatened, thus creating stress and undermining their self-confidence. Incivility is defined by
Clark (2010) as behavior that lacks authentic respect for others that requires time, presence,
willingness to engage in genuine discourse and intention to seek common ground. Clark notes
that it can be a short walk from incivility to aggressive behavior and violence. In addition,
interpersonal conflict can be manifested by mobbing, when employees “gang up” on an
Interpersonal ConflictIntrapersonal Conflict
Intergroup Conflict
FIGURE 21.2 • primary categories of conflict. Copyright ®
2006 Lippincott Williams & Wilkins. instructor’s resource
CD-rOM to Accompany Leadership roles and Management
Functions in Nursing, by Bessie L. Marquis and Carol J. huston.
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492 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
individual. The degree of harm a nurse experiences from bullying or mobbing often depends
upon the frequency, intensity, and duration of the behavior and/or tactic used (Hockley, 2014).
When bullying, incivility, and mobbing occur in the workplace, this is known as workplace
violence. Hockley (2014) maintains that in addition to physical violence, the term describes
various antisocial behaviors and incidents that lead a person to believe that he or she has
been harmed by the experience. It includes but is not limited to such behaviors as engaging
in favoritism, being verbally abusive, sending abusive correspondence, bullying, pranks,
and setting workers up for failure. It also includes economic aggression such as denying
workers promotional opportunities. Countless practice settings are hindered by maladaptive
social behaviors that victimize nurses and impact patient care. Hockley maintains that the
responsibility for dealing with this type of conflict should initially lie with front-line staff,
but the manager must become involved if the conflict is not resolved.
Unfortunately, many nurses report having been bullied during their work life. Indeed,
research by Roche, Diers, Duffield, and Catling-Pauli (2010) found that about one-third of
nurses perceived emotional abuse during the last five shifts worked, 14% reported threats,
and 20% reported actual violence. Hauge, Skogstad, and Einarsen (2009) suggested that this
occurs because bullying thrives in stressful working environments and individuals who are
bullied in the workplace often go on to bully others.
Violence and workplace aggression are increasingly being recognized as epidemic in the
health-care workplace.
While nurses of all ages and experience levels report bullying, new graduate nurses seem
to be victimized more often than any other group. These behaviors can, over a prolonged
time, cause the individual to develop low self-esteem, to feel worthless, or to feel frustrated
(Hockley, 2014). In addition, because this interpersonal conflict may not be reported or
managed, it often results in consequences such as absenteeism and turnover.
Inglis, Schaper, and Swartz (2013), recognizing the problem of the bullying of new
nurses, suggest that organizations can reduce this attrition and by providing new nurses with
opportunities to address strong negative emotional responses to conflict (hot buttons) and to
practice constructive strategies when engaging in conflict. In doing so, new graduates can
begin to recognize how their own behaviors may influence the escalation or de-escalation of
conflict (Examining the Evidence 21.1).
Source: Inglis, R. L., Schaper, A.M., & Swartz, S. L. (2013, April 14). Conflict engagement skill building for nurse
residents. Session presented at the Sigma Theta Tau International conference. Creating healthy work environments.
Indianapolis, IN. Virginia Henderson International Nursing Library. Retrieved June 20, 2013, from http://www
.nursinglibrary.org/vhl/handle/10755/290986
This presentation suggested that the experience of incivility in higher education may influence
how well a newly graduated nurse deals with conflict and disruptive behaviors in the workplace.
Noting that newly registered nurses frequently report acts of disrespect and destructive con-
flict resulting in high levels of attrition in the first year or two of employment, the researchers
suggested the addition of conflict resolution training to nurse residency programs as one strategy
for addressing the problem.
To test their hypothesis, a modified Conflict Engagement program, advocated by the American
Nurse Association, was delivered to 45 new graduates completing a nurse residency program.
The program included a 4-hour workshop followed by 1-hour monthly meetings termed “Lear-
ning Circles” for 6 months. The Learning Circles provided these new nurses with opportunities to
Examining the Evidence 21.1

http://www.nursinglibrary.org/vhl/handle/10755/290986

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Chapter 21 Effective Conflict Resolution and Negotiation 493
It is critical that leader-managers immediately confront and intervene when workplace
violence is occurring. Zero tolerance should be the expectation since bullying and incivility
impact turnover, productivity, and quality of care. Townsend (2012) reported that up to 70%
of nurses who were bullying victims leave their jobs; roughly 60% of new registered nurses
(RNs) quit their first job within 6 months of being bullied; and one in three new graduate
nurses considered quitting nursing altogether because of abusive or humiliating encounters.
In addition, researchers from Georgetown University and the Thunderbird School of Global
Management found that incivility and rude behavior influenced productivity and commitment
from workers and that nearly half (48%) intentionally decreased their work effort as a result,
while 38% intentionally decreased the quality of their work (Cheung-Larivee, 2013).
To end abusive behaviors, clear zero-tolerance policies must be communicated loudly and
clearly from upper administration and a culture of safety that encourages open, respectful
communication must be encouraged (Townsend, 2012). Also, the Joint Commission has
issued leadership standards that include creating processes for managing bullying behaviors
and adopting a code of conduct for staff (Townsend).
THE CONFLICT pROCESS
Before managers can or should attempt to intervene in conflict, they must be able to assess
its five stages accurately. The first stage in the conflict process, latent conflict, implies the
existence of antecedent conditions such as short staffing and rapid change. In this stage,
conditions are ripe for conflict, although no conflict has actually occurred and none may ever
occur. Much unnecessary conflict could be prevented or reduced if managers examined the
organization more closely for antecedent conditions. For example, change and budget cuts
almost invariably create conflict. Such events, therefore, should be well thought out so that
interventions can be made before the conflicts created by these events escalate.
If the conflict progresses, it may develop into the second stage: perceived conflict.
Perceived or substantive conflict is intellectualized and often involves issues and roles. The
person recognizes it logically and impersonally as occurring. Sometimes, conflict can be
resolved at this stage before it is internalized or felt. Stanton (2013) notes the importance
when conflict is first perceived, to directly address whether a conflict really exists. He notes
that “we often assume other people’s behavior is intentional when, in fact, they may not be
aware their actions are causing difficulties for someone else. In an environment characterized
by open communication and mutual support, many conflicts can be resolved simply by
pointing out the problem” (para 30).
The third stage, felt conflict, occurs when the conflict is emotionalized. Felt emotions
include hostility, fear, mistrust, and anger. It is also referred to as affective conflict. It is
address strong negative emotional responses to conflict (hot buttons) and to practice construc-
tive strategies when engaging in conflict. The Learning Circles incorporated role modeling, role
play, and case studies of conflict situations.
The trainers also provided personal consultation to help new nurses address unique conflict
situations. Nurse residents easily identified previous experiences of incivility in nursing educa-
tion, including incivility between nursing staff and nursing students during a clinical rotation;
however, they did not expect to experience incivility as a new nurse. Personal experiences with
conflict, particularly generational conflict, emerged as an influencing factor in understanding the
value of conflict engagement training. Between the third and fourth Learning Circle, a majority
of the nurse residents began to recognize how their own behaviors influenced the escalation or
de-escalation of conflict.
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494 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
possible to perceive conflict and not feel it (e.g., no emotion is attached to the conflict,
and the person views it only as a problem to be solved). A person also can feel the conflict
but not perceive the problem (e.g., he or she is unable to identify the cause of the felt
conflict).
In the fourth stage, manifest conflict, also called overt conflict, action is taken. The
action may be to withdraw, compete, debate, or seek conflict resolution. Individuals are
uncomfortable with or reluctant to address conflict for many reasons. These include fear of
retaliation, fear of ridicule, fear of alienating others, a sense that they do not have the right
to speak up, and past negative experiences with conflict situations. Indeed, people often
learn patterns of dealing with manifest conflict early in their lives, and family background
and experiences often directly affect how conflict is dealt with in adulthood. Gender also
may play a role in how we respond to conflict. Historically, men were socialized to respond
aggressively to conflict, whereas women were more likely taught to try to avoid conflicts or
to pacify them.
The final stage in the conflict process is conflict aftermath. There is always conflict
aftermath—positive or negative. If the conflict is managed well, people involved in the
conflict will believe that their position was given a fair hearing. If the conflict is managed
poorly, the conflict issues frequently remain and may return later to cause more conflict.
Figure 21.3 shows a schematic of this conflict process.
The aftermath of conflict may be more significant than the original conflict if the conflict has not
been handled constructively.
Latent conflict
(also called
antecedent conditions)
Manifest conflict
Conflict resolution
or
conflict management
Conflict aftermath
Felt conflict Perceived conflict
FIGURE 21.3 • the conflict process. Copyright ® 2006 Lippincott Williams & Wilkins.
instructor’s resource CD-rOM to Accompany Leadership roles and Management
Functions in Nursing, by Bessie L. Marquis and Carol J. huston.

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Chapter 21 Effective Conflict Resolution and Negotiation 495
CONFLICT MANAGEMENT
The optimal goal in resolving conflict is creating a win–win solution for all involved. This
outcome is not possible in every situation, and often the manager’s goal is to manage the
conflict in a way that lessens the perceptual differences that exist between the involved
parties. A leader recognizes which conflict management or resolution strategy is most
appropriate for each situation. Common conflict management strategies are identified in
Display 21.2. The choice of the most appropriate strategy depends on many variables, such
as the situation itself, the urgency of the decision, the power and status of the players, the
importance of the issue, and the maturity of the people involved in the conflict.
The optimal goal in resolving conflict is creating a win–win solution for all involved.
LEARNING EXERCISE 21.2
Personal Conflict Solving
it is important for managers to be self-aware regarding how they view and deal with conflict. in
your personal life, how do you solve conflict? is it important for you to win? When was the last
time you were able to solve conflict by reaching supraordinate goals with another person? Are
you able to see the other person’s position in conflict situations? in conflicts with family and
friends, are you least likely to compromise values, scarcities, or role expectations?
DISpLAy 21.2 Common Conflict Resolution Strategies
Compromising
Competing
Cooperating/accommodating
Smoothing
Avoiding
Collaborating
Compromising
In compromising, each party gives up something it wants. Although many see compromise
as an optimum conflict resolution strategy, antagonistic cooperation may result in a lose–lose
situation because either or both parties perceive that they have given up more than the other
and may therefore feel defeated. For compromising not to result in a lose–lose situation,
both parties must be willing to give up something of equal value. Compromising definitely
becomes a win–win when both parties perceive they have won more than the other person. It
is important that parties in conflict do not adopt compromise prematurely if collaboration is
both possible and feasible.
Competing
The competing approach is used when one party pursues what it wants at the expense of the
others. Because only one party typically wins, the competing party seeks to win regardless of
the cost to others. In addition, Stanton (2013) notes that it is entirely possible that both parties
may lose, particularly if the outcome adversely affects the subsequent working relationship.
This is because win–lose conflict resolution strategies leave the loser angry, frustrated, and
wanting to get even in the future.
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496 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Managers may use competing when a quick or unpopular decision needs to be made. It is
also appropriately used when one party has more information or knowledge about a situation
than the other. Competing in the form of resistance is also appropriate when an individual
needs to resist unsafe patient care policies or procedures, unfair treatment, abuse of power,
or ethical concerns.
Cooperating/Accommodating
Cooperating is the opposite of competing. In the cooperating approach, one party sacrifices
his or her beliefs and allows the other party to win. The actual problem is usually not solved
in this win–lose situation. Accommodating is another term that may be used for this strategy.
The person cooperating or accommodating often expects some type of payback or an
accommodation from the winning party in the future. Cooperating and accommodating are
appropriate political strategies if the item in conflict is not of high value to the person doing
the accommodating.
Smoothing
Smoothing is used to manage a conflict situation. Smoothing occurs when one party in a conflict
attempts to pacify the other party or to focus on agreements rather than differences. In doing so,
the emotional component of the conflict is minimized. Managers often use smoothing to get
someone to accommodate or cooperate with another party. Although it may be appropriate for
minor disagreements, smoothing rarely results in resolution of the actual conflict.
Avoiding
In the avoiding approach, the parties involved are aware of a conflict but choose not to
acknowledge it or attempt to resolve it. Avoidance may be indicated in trivial disagreements,
when the cost of dealing with the conflict exceeds the benefits of solving it, when the
problem should be solved by people other than you, when one party is more powerful than
the other, or when the problem will solve itself. The greatest problem in using avoidance is
that the conflict remains, often only to reemerge at a later time in an even more exaggerated
fashion. Stanton (2013) agrees, noting that passive approaches like avoidance, giving up, and
accommodating are likely to result in poor outcomes for one or both parties.
Unfortunately, American Sentinel (2012) notes that avoidance and withdrawal are the most
common conflict resolution strategies used by nurses. This finding was similar to research
conducted by Kaitelidou et al. (2012), which suggested that avoidance was the most frequent
mode of conflict resolution used by health-care personnel while accommodation was the least
frequently used mode (Examining the Evidence 21.2).
Source: Kaitelidou, D., Kontogianni, A., Galanis, P., Siskou, O., Mallidou, A., Pavlakis, A., & Liaropoulos, L. (2012).
Conflict management and job satisfaction in paediatric hospitals in Greece. Journal of Nursing Management, 20(4),
571–578.
Recognizing that conflict is inherent to hospitals as in all complex organizations, and that health-
care personnel deal with internal and external conflicts daily, the researchers administered a
five-part questionnaire, specific to conflicts in hospitals, to 286 health personnel (a response rate
of 66%). Thirty-seven percent of the study participants were physicians, 47% were nurses, and
16% were nursing assistants.
A majority (77%) of the respondents suggested they had no training in conflict resolution and
reported having conflicts with colleagues in their own ward. Physicians reported more conflicts
Examining the Evidence 21.2

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Chapter 21 Effective Conflict Resolution and Negotiation 497
In contrast, research conducted by Losa Iglesias and Becerro de Bengoa Vallejo (2012)
found that the most common conflict resolution strategy used by nurses to resolve workplace
conflict was compromising, followed by competing, avoiding, accommodating, and
collaborating. Accommodation was most common for nurses working in clinical settings,
whereas nurses employed in academic settings were more competitive in their approach.
Collaborating
Collaborating is an assertive and cooperative means of conflict resolution that results in a
win–win solution. In collaboration, all parties set aside their original goals and work together
to establish a supraordinate or priority common goal. In doing so, all parties accept mutual
responsibility for reaching the supraordinate goal.
Although it is very difficult for people truly to set aside original goals, collaboration cannot
occur if this does not happen. For example, a married couple experiencing serious conflict
over whether to have a baby may first want to identify whether they share the supraordinate
goal of keeping the marriage together. A nurse who is unhappy that she did not receive
requested days off might meet with her supervisor and jointly establish the supraordinate
goal that staffing will be adequate to meet patient safety criteria. If the new goal is truly a
jointly set goal, each party will perceive that an important goal has been achieved and that
the supraordinate goal is most important. In doing so, the focus remains on problem solving
and not on defeating the other party.
Collaboration is rare when there is a wide difference in power between the groups and
individuals involved. Many think of collaboration as a form of cooperation, but this is not
an accurate definition. In collaboration, problem solving is a joint effort with no superior–
subordinate, order-giving–order-taking relationships. True collaboration requires mutual
respect; open and honest communication; and equitable, shared decision-making powers.
Although conflict is a pervasive force in health-care organizations, only a small percentage of
time is spent in true collaboration.
Collaboration enhances a person’s participation in decision making to accomplish mutual
goals and therefore is the best method to resolve conflict to achieve long-term benefits.
Because it may involve others over whom the manager has no control and because its process
is often lengthy, it may not be the best approach for all situations.
with their colleagues (73.3%) than did nurses and nursing assistants (48.1% and 40.9%, respec-
tively). When asked what they do to resolve a conflict, the majority of both nurses and physicians
stated that they used avoidance (64% and 61%, respectively). Both physicians and nursing per-
sonnel chose collaboration as the second favorable technique to resolve their conflicts (45% and
42%, respectively), while competition was the third choice for both groups (26.4% for physicians
and 20% for nursing personnel). Physicians selected the competitive style of conflict resolution
more often than did nurses (v
2
= 2, P = 0.1). The least frequent mode was accepting the will
(accommodating) of the opposing side (9.5% of physicians and 6.7% of nurses).
The researchers concluded that while using avoidance as a conflict resolution strategy may
be appropriate as a short-term technique when a problem is emerging, it may be dysfunctional
if it lasts a long time since it prevents recognition that a problem exists. One-third of participants
(32.6%) agreed that detecting initial symptoms of conflict and adopting the most effective beha-
vior in conflict resolution is essential and noted that conflict has an influence on patients’ quality
of care since conflict results in communication between staff being interrupted and valuable
information about patients’ care needs being withheld.
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498 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
In addition, it is not easy. Vaughn (2009) suggests that the most common barriers to collaboration
between members of the multidisciplinary health-care team are patriarchal relationships; lack of
time; gender- and generational-based differences; cultural differences; and lack of role clarification
of team members. He concludes then that while collaboration evokes warm feelings in nursing
leadership circles as a result of its win–win outcomes, it is difficult to truly implement and requires
a high degree of self-awareness as well as conflict communication skills.
LEARNING EXERCISE 21.3
Conflicting Personal, Professional, and Organizational Obligations
You are an rN. You have been working on the oncology unit since your graduation from the
state college a year ago. Your supervisor, Mary, has complimented your performance. Lately,
she has allowed you to be relief charge nurse on the 3 to 11 pm shift when the regular charge
nurse is not there. Occasionally, you have been asked to work on the medical–surgical units
when your department has a low census. Although you dislike leaving your own unit, you have
cooperated because you felt that you could handle the other clinical assignments and wanted
to show your flexibility.
On arriving at work tonight, the nursing office calls and requests that you help out in the
busy delivery room. You protest that you do not know anything about obstetrics and that it is
impossible for you to take the assignment. Carol, the supervisor from the nursing office, insists
that you are the most qualified person; she says to “just go and do the best you can.” Your own
unit supervisor is not on duty, and the charge nurse says that she does not feel comfortable
advising you in this conflict. You feel torn between professional, personal, and organizational
obligations.
Assignment: What should you do? Select the most appropriate conflict resolution strategy.
Give rationale for your selection and for your rejection of the others. After you have made your
choice, read the analysis found in the Appendix.
MANAGING uNIT CONFLICT
Managing conflict effectively requires an understanding of its origin. Some of the sources
of organizational conflict are shown in Display 21.3. Some common causes of unit conflict
are unclear expectations, poor communication, lack of clear jurisdiction, incompatibilities or
disagreements based on differences of temperament or attitudes, individual or group conflicts
of interest, and operational or staffing changes. In addition, not only does diversity in gender,
age, and culture influence conflict resolution, it may also create conflict itself. This occurs as
a result of communication difficulties, including language and literacy issues and a growing
recognition that some factors are beyond assimilation.
l poor communication
l inadequately defined organizational structure
l individual behavior (incompatibilities or disagreements based on differences of temperament or
attitudes)
l Unclear expectations
l individual or group conflicts of interest
l Operational or staffing changes
l Diversity in gender, culture, or age
DISpLAy 21.3 Common Causes of Organizational Conflict

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Chapter 21 Effective Conflict Resolution and Negotiation 499
Ellis and Abbott (2012) suggest that managers may be tempted to ignore organizational
conflict, but should not since all these types of conflicts can disrupt working relationships
and result in lower productivity. Perhaps the most important reason though for the proactive
management of conflict is the impact that it has on patients (Ellis & Abbott). When a team
or individuals within a team are in conflict, patient care suffers since conflict breeds poor
communication and poor communication breeds poor care. It is imperative, then, that the
manager can identify the origin of unit conflicts and intervene as necessary to promote
cooperative, if not collaborative, conflict resolution.
At times, unit conflict requires that the manager facilitates conflict resolution between
others. CRM Learning (2013) suggests that it is almost always best for the individuals
involved in a conflict to work it out on their own, but sometimes they simply cannot or
will not. Before beginning to help other people in a conflict situation, the leader-manager
must first analyze the appropriateness of intervening. If the issue is extremely important
to them or the organization, it is likely worth intervening. The manager may also want to
intervene if the relationship with one or both parties is highly significant to them, even
if the issue is not. Finally, CRM Learning suggests that the manager should consider
what will happen if no one intervenes. If the short- or long-term results are extremely
negative, whether the issue or relationships are important, it might still be advisable to
intervene.
The following is a list of strategies that a manager may use to facilitate conflict resolution
between members in the workplace:
• Confrontation. Many times, team members inappropriately expect the manager to solve
their interpersonal conflicts. Managers instead can urge subordinates to attempt to
handle their own problems by using face-to-face communication to resolve conflicts, as
e-mails, answering machine messages, and notes are too impersonal for interpersonal
conflicts that can have significant conflict aftermath.
• Third-party consultation. Sometimes, managers can be used as a neutral party to help
others resolve conflicts constructively. This should be done only if all parties are
motivated to solve the problem and if no differences exist in the status or power of the
parties involved. If the conflict involves multiple parties and highly charged emotions,
the manager may find outside experts helpful for facilitating communication and
bringing issues to the forefront.
• Behavior change. This is reserved for serious cases of dysfunctional conflict. Educational
modes, training development, or sensitivity training can be used to solve conflict by
developing self-awareness and behavior change in the involved parties.
• Responsibility charting. When ambiguity results from unclear or new roles, it is often
necessary to have the parties come together to delineate the function and responsibility
of roles. If areas of joint responsibility exist, the manager must clearly define such areas
as ultimate responsibility, approval mechanisms, support services, and responsibility for
informing. This is a useful technique for elementary jurisdictional conflicts. An example
of a potential jurisdictional conflict might arise between the house supervisor and unit
manager in staffing or between an in-service educator and unit manager in determining
and planning unit educational needs or programs.
• Structure change. Sometimes, managers need to intervene in unit conflict by transferring
or discharging people. Other structure changes may be moving a department under
another manager, adding an ombudsman, or putting a grievance procedure in place.
Often, increasing the boundaries of authority for one member of the conflict will act
as an effective structure change to resolve unit conflict. Changing titles and creating
policies are also effective techniques.
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500 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
• Soothing one party. This is a temporary solution that should be used in a crisis when
there is no time to handle the conflict effectively or when the parties are so enraged that
immediate conflict resolution is unlikely. Waiting a few days allows most individuals to
deal with their intense feelings and to be more objective about the issues. Regardless of
how the parties are soothed, the manager must address the underlying problem later or
this technique will become ineffective.
NEGOTIATION
Negotiation in its most creative form is similar to collaboration and in its most poorly
managed form may resemble a competing approach. Negotiation frequently resembles
compromise when it is used as a conflict resolution strategy. During negotiation, each party
gives up something, and the emphasis is on accommodating differences between the parties.
Few people are able to meet all of their needs or objectives. Most day-to-day conflict is
resolved with negotiation. A nurse who says to another nurse “I’ll answer that call light if
you’ll count narcotics” is practicing the art of negotiation.
Although negotiation implies winning and losing for both parties, there is no rule that each
party must lose and win the same amount. Most negotiators want to win more than they lose,
but negotiation becomes destructively competitive when the emphasis is on winning at all
costs. A major goal of effective negotiation is to make the other party feel satisfied with the
outcome. The focus in negotiation should be to create a win–win situation.
Many small negotiations take place every day spontaneously and succeed without any
advance preparation. However, not all nurses are expert negotiators. If managers wish to
succeed in important negotiations for unit resources, they must (a) be adequately prepared,
(b) be able to use appropriate negotiation strategies, and (c) apply appropriate closure and
follow-up. To become more successful at negotiating, managers need to do several things
before, during, and after the negotiation (Display 21.4).
DISpLAy 21.4 Before, During, and After the Negotiation
BEFORE
1. Be prepared mentally by having done your homework.
2. Determine the incentives of the person you will be negotiating with.
3. Determine your starting point, trade-offs, and bottom line.
4. Look for hidden agendas, both your own and the parties with whom you are negotiating.
DURING
1. Maintain composure.
2. Ask for what you want assertively.
3. role model good communication skills (speaking and listening), assertiveness, and flexibility.
4. Be patient and take a break if either party becomes angry or tired during the negotiation.
5. Avoid using destructive negotiation techniques, but be prepared to counter them if they are used
against you.
AFTER
1. restate what has been agreed upon, both verbally and in writing.
2. recognize and thank all participants for their contributions to a successful negotiation.
Before the Negotiation
For managers to be successful, they must systematically prepare for the negotiation. As
the negotiator, the manager begins by gathering as much information as possible regarding
the issue to be negotiated. Because knowledge is power, the more informed the negotiator

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Chapter 21 Effective Conflict Resolution and Negotiation 501
is the greater is his or her bargaining power. Adequate preparation prevents others in the
negotiation from catching the negotiator off guard or making him or her appear uninformed.
In addition, individuals must remember that few negotiations begin at the table. This
makes it especially important to know the who, what, when, where, and how of an issue.
This is the area where strategies are prepared. For example, Witzler (2010a) suggests
that it is important, whenever possible, to determine the incentives of your counterpart
in negotiation, especially if they are not in perfect alignment with the group he or she is
representing.
However, another level of preparation is the emotional level, which is the human side
of every negotiation and interaction. Remember that the “opponents” you face across the
bargaining table are individuals like you. The way the other party perceives you as being fair
and open to negotiate often plays a role in the decisions that will be reached in the negotiation.
It is also important for managers to decide where to start in the negotiation. Brodow (2013)
notes that successful negotiators are not afraid to ask for what they want. In addition, they
should be assertive (not aggressive) since they know that everything is negotiable. He calls
this negotiation consciousness and suggests that it is what makes the difference between
effective negotiators and everybody else.
Because negotiators must be willing to make compromises, they should, however, choose
a starting point that is high but not ridiculous. This selected starting point should be at the
upper limits of their expectations, realizing that they may need to come down to a more
realistic goal. For instance, let us say that you would really like four additional full-time RN
positions and a full-time clerical position budgeted for your unit. You know that you could
make do with three additional full-time RN positions and a part-time clerical assistant, but
you begin by asking for what would be ideal.
It is almost impossible in any type of negotiation to escalate demands; therefore, the
negotiator must start at an extreme but reasonable point. It also must be decided beforehand
how much can be compromised and what is an acceptable bottom line (or the least acceptable
resolution). Can the manager accept, at a minimum, one full-time RN position or two or
three?
The very least for which a person will settle is often referred to as the bottom line.
The wise manager also has other options in mind when negotiating for important resources. An
alternative option is another set of negotiating preferences that can be used so that managers
do not need to use their bottom lines but still meet their overall goal. For instance, you have
requested four full-time RN positions and one full-time clerical position. You could get by with
three full-time RNs and one part-time clerk. However, you believe strongly that you cannot
continue to provide safe patient care unless you are given two RNs and a part-time clerk—your
bottom line. However, if the original negotiation is unsuccessful, reopen negotiations by saying
that a second option that does not entail increasing the staff would be to float a ward clerk for
4 hours each day, implement a unit-dose system, require housekeeping to pass out linen, and
have dietary pass all the patient meal trays. This way, the overall goal of providing more direct
patient care by the nursing staff could still be met without adding nursing personnel.
Stanton (2013) adds that expert negotiators always prepare in advance to concede
something. Knowing in advance what you can concede allows you to compromise without
feeling that you are giving up and makes it easier for the other party to agree on a workable
compromise. The manager also needs to consider other trade-offs that are possible in these
situations. Trade-offs are secondary gains, often future oriented, that may be realized as
a result of conflict. For example, while attending college, a parent may feel intrapersonal
conflict because he or she is unable to spend as much time as desired with his or her children.
The parent is able to compromise by considering the trade-off: eventually, everyone’s life will
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502 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
be better because of the present sacrifices. The wise manager will consider trading something
today for something tomorrow as a means to reach satisfactory negotiations.
The manager also must look for and acknowledge hidden agendas—the covert intention
of the negotiation. Usually, every negotiation has a covert and an overt agenda. For example,
new managers may set up a meeting with their superior with the established agenda of
discussing the lack of supplies on the unit. However, the hidden agenda may be that the
manager feels insecure and is really seeking performance feedback during the discussion.
Having a hidden agenda is not uncommon and is not wrong by any means. Everyone has
them, and it is not necessary or even wise to share these hidden agendas. Managers, however,
must be introspective enough to recognize their hidden agendas so that they are not paralyzed
if the agenda is discovered and used against them during the negotiation. If the manager’s
hidden agenda is discovered, he or she should admit that it is a consideration but not the heart
of the negotiation.
For instance, although the hidden agenda for increasing unit staff might be to build the
manager’s esteem in the eyes of the staff, there may exist a legitimate need for additional staff.
If, during the negotiations, the fiscal controller accuses the manager of wanting to increase
staff just to gain power, the manager might respond by saying, “It is always important for
a successful manager to be able to gain resources for the unit, but the real issue here is an
inadequate staff.”
Managers who protest too strongly that they do not have a hidden agenda appear defensive and
vulnerable.
During the Negotiation
Because negotiation may be a highly charged experience, the negotiator always wants to
appear calm, collected, and self-assured. At least part of this self-assurance comes from
having adequately prepared for the negotiation. Part of the preparation should have included
learning about the people with whom the manager is negotiating. People come with a variety
of personality types, and over the course of their careers, managers will come across most if
not all of these personality types in various negotiations. Preparation, however, is not enough.
In the end, the negotiator must have clarity in his or her communication, assertiveness, good
listening skills, the ability to regroup quickly, and flexibility.
Negotiation is psychological and verbal. The effective negotiator always appears calm and
self-assured.
Indeed, Brodow (2013) suggests that effective negotiators are like detectives; they ask
probing questions and then become quiet. The other negotiator will tell you everything you
need to know if you listen. He encourages negotiators to follow the 70/30 Rule—listen 70%
of the time, and talk only 30% of the time. In addition, you should encourage the other
negotiator to talk by asking lots of open-ended questions that cannot be answered with a
simple “yes” or “no. ”
In addition, the negotiator must remember that concerns about status pervade almost
every negotiation. For example, Witzler (2010b) suggests that most people are less likely to
accept a job offer, even one that would be a substantial improvement on a current job, if it is
worse than an offer made to a peer. “The desire to achieve better outcomes than others—from
friends and coworkers to competitors—can cause individuals to leave value on the table”
(Witzler, 2010b, para 4). Witzler suggests that negotiators often make implicit comparisons
with others and then fail to understand why the other side finds certain demands offensive.
Strategies commonly used by leaders during negotiation to increase their persuasiveness and
foster open communication are shown in Display 21.5.

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Chapter 21 Effective Conflict Resolution and Negotiation 503
Destructive Negotiation Tactics
Some negotiators win by using specific intimidating or manipulative tactics. People using
these tactics take a competing approach to negotiation rather than a collaborative approach.
These tactics might be conscious or unconscious but are used repeatedly because they have
been successful for that person. Successful managers do not use these types of tactics, but
because others with whom they negotiate may do so, they must be prepared to counter such
tactics.
One such tactic is ridicule. The goal in using ridicule is to intimidate others involved in
the negotiation. If you are negotiating with someone who uses ridicule, maintain a relaxed
body posture, steady gaze, and patient smile. Brodow (2013) notes it is very important in
1. Use only factual statements that have been gathered in research.
2. Listen carefully, and watch nonverbal communication.
3. Keep an open mind, because negotiation always provides the potential for learning. it is impor-
tant not to prejudge. instead, a cooperative (not competitive) climate should be established.
4. try to understand where the other party is coming from. it is probable that one person’s percep-
tion is different from that of another. the negotiation needs to concentrate on understanding,
not just on agreeing.
5. Always discuss the conflict. it is important not to personalize the conflict by discussing the
parties involved in the negotiation.
6. try not to belabor how the conflict occurred or to fix blame for the conflict. instead, the focus
must be on preventing its recurrence.
7. Be honest.
8. Start tough so that concessions are possible. it is much harder to escalate demands in the
negotiation than to make concessions.
9. Delay when confronted with something totally unexpected in negotiation. in such cases, the
negotiator should respond, “i’m not prepared to discuss this right now” or “i’m sorry, this was
not on our agenda; we can set up another appointment to discuss that.” if asked a question
about something that the negotiator does not know, he or she should simply say, “i don’t have
that information at this time.”
10. Never tell the other party what you are willing to negotiate totally. You may be giving up the ship
too early.
11. Know the bottom line, but try never to use it. if the bottom line is used, the negotiator must be
ready to back it up or he or she will lose all credibility. Negotiations should always result in both
sides improving their positions; however, in reality, people sometimes have to walk away from
the negotiating table if the situation cannot be improved because not every negotiation can
result in terms that are agreeable to each party.
Brodow (2013, para 10) says this is why someone should never negotiate without options. “if
you depend too much on the positive outcome of a negotiation, you lose your ability to say NO.
When you say to yourself, ‘i will walk if i can’t conclude a deal that is satisfactory,’ the other
side can tell that you mean business.” if, however, the bottom line is reached, the negotiator
should tell the other party that an impasse has been reached and that further negotiation is not
possible at this time. then, the other party should be encouraged to sleep on it and reconsider.
the door should always be left open for further negotiation. Another appointment can be made.
Both parties should be allowed to save face.
12. take a break if either party becomes angry or tired during the negotiation. Go to the bathroom
or make a telephone call. remember that neither party can effectively negotiate if either is en-
raged or fatigued. Brodow (2013) notes that being patient in negotiation can be very difficult
for Americans. We often are in a hurry to complete the negotiation while individuals from Asian,
South American, or Middle east cultures will tell you that they look at time differently. they
believe that rushing is more likely to cause mistakes and leave money on the table, so whoever
can be more flexible about time generally has the advantage (Brodow).
DISpLAy 21.5 Strategies to Increase Persuasiveness and Foster Open Communication
During the Negotiation
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504 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
negotiation not to take the issues or the other person’s behavior personally. All too often,
negotiations fail because one or both of the parties get sidetracked by personal issues
unrelated to the negotiation at hand. Successful negotiators focus on solving the problem,
which is: “How can we conclude an agreement that respects the needs of both parties?
Obsessing over the other negotiator’s personality, or over issues that are not directly pertinent
to making a deal, can sabotage a negotiation. If someone is rude or difficult to deal with, try
to understand their behavior and don’t take it personally” (Brodow, para 16).
Another tactic some people use is ambiguous or inappropriate questioning. For example,
in one negotiating situation, the ICU supervisor had requested additional staff to handle open
heart surgery patients. During her bargaining, the CEO suddenly said, “I never did understand
the heart; can you tell me about the heart?” The supervisor did not fall into this trap and
instead replied that the physiology of the heart was irrelevant to the issue. Because people
tend to answer an authority figure, it is necessary to be on guard for this type of diversionary
tactic.
Flattery is another technique that makes true collaboration in negotiation very difficult.
The person who has been flattered may be more reluctant to disagree with the other party in
the negotiation, and thus his or her attention and focus are diverted. One method that managers
can use to discern flattery from other honest attempts to compliment is to be aware of how
they feel about the comment. If they feel unduly flattered by a gesture or comment, it is a
good indication that they were being flattered. For example, asking for advice or instruction
may be a subtle form of flattery, or it may be an honest request. If the request for advice is
about an area in which the manager has little expertise, it is undoubtedly flattery. However,
exchanging positive opening comments with each other when beginning negotiation is an
acceptable and enjoyable practice performed by both parties.
Nurses are also particularly sympathetic to gestures of helplessness. Because nursing is a
helping profession, the tendency to nurture is high, and managers must be careful not to lose
sight of the original intent of the negotiation—securing adequate resources to optimize unit
functioning.
Some people win in negotiation simply by rapidly and aggressively taking over and
controlling the negotiation before other members realize what is happening. If managers
believe that this may be happening, they should call a halt to the negotiations before decisions
are made. Saying simply, “I need to have time to think this over” is a good method of stopping
an aggressive takeover. The manager needs to be aware of destructive negotiation tactics and
develop strategies to overcome them because such tactics are antithetical to collaboration.
Destructive negotiation tactics are never a part of collaborative conflict resolution.
Leaders use an honest, straightforward approach and develop assertive skills for use in
conflict negotiation. Maintaining human dignity and promoting communication require that
all conflict interactions be assertive, direct, and open. Conflict must be focused on the issues
and resolved through joint compromise.
Closure and Follow-Up to Negotiation
Just as it is important to start the formal negotiation with some pleasantries, it is also good
to close on a friendly note. Once a compromise has been reached, restate it so that everyone
is clear about what has been agreed upon. If managers win more in negotiation than they
anticipated, they should try to hide their astonishment. At the end of any negotiation, whether
it is a short 2-minute conflict negotiation in the hallway with another RN or an hour-long
formal salary negotiation, the result should be satisfaction by all parties that each has won
something. It is a good idea to follow up formal negotiation in writing by sending a letter or
a memo stating what was agreed.

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Chapter 21 Effective Conflict Resolution and Negotiation 505
ALTERNATIVE DISpuTE RESOLuTION
Many disputes can be solved informally. Occasionally, however, parties cannot reach
agreement through negotiation. In these cases, ADR may be indicated to keep some privacy in
the dispute and to avoid expensive litigation. Types of ADR include mediation, fact finding,
arbitration, due process hearings, and the use of ombudspersons.
Mediation, which uses a neutral third party, is a confidential, legally nonbinding process
designed to help bring the parties together to devise a solution to the conflict. As such, the
mediator does not take sides and has no vested interest in the outcome. Instead, the mediator
asks questions to clarify the issues at hand ( fact finding), listens to both parties, meets with
parties privately as necessary, and helps to identify solutions both parties can live with.
There are times, however, when mediators are unable to help conflicted parties come
to agreement. When this occurs, formal arbitration may be used. Unlike mediation, which
seeks to help conflicted parties come together to reach a decision themselves, arbitration is a
binding conflict resolution process in which the facts of the case are heard by an individual
who makes a final decision for the parties in conflict.
Due process hearings are actual court hearings, which focus on evaluating and resolving
conflicts through discovery, presentation of evidence, sworn testimony including that of
expert witnesses, and cross-examination (Mueller, 2009). A hearing officer objectively listens
to both sides of the issue and makes a decision following the letter of the law (Mueller). Case
law established through precedence often determines the outcome.
Another option for individuals experiencing conflict may be guidance from ombudspersons.
Ombudspersons generally hold an official title as such within an organization. Their function
is to investigate grievances filed by one party against another and to ensure that individuals
involved in conflicts understand their rights as well as the process that should be used to
report and resolve the conflict.
LEARNING EXERCISE 21.4
An Exercise in Negotiation Analysis
You are one of a group of staff nurses who believe that part of your job dissatisfaction results
from being assigned different patients every day. Your unit uses a system of total patient care,
and the head nurse makes assignments. two staff nurses have gone to the head nurse and
requested that each nurse be allowed to pick his or her own patients based on the previous
day’s assignment and the ability of the nurse. the head nurse believes that the staff nurses are
being uncooperative because it is the head nurse’s responsibility to see that all the patients get
assigned and receive adequate care. Although continuity of care is the goal, many part-time
nurses are used on the unit, and not all the nurses are able to care for every type of patient. At
the end of the conference, the two nurses are angry, and the head nurse is irritated. however,
the next day, the head nurse indicates willingness to meet with the staff nurses. the other nurses
believe this is a sign that the head nurse is willing to negotiate a compromise. they plan to get
together tonight to plan the strategy for tomorrow’s meeting.
Assignment: What are the goals for each party? What could be a possible hidden agenda
for each party? What could happen if the conflict escalates? Devise a workable plan that
would accomplish the goals of both parties and develop strategies for implementation (see the
Appendix for an analysis of these problems).
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506 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
SEEKING CONSENSuS
Consensus means that negotiating parties reach an agreement that all parties can support,
even if it does not represent everyone’s first priorities. Consensus decision making does
not provide complete satisfaction for everyone involved in the negotiation as an initially
unanimous decision would, but it does indicate willingness by all parties to accept the agreed-
upon conditions.
In committees or groups working on shared goals, consensus is often used to resolve
conflicts that may occur within the group. To reach consensus often requires the use of
an experienced facilitator, and having consensus-building skills is a requirement of good
leadership. Building consensus ensures that everyone within the group is heard but that the
group will ultimately end up with one agreed-upon course of action. Consensual decisions
are best used for decisions that relate to a core problem or need a deep level of group support
to implement successfully.
Perhaps the greatest challenge in using consensus as a conflict resolution strategy is
that like collaboration, it is time consuming. It also requires all of the parties involved in
the negotiation to have good communication skills and to be open minded and flexible.
It is also important for the leader to recognize when achieving consensus has become
unrealistic.
INTEGRATING LEADERSHIp SKILLS AND MANAGEMENT FuNCTIONS
IN MANAGING CONFLICT
There are many benefits to establishing and maintaining an appropriate amount of
conflict in the workplace, including increased harmony and productivity, a pleasant
working environment, reductions in stress and anxiety, and decreased victimized
behavior (Hudson, 2003–2013). In addition, the manager who creates a stable work
environment that minimizes the antecedent conditions for conflict has more time and
energy to focus on meeting organizational and human resource needs. When conflict does
occur in the unit, managers must be able to discern constructive from destructive conflict.
Conflict that is constructive will result in creativity, innovation, and growth for the unit.
When conflict is deemed to be destructive, managers must deal appropriately with that
conflict or risk an aftermath that may be even more destructive than the original conflict.
Consistently using conflict resolution strategies with win–lose or lose–lose outcomes will
create disharmony within the unit. Leaders who use optimal conflict resolution strategies
with a win–win outcome promote increased employee satisfaction and organizational
productivity.
Negotiation also requires both management functions and leadership skills. Well-
prepared managers know with whom they will be negotiating and prepare their negotiation
accordingly. They are prepared with trade-offs, multiple alternatives, and a clear bottom
line to ensure that their unit acquires needed resources. Successful negotiation mandates
the use of the leadership components of self-confidence and risk taking. If these attributes
are not present, the leader-manager has little power in negotiation and thus compromises
the unit’s ability to secure desired resources. Other attributes that make leaders
effective in negotiation are sensitivity to others and the environment and interpersonal
communication skills. The leader’s use of assertive communication skills, rather than
destructive tactics, results in an acceptable level of satisfaction for all parties at the close
of the negotiation.

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Chapter 21 Effective Conflict Resolution and Negotiation 507
ADDITIONAL LEARNING EXERCISES AND AppLICATIONS
KEY CONCEPTS
l Conflict can be defined as the internal discord that results from differences in ideas, values, or feelings
of two or more people.
l Because managers have a variety of interpersonal relationships with people with different values, beliefs,
backgrounds, and goals, conflict is an expected outcome.
l the most common sources of organizational conflict are communication problems, organizational
structure, and individual behavior within the organization.
l Conflict theory has changed dramatically during the last 100 years. Currently, conflict is viewed
as neither good nor bad because it can produce growth or be destructive, depending on how it is
managed.
l too little conflict results in organizational stasis, whereas too much conflict reduces the organization’s
effectiveness and eventually immobilizes its employees.
l Conflict also has a qualitative component, and the impact of a conflict on any individual varies
significantly in terms of how it is perceived and handled.
l the three categories of conflict are intrapersonal, interpersonal, and intergroup.
l the first stage in the conflict process is called latent conflict, which implies the existence of antecedent
conditions. Latent conflict may proceed to perceived conflict or to felt conflict. Manifest conflict may also
ensue. the last stage in the process is conflict aftermath.
l the optimal goal in conflict resolution is creating a win–win solution for everyone involved.
l Common conflict resolution strategies include compromise, competing, accommodating, smoothing,
avoiding, and collaboration.
l As a negotiator, it is important to win as much as possible, lose as little as possible, and make the other
party feel satisfied with the outcome of the negotiation.
l Because knowledge is power, the more informed the negotiator is, the greater is his or her bargaining
power.
l the leader, while able to recognize and counter negotiation tactics, always strives to achieve an honest,
collaborative approach to negotiation.
l the manager must know his or her bottom line but try never to use it.
l Closure and follow-up are important parts of the negotiation process.
l ADr usually involves at least one of the elements of mediation, fact finding, arbitration, and the use of
ombudspersons.
l Seeking consensus, a concord of opinion, although time consuming, is an effective conflict resolution
and negotiation strategy.
LEARNING EXERCISE 21.5
Choosing the Most Appropriate Resolution Approach
in the following situations, choose the most appropriate conflict resolution strategy (avoiding,
smoothing, accommodating, competing, compromising, or collaborating). Support your decision
with rationale, and explain why other methods of conflict management were not used.
(Continued )
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508 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Situation 1
You are a circulating nurse in the operating room. Usually, you are assigned to room 3 for
general surgery, but today you have been assigned to room 4, the orthopedic room. You are
unfamiliar with the orthopedic doctors’ routines and attempt to brush up on them quickly by
reading the doctors’ preference cards before each case today. So far, you have managed
to complete two cases without incident. the next case comes in the room, and you realize
that everyone is especially tense; this patient is the wife of a local physician, and the doctors
are performing a bone biopsy for possible malignancy. You prepare the biopsy area, and the
surgeon, who has a reputation for a quick temper, enters the room. You suddenly realize that you
have prepped the area with Betadine, and this surgeon prefers another solution. he sees what
you have done and yells, “You are a stupid, stupid nurse.”
Situation 2
You are the iCU charge nurse and have just finished an exhausting 8 hours on duty. Working
with you today were two nurses who work 12-hour shifts. each of you were assigned two
patients, all with high acuity levels. You are glad that you are going out of town tonight to attend
an important seminar, because you are certainly tired. You are also pleased that you scheduled
yourself an 8-hour shift today and that your replacement is coming through the door. You will
just have time to give report and catch your plane.
it is customary for 12-hour nurses to continue with their previous patients and for assignments
not to be changed when 8- and 12-hour staff are working together. therefore, you proceed to
give report on your patients to the 8-hour nurse coming on duty. One of your patients is acutely
ill with fever of unknown origin and is in the isolation room. it is suspected that he has meningitis.
Your other patient is a multiple trauma victim. in the middle of your report, the oncoming nurse
says that she has just learned that she is pregnant. She says, “i can’t take care of a possible
meningitis patient. i’ll have to trade with one of the 12-hour nurses.” You approach the 12-hour
nurses, and they respond angrily, “We took care of all kinds of patients when we were pregnant,
and we are not changing patients with just 4 hours left in our shift.”
When you repeat this message to the oncoming nurse, she says, “either they trade or i go
home!” Your phone call to the nursing office reveals that because of a flu epidemic, there are
absolutely no personnel to call in, and all the other units are already short staffed.
Situation 3
You are an rN graduate of a BSN nursing program. Since you graduated 6 months ago, you
have been working at an outpatient emergency clinic and have just recently begun to feel more
confident in your new role. however, one of the older, diploma-educated nurses working with
you constantly belittles baccalaureate nursing education. Whenever you request assistance in
problem solving or in learning a new skill, she says, “Didn’t they teach you anything in nursing
school?” the clinic supervisor has given you satisfactory 3- and 6-month evaluations, but you
are becoming increasingly defensive regarding the comments of the other nurse.
Situation 4
You are the charge nurse on a step-down unit. it is your first day back from a 2-week vacation.
the shift begins in 10 minutes, and you sit down to make staffing assignments. the central
staffing office has noted that you must float one of your rNs to the oncology unit. When you
check the floating roster, you note that Jenny, one of the rNs assigned to work on your unit
today, was the last to float. (She floated yesterday.) that leaves you to choose from Mark and
Lisa, your other two rNs. According to the float roster, Mark floated 10 days ago, and Lisa
floated last 11 days ago. You tell Lisa that it is her turn to float.

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Chapter 21 Effective Conflict Resolution and Negotiation 509
Lisa states that she floated three times in a row while Mark was on vacation for 2 weeks last
month. Mark says that vacations should not count and that he should not float because it is not
his turn. Lisa says that Jenny should float, as she floated to oncology yesterday and already
knows the patients. Jenny says that she agreed to come in and work today (on her day off) to
help the unit, and she would not have agreed to do this if she had known that she would have
to float. Mark says that it is the last day of a 6-day stretch, and he does not want to float. Jenny
says that it is not her turn to float, and she does not want to float willingly.
Situation 5
You are a new nurse working on a busy medical/surgical floor. the mode of patient care delivery
used on the unit is team nursing. You have grown increasingly frustrated, however, with a
licensed vocational nurse (LVN)/licensed professional nurse (LpN) on your team who is unwilling
to answer call lights. You have directly observed her both ignore call lights and go out of her way
to avoid answering the lights. When you confront her, she always provides an excuse such as
she was on her way to do something for another patient or that she did not notice the blinking
call light. the end result is that you often must run from one end of the hall to the other to answer
the call lights since patient safety could be at risk. Your frustration level has risen to the point
that you no longer wish to work with this person.
Situation 6
You are a staff nurse on a small telemetry unit. the unit is staffed at a ratio of one nurse for
every four patients and the charge nurse is counted in this staffing since there is a full-time
unit secretary and monitor technician to assist at the desk. the charge nurse is responsible
for making the daily staffing assignments. While you recognize that the charge nurse needs to
reduce her patient care assignment to have time to perform the charge nurse duties, you have
grown increasingly frustrated that she normally assigns herself only one patient, if any, and these
patients always have the lowest acuity level on the floor. this has placed a disproportionate
burden on the other nurses, who often feel the assignment they are being given may be unsafe.
the charge nurse is your immediate supervisor. She has not generally been responsive to
concerns expressed by the staff to her about this problem.
LEARNING EXERCISE 21.6
Negotiating the Graduation Ceremony
Often, one group is more powerful or has greater status and refuses to relinquish this power
position, thus making collaboration impossible. therefore, negotiating a compromise to a win–
win solution, rather than a lose–lose solution, becomes imperative. in the following situation,
describe if you could, and how you would, go about negotiating a win–win solution to conflict.
You are a senior member of a traditional on-campus baccalaureate nursing class. three years
ago, your university implemented an online rN-BSN program. the first students from that
program graduated last year, and they held a small, private end-of-program ceremony, separate
from the on-campus BSN students.
this year, as a result of ongoing state budget cuts, the school of nursing can no longer
subsidize two separate end-of-program ceremonies. this means that the 21 rN-BSN students
and the 33 on-campus BSN students must now work together to plan a joint ceremony.
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510 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
resistance is high. the two groups of students have spent no time together and do not know
each other. the on-campus students have been planning their ceremony since they started the
nursing program and have collected additional money each semester to fund a formal dinner and
dance reception in the evening and breakfast at one of the nicest hotels in town. Money from
the school of nursing would be used to subsidize the cost of a live band and the reception hall.
the online students would like to limit the evening reception to cake and punch at the college
to reduce the cost because most of them will incur additional travel and lodging costs to attend
graduation. however, they would like to have the school of nursing use the funds available to
host a “picnic in the park” the following day, to which they can bring their families. Both groups
perceive that the “other group is trying to control the situation and is not being sensitive to our
needs or wants.” Both groups have contacted university officials to complain about the situation,
and a number of students are threatening not to attend the ceremony if the two groups must
be merged.
You have been appointed as the unofficial spokesperson for the rN-BSN graduates. Joan is the
unofficial spokesperson for the on-campus BSN students. You live only 30 miles from campus,
so coming to campus to try to resolve the conflict is not a significant hardship.
the faculty member, Alice, who is the liaison for the end-of-program ceremony has become
alarmed at the situation and has contacted both you and Joan. She states that she will cancel
the ceremony if the conflict is not resolved. the faculty member agrees to work with you and
Joan to mediate the conflict, but time is of the essence. the semester ends soon, and the
on-campus students can get no refund on their reception hall deposit after the end of the current
week. She wants the conflict resolved in a win–win situation so that no parties leave angry.
Assignment: Where will you begin? how will you get input from the group that you are
representing? Would you plan a face-to-face meeting with Joan to attempt to resolve this
conflict? What strategies might you use to help both groups win as much as possible and lose
as little as possible? explain your rationale. remember, you wish to negotiate a compromise, and
although you desire a win–win solution, you are limited in time and may not be able to facilitate
a true collaboration. how will you deal with conflicted parties who perceive that they have lost
more than they have won? What is your bottom line?
LEARNING EXERCISE 21.7
Behavioral Tactics—Appropriate or Not?
You are a woman who is a unit manager with a master’s degree in health administration. You
are about to present your proposed budget to the CeO, who is a man. You have thoroughly
researched your budget and have adequate rationale to support your requests for increased
funding. Because the CeO is often moody, predicting his response is difficult.
You are also aware that the CeO has some very traditional views about women’s role in the
workplace, and generally this does not include a major management role. Because he is fairly
paternalistic, he is charmed and flattered when asked to assist “his” nurses with their jobs.
Your predecessor, also a woman, was fired because she was perceived as brash, bossy, and
disrespectful by the CeO. in fact, the former unit manager was one of a series of nursing
managers who had been replaced in the last several years because of these characteristics.
From what you have been told, the nursing staff did not share these perceptions.
You sit down and begin to plan your strategy for this meeting. You are aware that you are
more likely to have your budgetary needs met if you dress conservatively, beseech the CeO’s
assistance and support throughout the presentation, and are fairly passive in your approach.

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Chapter 21 Effective Conflict Resolution and Negotiation 511
in other words, you will be required to assume a traditionally feminine, helpless role. if you
appear capable and articulate, you may not achieve your budgetary goals and may not even
keep your job. it would probably not be necessary for you to continue to act this way, except in
your interactions with the CeO.
Assignment: Are such behavioral tactics appropriate if the outcome is desirable? Are such
tactics simply smart negotiation, or are they destructively manipulative? What would you do in this
situation? Outline your strategy for your budget presentation, and present rationale for your choices.
LEARNING EXERCISE 21.9
Handling Staff–Patient Conflict
You are the supervisor of a rehabilitation unit. two of your youngest female nursing assistants
come to your office today to report that a young male paraplegic patient has been making lewd
sexual comments and gestures when they provide basic care. When you question them about
their response to the actions of the patient, they maintain that they normally simply look away
and try to ignore him, although they are offended by his actions. they are reluctant to confront
the patient directly.
Because it is anticipated that this patient may remain on your unit for at least a month, the
nursing assistants have asked you to intervene in this conflict by either talking to the patient or
by assigning other nurses responsibility for his care.
Assignment: how will you handle this staff–patient conflict? is avoidance (assigning different
staff to care for the patient) an appropriate conflict resolution strategy in this situation? Will you
encourage the nursing assistants to confront the patient directly? What coaching or role playing
might you use with them if you choose this approach? Will you confront the patient yourself?
What might you say?
LEARNING EXERCISE 21.8
Your First Budget Presentation
You are the unit manager of the new oncology unit. it is time for your first budget presentation to
the administration. You have already presented your budget to the Director of Nurses, who had a
few questions but expressed general agreement. however, it is the policy at Memorial hospital
that the unit manager’s present budget be presented to the budget committee, consisting of
the fiscal manager, the Director of Nurses, a member of the board of trustees, and the executive
Director. You know that money is scarce this year because of the new building, but you really
believe that you need the increases you have requested in your budget. Basically, you have
asked for the following:
● replace the 22% aides on your unit with 10% LVNs/LpNs and 12% rNs.
● increase educational time paid by 5% to allow for certification in chemotherapy.
● provide a new position of clinical nurse specialist in oncology.
● Convert one room into a sitting room and mini-kitchen for patients’ families.
● Add shelves and a locked medication box in each room to facilitate primary nursing.
● provide no new equipment, but replace existing equipment that is broken or outdated.
Assignment: Outline your plan. include your approach what is and what is not negotiable and
what arguments you would use. Give a rationale for your plan.
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512 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
LEARNING EXERCISE 21.10
Handling Personal Issues in a Professional Manner
You are a male unit supervisor of a pediatric trauma unit at Children’s hospital. three years ago,
you ended a serious romantic relationship with a nurse named Susan, who was employed at a
different hospital in the same city. the break up was not mutual, and Susan was hurt and angry.
Six months ago, Susan accepted a position as a unit supervisor at Children’s hospital. this
has required you and Susan to interact formally at department head meetings and informally
regarding staffing and personnel issues on a regular basis. Often, these interactions have been
marked by either covert hostility on Susan’s part, nonverbal aggression, or sniping comments.
When you attempted to confront Susan about her behavior, she stated that “she didn’t have a
problem and that you shouldn’t flatter yourself to think that she does.”
the situation is becoming increasingly more difficult to “work around,” and both staff and fellow
unit supervisors have become aware of the ongoing tension. You love your position and do not
want to leave Children’s hospital, but it is becoming increasingly apparent that the situation
cannot continue as it is.
Assignment: Answer the following questions:
1. how might gender have influenced the latent conditions, perceived or felt conflict, manifest
conflict, and conflict aftermath in this situation?
2. What conflict strategies might you use to try to resolve this conflict? Avoidance? Smoothing?
Accommodation? Competing? Compromise? Collaboration?
3. Would the use of a mediator be helpful in this situation?
LEARNING EXERCISE 21.11
Choosing the Most Appropriate Resolution Approach
Choose one of the following situations and write a one-page essay, discussing which conflict
resolution strategy is most appropriate for this situation. explain why other conflict resolution
strategies were rejected.
Situation 1
You are an rN on a surgical unit. MJ is an orthopedic surgery patient who is 2 days postop.
her physician has ordered patient-controlled analgesia (pCA) using morphine, as well as prn
iM injections of Demerol every 3 to 4 hours. the patient has continued to verbalize a significant
amount of pain.
today, Dr. Jones writes an order for you to give MJ an additional 100 mg Demerol iM now,
even though she had 100 mg less than 1 hour ago as well as her pCA. the dose he ordered is
contraindicated in your drug handbook. You approach Dr. Jones with your concerns about the
safety of such a dose as well as your questioning of the patient’s pain level. Dr. Jones interrupts
you shortly after you begin and says in a curt, hostile tone, “i am the doctor and i write the
medication orders. You are the nurse and your responsibility is to implement my care plan. Give
the medication now or i will see that you are fired.”
Situation 2
today is Wednesday. Julie, a long-time employee on your unit where you are a manager, believes
she is entitled to certain privileges regarding scheduling. You have told her to review the policy
concerning weekends and days off. Julie believes she deserves every other weekend off, with
Friday and Monday off on the weekends she works.

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Chapter 21 Effective Conflict Resolution and Negotiation 513
REFERENCES
You have been able to meet Julie’s request for the last 3 years because other employees
preferred working weekends. Your recent employee turnover, however, means that meeting this
request is no longer possible. Julie was scheduled to work Monday because of low staffing,
but she refused, stating that Monday is her regular day off. You believe you can guarantee no
employee any regular day off other than having 2 days off each week. Julie is scheduled to work
on Friday.
American Sentinel. (2012, September 24). Nursing career
strategies: Guidelines for painless conflict resolution.
Nursetogether.com. Retrieved June 21, 2013, from
http://www.nursetogether.com/nursing-career
-strategies-guidelines-for-painless-conflict
-resolution#sthash.Y0q2bYSh.dpuf
Brodow, E. (2013). Ten tips for negotiating in 2013. Ed
Brodow Seminars. Retrieved June 21, 2013, from
http://www.brodow.com/Articles/NegotiatingTips.html
Cheung-Larivee, K. (2013, January 31). How rude!
Workplace incivility hurts bottom line.
FierceHealthcare. Retrieved June 21, 2013, from
http://www.fiercehealthcare.com/story/how-rude
-workplace-incivility-hurts-bottom-line/2013-01
-31#ixzz2Wss5nNiD
Clark, C. M. (2010) Why civility matters. Reflections on
Nursing Leadership, 36(1). Retrieved June 21, 2013,
from http://www.reflectionsonnursingleadership.org/
Pages/Vol36_1_Clark2_civility.aspx
CRM Learning. (2013, June 16). The decision to get
involved—4 things to consider. Retrieved June
21, 2013, from http://www.crmlearning.com/
blog/?tag=conflict-management
Ellis, P., & Abbott, J. (2012). Strategies for managing
conflict within the team. British Journal of Cardiac
Nursing, 7(3), 138–140.
Hauge, L., Skogstad, A., & Einarsen, S. (2009, October–
December). Individual and situational predictors of
workplace bullying: Why do perpetrators engage
in the bullying of others? Work & Stress, 23(4),
349–358.
Hockley, C. (2014). Violence in nursing: The expectations and
the reality. In C. J. Huston (Ed.), Professional issues
in nursing: Challenges and opportunities (3rd ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Hudson, K. (2003–2013). Conflict resolution. Dynamic
nursing education. Retrieved June 21, 2013, from
http://dynamicnursingeducation.com/class.php?class
_id=70&pid=14
Inglis, R. L., Schaper, A. M., & Swartz, S. L. (2013,
April 14). Conflict engagement skill building for
nurse residents. Session presented at the Sigma
Theta Tau International conference Creating Healthy
Work Environments, Indianapolis, IN. Virginia
Henderson International Nursing Library. Retrieved
June 20, 2013, from http://www.nursinglibrary.org/
vhl/handle/10755/290986
Kaitelidou, D., Kontogianni, A., Galanis, P., Siskou, O.,
Mallidou, A., Pavlakis, A., & Liaropoulos, L.
(2012). Conflict management and job satisfaction in
paediatric hospitals in Greece. Journal of Nursing
Management, 20(4), 571–578.
Losa Iglesias, M. E., & Becerro de Bengoa Vallejo, R.
(2012). Conflict resolution styles in the nursing
profession. Contemporary Nurse: A Journal for
the Australian Nursing Profession, 43(1), 73–80.
Mueller, T. (2009, June). Alternative dispute resolution: A
new agenda for special education policy. Journal of
Disability Policy Studies, 20(1), 4–13.
Roche, M., Diers, D., Duffield, C., & Catling-Pauli,
C. (2010). Violence toward nurses, the work
environment, and patient outcomes. Journal of
Nursing Scholarship, 42(1), 13–22.
Stacey G., Johnston, K., Stickley, T. & Diamond, B. (2011)
How do nurses cope with values and practice
conflict? Nursing Times,107(5), 20–23.
Stanton, K. (2013). Resolving workplace conflict.
Advance for Nurses. Retrieved June 20, 2013,
from http://nursing.advanceweb.com/Continuing
-Education/CE-Articles/Resolving-Workplace
-Conflict.aspx
Townsend, T. (2012, January). Break that bullying cycle.
American Nurse Today. Retrieved June 21, 2013,
from http://www.americannursetoday.com/article
.aspx?id=8648
Vaughn, P. (2009, September–November). Collaboration
and conflict management: A brief review of current
thought. Oklahoma Nurse, 54(3), 4.
Witzler, L. (2010a, March 2). Understand your counterpart’s
incentives. The President and Fellows of Harvard
College. Retrieved June 20, 2013, from http://
www.pon.harvard.edu/daily/business-negotiations/
understand-your-counterparts-incentives/
Witzler, L. (2010b, February 16). How status conscious are
you? The President and Fellows of Harvard College.
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.harvard.edu/daily/business-negotiations/how-status
-conscious-are-you/
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http://www.nursetogether.com/nursing-career-strategies-guidelines-for-painless-conflict-resolution#sthash.Y0q2bYSh.dpuf

http://www.fiercehealthcare.com/story/how-rude-workplace-incivility-hurts-bottom-line/2013-01-31#ixzz2Wss5nNiD

http://www.reflectionsonnursingleadership.org/Pages/Vol36_1_Clark2_civility.aspx

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http://www.nursinglibrary.org/vhl/handle/10755/290986

http://nursing.advanceweb.com/Continuing-Education/CE-Articles/Resolving-Workplace-Conflict.aspx

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http://www.pon.harvard.edu/daily/business-negotiations/understand-your-counterparts-incentives/

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514
22
Collective Bargaining, Unionization,
and Employment Laws
During the past decade, the downsizing of nursing staffs, systems redesign, and oppressive
management practices have created such poor nursing practice environments that improvement in
wages no longer is viewed as the primary purpose of collective bargaining.
—Karen Budd, Linda Warino, and Mary Ellen Patton
… Organizations with unfair management policies are more likely to become unionized. It is within
managerial power to eliminate some of the needs that staff have for joining unions.
—Carol Huston
CROSSWALK tHis CHaPtEr addrEssEs:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential V: Health-care policy, finance, and regulatory environments
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
BSN Essential VII: Professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential III: Quality improvement and safety
MSN Essential VI: Health policy and advocacy
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: teamwork and collaboration
QSEN Competency: Quality improvement
QSEN Competency: safety
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: Professionalism
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l identify factors that influence whether nurses join unions
l describe the relationship between national economic prosperity, the existence of nursing
shortages and surpluses, and the unionization rates of nurses
l differentiate between the leader’s and manager’s roles in collective bargaining
l identify major legislation that has impacted the ability of nurses to unionize
l identify the steps necessary to start a union
l identify the largest unions representing health-care employees, and nurses in particular

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 515
l philosophically debate the potential conflicts inherent in having a professional organization
also serve as a collective bargaining agent
l reflect on whether going on strike can be viewed as an ethically appropriate action for
professional nurses
l differentiate between federal and state labor standards and labor contracts
l explore labor laws regarding overtime and working conditions present in the state in which
he or she lives or will seek employment
l explain how equal employment legislation has affected employment and hiring practices
l identify how the Civil rights act, the americans with disabilities act, and the age
discrimination and Employment act have attempted to reduce discrimination in the workplace
l identify the purpose of the Occupational safety and Health act (OsHa)
l identify strategies for eliminating sexual harassment in the workplace
Factors that have an impact on the directional aspects of management include collective
bargaining, unionization, and employment laws. It is possible to make these factors positive
rather than negative influences on management effectiveness. To accomplish this, managers
must first understand the interrelationship of unionization and management, the proliferation
of legislation regarding employment practices, and the impact of both on the health-care
industry.
Managers must be able to see collective bargaining and employment legislation from
four perspectives: the organization, the worker, general historical and societal, and personal.
Managers who can gain this broad perspective will better understand how management and
employees can work together cooperatively despite unionization and employment legislation.
Many industrialized countries have adopted an attitude of acceptance and tolerance for
the difficulties of managing under these influences. However, in the United States, many
organizations view these forces with resentment and hostility.
This chapter examines the leadership roles and management functions necessary to create
a climate in which unionization and legislation are compatible with organizational goals. The
leadership roles and management functions inherent in dealing with collective bargaining,
unionization, and employment laws are shown in Display 22.1.
DISPLAY 22.1 Leadership Roles and Management Functions Associated with Collective
Bargaining, Unionization, and Employment Laws
LEADERSHIP ROLES
1. is self-aware regarding personal attitudes and values regarding collective bargaining and
employment laws.
2. recognizes and accepts reasons why people seek unionization.
3. Creates a work environment that is sensitive to employee needs, thereby reducing the need for
unionization.
4. Maintains an accommodating or cooperative approach when dealing with unions and employ-
ment legislation.
5. is a role model for fairness.
6. is nondiscriminatory in all personal and professional actions.
7. Examines the work environment periodically to ensure that it is supportive for all members
regardless of gender, race, age, disability, or sexual orientation.
8. immediately confronts and addresses sexual harassment in adopting a zero tolerance approach
to the problem.
9. Embraces the intent of laws barring discrimination and providing equal opportunity.
10. actively seeks a culturally and ethnically diverse workforce to meet the needs of an increasingly
diverse client population.
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516 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
UNIONS AND COLLECTIVE BARGAINING
Collective bargaining involves activities occurring between organized labor and management
that concern employee relations. Such activities include the negotiation of formal labor
agreements and day-to-day interactions between unions and management. Huston (2014a)
maintains that the issue at the heart of the debate on collective bargaining and nursing
is whether nursing—long recognized as a care-giving profession—should be a part of
bargaining efforts to improve working conditions. Although this may seem to represent a
dichotomy, it is also true that unions and collective bargaining are very much a part of many
nurses’ lived experience.
Although first- and middle-level managers usually have little to do with negotiating the
labor contract, they are greatly involved with the contract’s daily implementation. The middle
manager has the greatest impact on the quality of the relationship that develops between labor
and management. Terminology associated with unions and collective bargaining is shown in
Display 22.2.
MANAGEMENT FUNCTIONS
1. Understands and appropriately implements union contracts.
2. administers personnel policies fairly and consistently.
3. Works cooperatively with the personnel department and top-level administration when dealing
with union activity.
4. Promotes worker identification with management.
5. immediately and fully investigates all complaints regarding violations of the collective bargain-
ing contract and takes appropriate action.
6. Creates opportunities for subordinates to have input into organizational decision-making to
discourage unionization.
7. is alert for discriminatory employment practices in the workplace and intervenes immediately
when problems exist.
8. Ensures that the unit or department meets state licensing regulations.
9. Understands and follows labor and employment laws that relate to the manager’s sphere of
influence and organization responsibilities.
10. Ensures that the work environment is safe.
11. Works closely with human resource management when dealing with employment legislation
issues.
Agency shop: also called an open shop. Employees are not required to join the union.
Arbitration: terminal step in the grievance procedure, where a third party reviews the grievance,
completes fact finding, and reaches a decision. always indicates the involvement of a third party.
arbitration may be voluntary on the part of management and labor or imposed by the government
in a compulsory arbitration.
Collective bargaining: relations between employers, acting through their management representa-
tives, and organized labor.
Conciliation and mediation: synonymous terms that refer to the activity of a third party to help
disputants reach an agreement. However, unlike an arbitrator, this person has no final power of
decision-making.
Fact finding: rarely used in the private sector but used frequently in labor–management disputes
that involve government-owned companies. in the private sector, fact finding is usually performed
by a board of inquiry.
DISPLAY 22.2 Collective Bargaining Terminology

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 517
HISTORICAL PERSPECTIVE OF UNIONIZATION IN AMERICA
Unions have been present in America since the 1790s. Skilled craftsmen formed early unions
to protect themselves from wage cuts during the highly competitive era of industrialization.
The history of unionization reveals that union membership and activity increase sharply
during times of high employment and prosperity and decrease sharply during economic
recessions and layoffs.
Union activity also tends to change in response to workforce excesses and shortages. For
decades, employment demand for nurses has increased and decreased periodically. High
demand for nurses is tied directly to a healthy national economy, and historically, this has
been correlated with increased union activity. Similarly, when nursing vacancy rates are low,
union membership and activity tends to decline.
Nurses’ perceptions of whether they are valued by their employers have also always had an
impact on unionization rates. The rapid downsizing and restructuring of the 1990s left many
nurses feeling that management did not listen to them or care about their needs.
Management that is perceived to be deaf to the workers’ needs provides a fertile ground
for union organizers, because unions thrive in a climate that perceives the organizational
philosophy to be insensitive to the worker.
For many reasons, however, collective bargaining was slow in coming to the health-care
industry. Until labor laws were amended, the unionization of health-care workers was illegal.
Nursing’s long history as a service commodity further delayed labor organization in health-
care settings. Initial collective bargaining in the profession took place in organizations that
were deemed government or public. This was made possible by Executive Order 10988,
authored in 1962. This order lifted restrictions preventing public employees from organizing.
Therefore, collective bargaining by nurses at city, county, and district hospitals and health-
care agencies began in the 1960s.
In 1974, Congress amended the Wagner Act, extending national labor laws to private,
nonprofit hospitals; nursing homes; health clinics; health maintenance organizations; and
other health-care institutions. These amendments opened the door to much union activity for
professions and the public employee sector. Indeed, a review of union-membership figures
readily shows that, since 1960, most collective bargaining activity in the United States
Free speech: Public Law 101, section 8, states that “the expressing of any views, argument, or
dissemination thereof, whether in written, printed, graphic, or visual form, shall not constitute or
be evidence of an unfair labor practice under any provisions of this act, if such expression con-
tains no threat of reprisal or force or promise of benefit.”
Grievance: Perception on the part of a union member that management has failed in some way to
meet the terms of the labor agreement.
Lockout: Closing a place of business by management in the course of a labor dispute for the
purpose of forcing employees to accept management terms.
National Labor Relations Board (NLRB): Labor board formed to implement the Wagner act. its
two major functions are to (a) determine who should be the official bargaining unit when a new
unit is formed and who should be in the unit and (b) adjudicate unfair labor charges.
Professionals: Professionals have the right to be represented by a union but cannot belong to a
union that represents nonprofessionals unless a majority of them vote for inclusion in the non-
professional unit.
Strike: Concerted withholding of labor supply to bring about economic pressure on employers and
cause them to grant employee demands.
Union shop: also called a closed shop. all employees are required to join the union and pay dues.
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518 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
occurred in the public and professional sectors of industry, most notably among faculty at
institutions of higher education, teachers at primary and secondary levels, and physicians.
There have been gradual declines in unionization in the private and blue-collar sectors since
membership peaked in the 1950s.
From 1962 through 1989, slow but steady increases occurred in the numbers of nurses
represented by collective bargaining agents. In 1989, the NLRB ruled that nurses could form
their own separate bargaining units, and union activity increased. However, the American
Hospital Association immediately sued the American Nurses Association (ANA), and the
ruling was halted until 1991 when the Supreme Court upheld the 1989 NLRB decision.
Table 22.1 outlines the legislation that led to unionization in health care.
UNION REPRESENTATION OF NURSES
As of 2012, just over 18% of the nation’s registered nurses (RNs) belonged to unions, down
from almost 20% in 2008 (Moberg, 2013). Not only did the proportion of unionized nurses
drop in those 4 years, so did the actual number, despite the total number of nurses increasing
by about 70,000. Still, nurses are roughly twice as likely to be in a union as are other workers
(Moberg).
Nurses are roughly twice as likely to be in a union as are other workers.
In fact, as of 2012, the union-membership rate of wage and salary workers in the United
States across all areas of employment was 11.3%, compared with 11.8% in 2011 (Warner,
2013). The 2012 figure represents a 97-year low and those who are unionized are primarily
the shrinking public sector (Liu, 2013). In the private sector, unionization fell to 6.6%, down
from a peak of 35% during the 1950s (Liu).
Nurses are represented by a multitude of unions. The California Nurses Association
(CNA)/National Nurses Organizing Committee joined with two other nurses’ unions (United
American Nurses [UANs] and the Massachusetts Nurses Association) to create a new
150,000+ member advocacy association known as National Nurses United (NNU) in 2009.
While all three unions maintained their separate identities, the merger did give these members
a greater national voice with the end result being that NNU won most—if not all—of the
organizing efforts it has undertaken since the merger (Commins, 2012).
The Service Employees International Union (SEIU) is another large union in the health-
care industry, representing more than 1.1 million nurses, licensed practical nurses (LPNs),
doctors, lab technicians, nursing home workers, and home care workers (SEIU, 2013).
Year Legislation Effect
1935 National Labor act/Wagner act Gave unions many rights in organizing; resulted in
rapid union growth
1947 taft-Hartley amendment returned some power to management; resulted in a
more equal balance of power between unions and
management
1962 Kennedy Executive Order 10988 amended the 1935 Wagner act to allow public
employees to join unions
1974 amendments to Wagner act allowed nonprofit organizations to join unions
1989 National Labor relations Board ruling allowed nurses to form their own separate bargaining
units
TABLE 22.1 Labor Legislation

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 519
In addition, the National Federation of Nurses (NFN) merged with the American Federation
of Teachers (AFT) in February 2013, making AFT the nation’s third largest nurses’ union,
after NNU and SEIU (Moberg, 2013).
Also in 2013, the National Union of Healthcare Workers (NUHW), which formed in 2009
when SEIU took control of California local United Healthcare Workers West, affiliated with
CNA. This affiliation unites 10,000 health-care workers at NUHW with 85,000 RNs at CNA
(Robertson, 2013). Like NNU, this is a strategic alliance, and not a merger. Such alliances are
becoming increasingly commonplace as unions recognize that increased negotiating power
comes with greater membership.
Some of the other unions that represent nurses include the ANA; the National Union of
Hospital and Health Care Employees of the Retail, Wholesale and Department Store Union;
the American Federation of Labor–Congress of Industrial Organizations (AFL-CIO); the
United Steelworkers of America; the American Federation of Government Employees,
AFL-CIO; the American Federation of State, County, and Municipal Employees, AFL-CIO;
the International Brotherhood of Teamsters; the American Federation of State, County, and
Municipal Employees, which operates mostly in the public sector; the “24/7 Frontline Service
Alliance,” and the United Auto Workers.
Union representation also varies by state. The states with the most union-organizing for
all industries, including health care, are New York, California, Pennsylvania, Michigan, and
Illinois (Huston, 2014a).
AMERICAN NURSES ASSOCIATION AND COLLECTIVE BARGAINING
One difficult union issue faced by nurse-managers that is not typically encountered in other
disciplines stems from the dual role of their professional organization—ANA. The mission
of the ANA is to represent the interests of the nation’s 3.1 million RNs through its constituent
member nurses associations, its organizational affiliates, and its workforce advocacy
affiliate—the Center for American Nurses (ANA, 2013).
The NLRB, however, recognizes the ANA, at most state levels, as a collective bargaining
agent. The use of state associations as bargaining agents has been a divisive issue among
American nurses. Some nurse-managers believe that they have been disenfranchised by their
professional organization. Other managers recognize the conflicts inherent in attempting to
sit on both sides of the bargaining table. For some members of the nursing profession, this
issue presents no conflict. Regardless of individual values, however, there does appear to be
some conflict in loyalty.
This conflict has manifested itself in the recent splitting away of state nurses associations
from the parent ANA organization. Since California RNs broke from the ANA in 1995 over
dissatisfaction with the control held by nurses in managerial positions in hospitals, other
states have also disaffiliated, including Massachusetts, Maine, New York, and Pennsylvania.
In addition, many nurses unions, including the just-absorbed NFN, split off from the ANA as
a result (Moberg, 2013). In 1999, the ANA responded by establishing, then spinning off, the
UANs as a parallel association of state collective bargaining organizations. NFN consisted
of some of the UAN groups that did not want to join with NNU, but then the New York
State Nurses Association left NFN. Moberg questions whether new mergers will lead to
more cooperation among the sometimes rancorous nursing unions—or to more progress in
organizing a field that is growing faster than its union membership.
There are no easy solutions to the dilemma created by the dual role held by the ANA.
Clarifying issues begins with the manager examining the motivation of nurses to participate
in collective bargaining. The manager must at least try to hear and understand the employees’
points of view.
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520 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
EMPLOYEE MOTIVATION TO JOIN OR REJECT UNIONS
Knowing that human behavior is goal-oriented, it is important to examine what personal goals
union membership fulfills. Nurse-managers often tell each other that health-care institutions
differ from other types of industrial organizations. This is really a myth, because most
nurses work in large and impersonal organizations. The nurse frequently feels powerless and
vulnerable as an individual alone in a complex institution. It is this vulnerability that often
encourages nurses to join unions.
The reality though is that at least six primary motivations for joining a union exist
(Display 22.3). The first is to increase the power of the individual. Liu (2013) notes that
unions restore demand to an economy, by raising wages for their members and putting more
purchasing power to work. This enables more hiring. Wages are typically higher in health-
care organizations that have been unionized.
LEARNING EXERCISE 22.1
The Role of the ANA as Collective Bargaining Agent
How do you feel about the aNa’s certification as a collective bargaining agent? do you belong
to the state student nurses association? Why or why not? do you plan to join your state aNa?
What are the primary driving and restraining forces for your decision? divide into two groups to
debate the pros and cons of having the aNa, rather than other unions, represent nurses.
REASONS WHY NURSES JOIN UNIONS
1. to increase the power of the individual
2. to increase their input into organizational decision-making
3. to eliminate discrimination and favoritism
4. Because of a social need to be accepted
5. Because they are required to do so as part of employment (closed shop)
6. Because they believe it will improve patient outcomes and quality of care
REASONS WHY NURSES DO NOT WANT TO JOIN UNIONS
1. a belief that unions promote the welfare state and oppose the american system of free enterprise
2. a need to demonstrate individualism and promote social status
3. a belief that professionals should not unionize
4. an identification with management’s viewpoint
5. Fear of employer reprisal
6. Fear of lost income associated with a strike or walkout
DISPLAY 22.3 Union Membership: Pros and Cons
In addition, employees know that singly, they are much more dispensable. Because a large
group of employees is less dispensable, nurses generally increase their bargaining power and
reduce their vulnerability by joining a union. This is a particularly strong motivating force for
nurses when jobs are scarce and they feel vulnerable. Indeed, during the massive downsizing
and restructuring of the 1990s, collective bargaining priorities shifted from wages and
benefits to job security. Moberg (2013) suggests that current health-care environment again
seems ripe for unionization, noting that hospital professionals are frustrated that their control
over their work has been undermined by new for-profit hospital chains and corporatized
nonprofit chains.

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 521
A feeling of powerlessness or the perception that the administration does not care about the
employees is a major driving force for unionization.
When there are nursing shortages, nurses feel less vulnerable, and other reasons to join unions
become motivating factors. A second motivator driving nurses toward unionization is the
desire to communicate their aims, feelings, complaints, and ideas to others and to have input
into organizational decision-making.
Because unions emphasize equality and fairness, nurses also join them because they need
to eliminate discrimination and favoritism. This might be a particularly strong motivator for
members of groups that have experienced discrimination, such as women and minorities.
Many social factors also act as motivators to nurses with regard to union activity. A
fourth motivation stems from the social need to be accepted. Sometimes, this social need
results from family or peer pressure. Because many working-class families have a long
history of strong union ties, children are frequently raised in a cultural milieu that promotes
unionization.
A fifth reason why nurses sometimes join unions is because the union contract dictates that
all nurses belong to the union. This has been a big driving force among blue-collar workers.
However, the closed shop—or requirement that all employees belong to a union—has never
prevailed in the health-care industry. Most health-care unions have open shops, allowing
nurses to choose if they want to join the union.
Finally, some nurses join unions because they believe that patient outcomes are better
in unionized organizations due to better staffing and supervised management practices.
Johnstone (2012) suggests that seeking union membership to promote better working
conditions actually supports patient safety ethics. This is because the nurse is demonstrating
genuine moral concern about the risks to patient safety associated with inappropriate skill mix
and nurse–patient ratios that jeopardize patient safety and quality care.
Although historically, unions focus heavily on wage negotiations, current issues deemed by
nurses to be just as or more important are nonmonetary, such as guidelines for staffing, float
provisions, shared decision-making, and scheduling.
Just as there are many reasons to join unions, there are also a number of reasons why nurses
reject unions (Display 22.3). Perhaps the strongest reasons are societal and cultural factors.
Many people distrust unions because they believe that unions promote the welfare state and
undermine the American system of free enterprise. Other reasons for rejecting unions might
be a need to demonstrate that nurses can get ahead on their own merits.
Professional employees have also been slow in forming unions for several reasons that
deal with class and education. They argue that unions were appropriate for the blue-collar
worker but not for the university professor, physician, or engineer. Nurses who reject unions
on this basis usually are driven by a need to demonstrate their individualism and social status.
Some employees identify with management, and thus, frequently adopt its viewpoint toward
unions. Such nurses, therefore, would reject unions because their values more closely align
with management than with workers. Although employees are protected under the National
Labor Relations Act (NLRA), many reject unions because of fears of employer reprisal.
Nurses who reject unions on this basis could be said to be motivated, most of all, by a need
to keep their job.
In addition, some employees reject unions simply because they have a right to not belong
to a union. The United States is comprised of 24 “right-to-work” states that grant workers
a choice about whether or not to belong to a union. In the other 26 and Washington, D.C.,
employees do not have to belong to the union but must still pay a portion of the union dues
that go toward collective bargaining and other nonpolitical union-related activities (Right to
Work, 2013).
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522 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Finally, some nurses reject unions out of the fear of lost income associated with a strike or
walkout. Strikes and walkouts are, however, closely regulated by law. The NLRA states in part
that “employees shall have the right to engage in other concerted activities for the purpose
of collective bargaining or other mutual aid or protection.” The phrase other concerted
activities refers to “working to rule,” “blue flu” epidemics, work slowdowns, filing a barrage
of grievances, participating in informational or recognition picketing, and striking. Unions
must, however, give employers and the Federal Mediation and Conciliation Service 10 days
notice of their intent to strike. In doing so, the facility should have a reasonable amount
of time to stop admitting patients, transfer existing patients to other facilities, and reduce
medical procedures that require nurse-intensive labor. Problems occur when management
continues to admit new patients or attempts to maintain normal operations.
The threat of strikes though is very real to union members. Selvam (2012) notes that the
NNU threatened strikes 18 times in 2011, affecting 46 hospitals. This forced hospitals to
hire replacement nurses for at least 60 hours to 5 days, negatively impacting both hospital
budgets and employee paychecks (Selvam). It should be noted, however, that nurses do have
the option to refuse to participate in strikes or to cross picket lines when strikes occur. They
risk derision by their peers in doing so, however, since strikebreakers—commonly known as
“scabs”—are viewed as taking the management’s side on the issue and may never be fully
accepted by their peers after the strike action has ended (Huston, 2014a).
AVERTING THE UNION
Once managers understand the drives and needs behind joining unions, they can begin to
address those needs and possibly avert some of them. One way to remain abreast of employee
potential concerns that may encourage them to seek union representation is to review the
current literature and research on nurse satisfaction and dissatisfaction. When managers are
aware of the concerns of RNs nationwide, they are better able to assess their own staff’s
potential for the type of dissatisfaction that can lead to unionization.
It is within managerial power to eliminate some of the needs that staff have for joining unions.
Clearly, organizations with unfair management policies are more likely to become unionized.
Managers can encourage feelings of power by allowing subordinates to have input into
decisions that will affect their work. Managers can also listen to ideas, complaints, and
feelings and take steps to ensure that favoritism and discrimination are not part of their
management style. Additionally, the manager can strengthen the drives and needs that make
nurses reject unions. By building a team effort, sharing ideas and future plans from upper
management with the staff, and encouraging individualism in employees, the manager can
facilitate the worker’s identification with management.
When nurses begin to show signs of job dissatisfaction and when they feel frustrated,
stressed, or powerless, they send a wake-up call to nursing management. Leaders must be alert
to employment practices that are unfair or insensitive to employee needs and must intervene
appropriately before such issues lead to unionization. However, organizations offering liberal
benefit packages and fair management practices may still experience union activity if certain
social and cultural factors are present. If union activity does occur, managers must be aware
of specific employee and management rights so that the NLRA is not violated by managers
or employees.
Display 22.4 lists practices the organization may put in place to discourage union
activity. If the organization waits until the union arrives, it will be too late to perform these
functions.

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 523
THE NURSE AS SUPERVISOR: ELIGIBILITY FOR PROTECTION
UNDER THE NATIONAL LABOR RELATIONS ACT
Mayer and Shimabukuro (2012) note that the NLRA establishes certain protections for
private sector employees who want to form or join a labor union. These protections do not,
however, extend to supervisors.
The NLRA defines a supervisor as “any individual having authority, in the interest of
the employer, to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward,
or discipline other employees, or responsibly to direct them, or to adjust their grievances, or
effectively to recommend such action, if in connection with the foregoing, the exercise of
such authority is not of a merely routine or clerical nature, but requires the use of independent
judgment” (Matthews, 2010, para 12).
However, a 2006 NLRB ruling deemed that charge nurses might also be considered
supervisors since they are responsible for the coordination and provision of patient care
throughout a unit (Matthews, 2010). Even part-time charge nurses were so labeled. This
finding has been contested legally since that time and several interpretations have occurred.
Reinterpretations by the NLRB are expected in the future.
In addition, the definition of supervisor in nursing came into question with several
administrative and court rulings in the early 1990s. These rulings came about as a
result of a case involving four LPNs/LVNs (licensed vocational nurses) employed at
Heartland Nursing Home in Urbana, Ohio. During late 1988 and early 1989, these LPNs
complained to management about what they thought were disparate enforcement of the
absentee policy; short staffing; low wages for nurses’ aides; an unreasonable switching
of prescription business from one pharmacy to another, which increased the nurses’
paperwork; and management’s failure to communicate with employees (NLRB, n.d.).
Despite assurances from the Vice President for Operations that they would not be harassed
for bringing their concerns to headquarters’ attention, three of the LPNs were terminated
as a result of their actions.
1. Know and care about your employees.
2. Establish fair and well-communicated personnel policies.
3. Use an effective upward and downward system of communication.
4. Ensure that all managers are well-trained and effective.
5. Establish a well-developed formal procedure for handling employee grievances.
6. Have a competitive compensation program of wages and benefits.
7. Have an effective performance appraisal system in place.
8. Use a fair and well-communicated system for promotions and transfers.
9. Use organizational actions to indicate that job security is based on job performance, adherence
to rules and regulations, and availability of work.
10. Have an administrative policy on unionization.
DISPLAY 22.4 Before the Union Comes
LEARNING EXERCISE 22.2
Discussing the Pros and Cons of Unions
List the reasons why you would or would not join a union. share this with others in your group
and examine the following questions. Would you feel differently about unions if you were a
manager? What influences you the most in your desire to join or reject unions? Have you ever
felt discriminated against or powerless in the workplace?
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524 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
In response to what they perceived to be illegal termination, the LPNs filed for protection
under the NLRA. The NLRB ruled that because the LPNs had responsibility to ensure
adequate staffing, to make daily work assignments, to monitor the aides’ work to ensure
proper performance, to counsel and discipline aides, to resolve aides’ problems and
grievances, to evaluate aides’ performances, and to report to management, they should be
classified as “supervisors,” thereby making them ineligible for protection under the NLRA.
On appeal, the administrative law judge (ALJ) disagreed, concluding that the nurses were
not supervisors and that the nurses’ supervisory work did not equate to responsibly directing
the aides in the interest of the employer, noting that the nurses’ focus is on the well-being of
the residents rather than on the employer.
In another turnabout, the U.S. Court of Appeals for the Sixth Circuit then reversed the
decision of the ALJ, arguing that the NLRB’s test for determining the supervisory status of
nurses was inconsistent with the statute and that the interest of the patient and the interest
of the employer were not mutually exclusive. The court said that, in fact, the interests of
the patient are the employer’s business and argued that the welfare of the patient was no less
the object and concern of the employer than it was of the nurses. The court also argued
that the statutory dichotomy the NLRB first created was no more justified in the health-care
field than it would be in any other business in which supervisory duties are necessary to
the production of goods or the provision of services (NLRB v. Health Care & Retirement
Corp., 1994).
The court further stated that it was up to Congress to carve out an exception for the health-care
field, including nurses, should Congress not wish for such nurses to be considered supervisors.
The court reminded the NLRB that the courts, and not the board, bear the final responsibility
for interpreting the law. After concluding that the board’s test was inconsistent with the statute,
the court found that the four LPNs involved in this case were indeed supervisors and ineligible
for protection under the NLRA (NLRB v. Health Care & Retirement Corp., 1994).
This same interpretation, at least for full-time charge nurses, was used in another
landmark court case in September 2006 to determine whether charge nurses, both permanent
and rotating, at Oakwood Healthcare Inc. were “supervisors” within the meaning of the
NLRA, and thus could be excluded from a unit of nurses represented by a union (Mayer &
Shimabukuro, 2012). Upholding the definition that supervisors “assign,” and “responsibly
direct” employees as well as exercise “independent judgment,” the NLRB concluded that
12 permanent charge nurses employed by Oakwood Healthcare were supervisors. Rotating
charge nurses were not if this role was less than 10% to 15% of their work time.
Matthews (2010) notes that the Oakwood case has set precedence and figured in
approximately 35 subsequent decisions in both health-care and industrial settings, although
there have been no further rulings addressing the charge nurse/supervisor status. Hence, the
Oakwood ruling is still in effect today, specifying that nurses, on average, with less than 10%
to 15% (equal to about one shift per pay period) of their time as charge nurse are considered
staff nurses, while nurses working more than 15% of their professional time as charge nurses
are considered supervisors.
UNION-ORGANIZING STRATEGIES
Unions use a number of strategies to organize health-care workers (Display 22.5), including
one-on-one and group meetings with union representatives. Other strategies include
providing literature about union benefits, writing letters, and otherwise contacting potential
union members. However, Haugh (2006) suggests that unions have added additional methods
of organizing—namely, community and corporate pressure. This pressure is usually directed
at acute-care hospitals.

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 525
In corporate campaigns, the union uses public events, political connections, and the local
media to bring into question a hospital’s quality of care, level of charity work, its tax exempt
status (if nonprofit), and nurse staffing. Haugh (2006) maintains that unions are very effective
in involving influential power brokers, both financiers and lawmakers. Unions are designing
corporate campaigns using allegations of discrimination, boycotts, rallies, and visits to Board
members’ homes. Another strategy contributing to labor union successes is activism. Central
labor councils, local labor unions, and state labor federations are reaching out to community
groups, faith-based organizations, and elected officials in an effort to create unrest and to
change the community environment in which workers organize.
In addition, unions often file lawsuits against the employer. Labor unions maintain the goal
of breaking employer resolve and demonstrate their ability to protect employees by initiating
legal action on behalf of employees against targeted employers. Other corporate strategies
include union organizers establishing Web sites to enable them to keep tabs on the hospital
system (Haugh, 2006). The Internet has made information about how to organize a union very
accessible to interested workers. E-mail has also proved to be an inexpensive and efficient
means of mass communication with regard to critical union issues.
MANAGERS’ ROLE DURING UNION-ORGANIZING
Because of the health-care industry’s movement toward unionization, most nurses will
probably be involved with unions in some manner during their careers. Managers who are not
employed in a unionized health-care organization should anticipate that one or more unions
will attempt to organize nurses within the next few years.
Nurse-managers, as legally defined hospital “supervisors,” are legal spokespersons for
the hospital. As such, the NLRB closely monitors what they may say and do. Prohibited
managerial activities include threatening employees, interrogating employees, promising
employee rewards for cessation of union activity, and spying on employees. However, if the
astute manager picks up early clues of union activity, the organization may be able to take
steps that will discourage the unionization of its employees.
Employees have a right to participate in union-organizing under the NLRA, and managers must
not interfere with this right.
There have been some small gains, however, recently in terms of restoring some rights to
management. The U.S. Court of Appeals for the District of Columbia Circuit ruled in May 2013
that health-care organizations do not have to display a list of workers’ collective bargaining
rights, including the rights of workers to join a union and bargain collectively to improve
wages and working conditions (Bump, 2013). This overturned a ruling scheduled to go into
1. Meetings (both group and one-on-one)
2. Leaflets and brochures
3. Pressure on the hospital corporation through media and community contacts
4. Political pressure of regional legislators and local lawmakers
5. Corporate campaign strategies
6. activism of local employees
7. Using lawsuits
8. Bringing pressure from financiers
9. technology
DISPLAY 22.5 Some Union-Organizing Strategies
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526 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
effect in January. The Court said the NLRB violated employers’ free speech rights in trying
to force them to display the posters or face charges of committing an unfair labor practice.
“Unions had hoped the posters would help them boost falling membership, but business groups
argued that they were too one-sided in favor of unionization” (Hananel, 2013, para 3).
STEPS TO ESTABLISH A UNION
The first step in establishing a union is demonstrating an adequate level of desire for
unionization among the employees. The NLRB requires that at least 30% of employees sign
an interest card before an election for unionization can be held. Most unions, however, will
require between 60% and 70% of the employees to sign interest cards before spending the
time and money involved in an organizing campaign.
Union representatives have generally been careful to keep a campaign secret until they
were ready to file a petition for election. They did this so that they could build momentum
without interference from the employer.
After a designated number of cards have been generated, the organization is forced to have
an election. At that time, all employees of the same classification, such as RNs, would vote on
whether they desire unionization. A choice in every such election is no representation, which
means that the voters do not want a union. During the election, 50% plus one of the petitioned
units must vote for unionization before the union can be recognized. A process similar to that
of certification can also decertify unions. Decertification may occur when at least 30% of the
eligible employees in the bargaining unit initiate a petition asking to no longer be represented
by the union.
It is important to remember that there are differences between organizing in a health-care
facility and other types of organizations. Generally, the solicitation and distribution of union
literature is banned entirely in “immediate patient care areas.” Middle-level and first-level
managers should never, however, independently attempt to deal with union-organizing
activity. They should always seek assistance and guidance from upper management and the
personnel department.
The entire list of rights for management and labor during the organization and
establishment phases of unionization is beyond the scope of this book. Throughout the
years, Congress has amended various labor acts and laws so that power is balanced between
management and labor. At times, the balance of power has shifted back and forth, but
Congress eventually enacts laws that restore the balance. The manager must ensure that the
rights of management and employees are protected. The two most sensitive areas of any
union contract, once wages have been agreed upon, are discipline and the grievance process,
which are discussed in Unit VII.
EFFECTIVE LABOR–MANAGEMENT RELATIONS
Before the 1950s, labor–management relations were turbulent. History books are filled with
battles, strikes, mass-picketing scenes, and brutal treatment by management and employees.
Over the last 30 years, employers and unions have substantially improved their relationships.
Although evidence is growing that contemporary management has come to accept the reality
that unions are here to stay, businesses in the United States are still less comfortable with
unions than their counterparts in many other countries. Likewise, unions have come to accept
the fact that there are times when organizations are not healthy enough to survive aggressive
union demands.
It is possible to create a climate in which labor and management can work together to
accomplish mutual goals.

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 527
Faced with the reality of negotiations with a bargaining agent, management has several
choices. It may actively oppose the union by using various union-busting techniques, or it
may more subtly oppose the union by attempting to discredit it and win employee trust.
Acceptance also may run along a continuum. Management may accept the union with
reluctance and suspicion. Although managers know that the union has legitimate rights, they
often believe that they must continually guard against the union encroaching further into
traditional management territory.
There is also the type of union acceptance known as accommodation. Increasingly
common, accommodation is characterized by management’s full acceptance of the union,
with both the union and the management showing mutual respect. When these conditions
exist, labor and management can establish mutual goals, particularly in the areas of safety,
cost reduction, efficiency, elimination of waste, and improved working conditions. Such
cooperation represents the most mature and advanced type of labor–management relations.
The attitudes and philosophies of the leaders in management and the union determine the
type of relationship that develops between the two parties in any given organization. When
dealing with unions, managers must be flexible. It is critical that they do not ignore issues or
try to overwhelm others with power. The rational approach to problem-solving must be used.
Unionization in the health-care industry will undoubtedly expand. It is important to learn
how to deal with this potential constraint to effective management. Managers must learn to
work with unions and to develop the art of using unions to assist the organization in building
a team effort to meet organizational goals.
LEARNING EXERCISE 22.3
List and Support Your Reasons for or Against Striking
You are a staff nurse in the intensive care unit (iCU) at one of your city’s two hospitals. You have
worked at this hospital for 5 years and transferred to the iCU 2 years ago. You love nursing
but are sometimes frustrated in your job due to a short supply of nurses, excessive overtime
demands, and the stress of working with critically ill patients.
the hospital has a closed shop, so union dues are deducted from your pay even though you
are not actively involved in the union. the present union contract is up for renegotiation, and the
union and management have been unable to agree on numerous issues. When the management
made its last offer, the new contract was rejected by the nurses. Now that the old contract has
expired, nurses are free to strike if they vote to do so.
You had voted for accepting the management offer; you have two children to support, and it
would be devastating to be without work for a long time. Last night, the nurses voted on whether
to return to the bargaining table and try to renegotiate with management or to go out on strike.
again, you voted for no strike. You have just heard from your friend that the strike vote won. Now,
you must decide if you are going to support your striking colleagues or cross the picket line and
return to work tomorrow. Your friends are pressuring you to support their cause. You know that
the union will provide some financial compensation during the strike but believe that it will not
be adequate for you to support yourself and your children. You agree with union assertions that
the organization has overworked and underpaid you and that it has been generally unresponsive
to nursing needs. On the other hand, you believe that your first obligation is to your children.
Assignment: List all of the reasons for and against striking. decide what you will do. Use
appropriate rationale from outside readings to support your final decision. share your thoughts
with the class. take a vote in class to determine how many would strike and how many would
cross the picket line.
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528 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
EMPLOYMENT LEGISLATION
Like unionization, the many legal issues involved in recruitment and employment have
an impact on the directing function. These potential constraints are present regardless of
union presence. The American industrial relations system is regarded as one of the most
legalistic in the Western world, and it continues to grow. Few aspects of the employment
relationship are free from regulation by either state or federal law. Employment laws
discussed here provide a cursory examination of such laws. Many of these regulations
relate to specific aspects of personnel management, such as the laws that deal with
collective bargaining or the equal employment laws that regulate hiring. Some personnel
regulations are discussed in previous chapters and others are discussed later. The prudent
manager will always work closely with human resource management when dealing with
employment legislation issues.
Some observers believe that employment and labor–management laws have become so
prescriptive that they preclude experimentation and creativity on the part of management.
Others believe that, like collective bargaining, the proliferation of employment laws must
be viewed from a historical standpoint to understand their need. Regardless of whether one
believes such laws and regulations are necessary, they are a fact of each manager’s life.
The feeling that the employer is fair to all will set the stage for the type of team-building that is
so important in effective management.
Being able to handle management’s legal requirements effectively requires a comprehension
of labor laws and their interpretation. The leader who embraces the intent of laws barring
discrimination and providing equal opportunity becomes a role model for fairness.
Employment laws, such as those given in Table 22.2, fall into one of five categories:
1. Labor standards. These laws establish minimum standards for working conditions
regardless of the presence or absence of a union contract. Included in this set are
minimum wage, health and safety, and equal pay laws.
2. Labor relations. These laws relate to the rights and duties of unions and employers in
their relationship with each other.
3. Equal employment. The laws that deal with employment discrimination were
introduced in Chapter 15.
4. Civil and criminal laws. These are statutory and judicial laws that proscribe certain
kinds of conduct and establish penalties.
5. Other legislation. Nursing managers have some legal responsibilities that do not
generally apply to industrial managers. For instance, licensed personnel are required to
Title of Legislation Regulation
Fair Labor standards act (1938); has been
amended many times since 1938
sets minimum wage and maximum hours that can be
worked before overtime is paid
Civil rights act of 1964 sets equal employment practices
Executive Order 11246 (1965) and Executive
Order 11375 (1967)
sets affirmative action guidelines
age discrimination act (1967) and 1978
amendment
Protects against forced retirement
rehabilitation act (1973) Protects the disabled
Vietnam Veterans act (1973/1974) Provides reemployment rights
TABLE 22.2 Employment and Labor Laws

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 529
have a current, valid license from the state in which they practice. Additionally, most
states require that employers of nurses report certain types of substance abuse to the
state licensing boards. Confidentiality laws also have a significant impact on health-
care organizations.
Labor Standards
Labor standards are regulations dealing with the conditions of the employee’s work, including
physical conditions, financial aspects, and the number of hours worked. Regulations may
be issued by state and/or federal bodies. When the regulations overlap, the more stringent
regulation is likely the one that applies.
State and federal employment legislation often overlap; as a general rule, the employer must
abide by the stricter of the two regulations.
Minimum Wages and Maximum Hours
More than 85% of all nonsupervisory employees are now covered by the Fair Labor Standards
Act (FLSA). This law was enacted by Congress in 1938 and established an hourly minimum
wage at that time of 25 cents. Since then, the law has been amended numerous times.
It is often said that in addition to putting a “floor under wages,” the FLSA also puts a
“ceiling over hours.” The latter statement, however, is not quite accurate. The FLSA sets a
maximum number of hours in any week beyond which a person may be employed only if he
or she is paid an overtime rate. Some states have enacted a law that makes an exception to this
weekly rule on overtime. The exception is an 80-hour, 2-week pay period ceiling, after which
the employee must receive overtime pay. Overtime pay can be significant, so it is imperative
that managers know which standard their organization is using.
Hours worked includes all the time that the employee is required to be on duty. Therefore,
mandatory classes, orientation, conferences, etc., must be recorded as duty time and are
subject to the overtime rules. The FLSA does not require time clocks but does require that
some record be maintained of hours worked.
The FLSA also regulates the minimum amount of overtime pay, which is at least 1.5 times
the basic rate. When state and federal laws differ on when overtime pay begins, the stricter
rule usually applies. Some union contracts also have stricter overtime pay agreements than
the FLSA.
Federal labor laws exempt certain employees from the minimum wage and overtime pay
requirements. Executive employees, administrative employees, and professional employees
are the three most notable white-collar exemptions. The functions of the position, rather
than the title or the fact that employees are paid a monthly wage, differentiate an exempt
employee. Certain students, apprentice learners, and other special circumstances also may
qualify an employee for an exemption to FLSA regulations. The personnel department in any
large organization is particularly helpful to the manager in implementing these labor laws.
Managers, however, should have a general understanding of how these laws restrict staffing
and scheduling policies.
The Equal Pay Act of 1963 requires that men and women performing equal work receive
equal compensation. Four equal pay tests exist: equal skill, equal effort, equal responsibility,
and similar working conditions. This law had a great impact on nursing management when
it was enacted. Before 1963, male orderlies were routinely paid a higher wage than female
aides performing identical duties. Although this fact seems incredible today, at the time, many
managers condoned this widespread practice of blatant wage discrimination. Most health-care
agencies now call these employees “nursing assistants,” whether they are male or female, and
all are paid the same wage.
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530 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
Labor Relations Laws
In addition to laws regarding collective bargaining, the manager needs to be aware of one
section of the Wagner Act (1935) and the Taft-Hartley Amendment (1947), which deals with
unfair labor practices by employers and unions. The original Wagner Act listed and prohibited
five unfair labor practices:
1. To interfere with, restrain, or coerce employees in a manner that interfered with their
rights as outlined under the act. Examples of these activities are spying on union
gatherings, threatening employees with job loss, or threatening to close down a
company if the union organizes.
2. To interfere with the formation of any labor organization or to give financial
assistance to a labor organization. This provision was included to prohibit “employee
representation plans” that were primarily controlled by management.
3. To discriminate with regard to hiring, tenure, etc., to discourage union membership.
4. To discharge or discriminate against an employee who filed charges or testified before
the NLRB.
5. To refuse to bargain in good faith.
The original Wagner Act gave so much power to the unions that it was necessary in 1947
to pass additional federal legislation to restore a balance of power to labor–management
relations. The Taft-Hartley Amendment retained the provisions under the Wagner Act
that guaranteed employees the right to collective bargaining. However, the Taft-Hartley
Amendment added the provision that employees have the right to refrain from taking part in
unions. In addition to that provision, the Taft-Hartley Amendment added and prohibited the
following six unfair labor practices of unions:
1. Requiring a self-employed person or an employer to join a union.
2. Forcing an employer to cease doing business with another person. (This placed a ban
on secondary boycotts, which were then prevalent in unions.)
3. Forcing an employer to bargain with one union when another union has already been
certified as the bargaining agent.
4. Forcing the employer to assign certain work to members of one union rather than another.
5. Charging excessive or discriminatory initiation fees.
6. Causing or attempting to cause an employer to pay for unnecessary services. This
prohibited featherbedding, a term used to describe union practices that prevented the
displacement of workers due to advances in technology.
Equal Employment Opportunity Laws
Under the American free enterprise system, employers have historically been able to hire
whomever they desired. Today, a transplanted employer of the 1920s might be shocked to
LEARNING EXERCISE 22.4
Time Clocks
Until the 1950s, most health-care organizations did not require that employees use a time clock
when arriving at or leaving work for meal breaks. Now, time clocks are the norm for hospitals
and some other, but not all, health-care organizations.
Assignment: survey several community hospitals, clinics, student health centers, home health-
care facilities, and other organizations that employ nurses. How many of them require nurses to
use time clocks? How do you feel about professionals being required to use a time clock for
meal breaks? discuss this issue in class and with the nurses you know.

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 531
see that racial and ethnic minorities, women, the elderly, and the disabled have acquired
substantial rights in the workplace. The first legislation in the area of employment hiring
practices resulted from years of discrimination against minorities. More recent legislation has
been aimed at eliminating discrimination that occurs for other reasons. The US government’s
Equal Employment Opportunity Commission (USEEOC) Web site lists the following types of
discrimination: age, disability, equal pay/compensation, genetic information, national origin,
pregnancy, race/color, religion, retaliation, sex, and sexual harassment (USEEOC, n.d.-a).
Equal employment opportunities have fostered profound changes in the American workplace.
Women, minorities, and the handicapped have had success in gaining jobs previously denied
to them. However, only modest gains in achieving ethnic diversity have occurred in nursing
(Huston, 2014b).
Although men are seen as a minority in nursing, there are those who feel that male minority
status has led to advantages rather than discrimination, particularly in hiring and promotion.
Some experts have suggested that the more rapid career trajectory and relatively higher pay
for male nurses compared with female nurses likely reflect the historical trend that more men
are employed full time in their career paths while women tend to have career gaps related to
child bearing or rearing families and often work fewer hours (Huston, 2014b).
Discrimination involving pregnant employees particularly interests nurse-managers
because nursing is such a predominately female profession and because nurses are often
exposed to hazardous chemical, radiation, and infectious organisms. The Pregnancy
Discrimination Act, which amended Title VII of the Civil Rights Act of 1964, requires that
pregnant employees be treated the same as other employees who are temporarily disabled.
Managers should use common sense as well as ethical and humane treatment when dealing
with the pregnant employee.
Civil Rights Act of 1964
The Civil Rights Act of 1964 laid the foundation for equal employment in the United States.
The thrust of Title VII of the Civil Rights Act is twofold: It prohibits discrimination based
on factors unrelated to job qualifications and it promotes employment based on ability and
merit. The areas of discrimination specifically mentioned are race, color, religion, sex, and
national origin.
This act was strengthened by President Lyndon Johnson’s Executive Order 11246 in 1965
and Executive Order 11375 in 1967. These executive orders sought to correct past injustices.
Because the government believed that some groups had a long history of being discriminated
against, it wanted to build in a mechanism that would assist those groups in “catching up” with
the rest of the American workforce. Therefore, it created an affirmative action component.
Affirmative action plans are not specifically required by law but may be required by court
order. In most states, affirmative action plans are voluntary unless government contracts are
involved. Some states, such as California, have voted to eliminate affirmative action in the
workplace, arguing that it actually resulted in reverse discrimination. Many organizations,
however, have voluntarily put an affirmative action plan in place when the plan does not
conflict with state regulations.
Affirmative action differs from equal opportunity. The United States Equal Employment
Opportunity legislation is aimed at preventing discrimination. Affirmative action plans
are aimed at actively seeking to fill job vacancies with members from groups who are
underrepresented, such as women, ethnic minorities, and the handicapped.
The USEEOC is responsible for enforcing Title VII of the Civil Rights Act and the
investigatory responsibility of the USEEOC is broad. When it finds that a charge of
discrimination is justified, the agency attempts to reach an agreement through persuasion
and conciliation. When the USEEOC is unable to reach an agreement, it has the power to
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532 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
bring civil action against the employer. When discrimination is found, the courts will order
restoration of rightful economic status; this means that the court may order that the employee
receives back the pay for up to 2 years. In health-care organizations, when discrimination
has been found (such as unequal pay for men and women in nursing assistant jobs), financial
awards in class action suits have been extraordinarily high. Managers must be alert for any
such discriminatory practices. Some states have fair employment legislation that is stricter
than the federal act. Again, the stricter regulations always apply.
Age Discrimination and Employment Act
Enacted by Congress in 1967, the purpose of the Age Discrimination in Employment Act
(ADEA) was to promote the employment of older people based on their ability rather than
age. In early 1978, the ADEA was amended to increase the protected age to 70. In 1987,
Congress voted to remove even this age restriction except in certain job categories.
Although some people are alarmed by the removal of mandatory age retirements, trends
continue toward earlier retirement. However, reversal of this trend may have serious consequences
for some organizations. In particular, it could have a significant impact on organizations that are
labor-intensive, particularly if those labor-intensive organizations also have demanding physical
requirements such as those in nursing. For example, a 49-year-old nurse in Tennessee filed suit
in mid-2013, claiming violation of the ADEA and state law when her employer began openly
seeking “young rising stars” to replace older workers (Yamada, 2013).
LEARNING EXERCISE 22.5
Addressing Mary’s Failing Health
You are the manager of a well-baby newborn nursery. among your staff is 79-year-old LVN/LPN
Mary Jones, who has worked for the hospital for 50 years. No mandatory retirement age exists.
this has not been a problem in the past, but Mary’s general health is now making this a problem
for your unit. Mary has grown physically fragile. Cataracts cloud her vision, and she suffers from
hypertension. Last month, she began to prepare a little girl for circumcision because she did
not read the armband properly.
Your staff has become increasingly upset over Mary’s inability to fulfill her job duties. the
physicians, however, support Mary and found the circumcision incident humorous. Last week,
you requested that Mary have a physical examination, at hospital expense, to determine her
physical ability to continue working.
You were not particularly surprised when she returned with medical approval. Her physician
spoke sharply with you. admitting privately that Mary’s health was rapidly failing, the physician
told you that working was Mary’s only reason for living and left you with these words: “Force
Mary to retire and she will die within the year.”
Assignment: Using your knowledge of age discrimination, patient safety, employee rights,
and management responsibilities, decide on an appropriate course of action for this case. Be
creative and think beyond the obvious. Be able to support your decisions.
Sexual Harassment
Although job discrimination related to gender became illegal with the Civil Rights Act of
1964, it was not until 1977 that the federal appeals court upheld a claim that a supervisor’s
verbal and physical advances constituted sexual harassment in the workplace. Since then,
sexual harassment has been recognized as a form of sex discrimination that violates Title VII
of the Civil Rights Act.

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 533
The USEEOC (n.d.-b, para 2) defines sexual harassment as “unwelcome sexual
advances, requests for sexual favors, and other verbal or physical conduct of a sexual
nature when submission to or rejection of this conduct explicitly or implicitly affects an
individual’s employment; unreasonably interferes with an individual’s work performance;
or creates an intimidating, hostile, or offensive work environment.” The EEOC (n.d.-b)
states that sexual harassment can occur in a variety of circumstances including but not
limited to the following:
• The victim as well as the harasser may be a woman or a man. The victim does not have
to be of the opposite sex.
• The harasser can be the victim’s supervisor, an agent of the employer, a supervisor in
another area, a coworker, or a nonemployee.
• The victim does not have to be the person harassed but could be anyone affected by the
offensive conduct.
• Unlawful sexual harassment may occur without economic injury to or discharge of the
victim.
• The harasser’s conduct must be unwelcome.
Since the 1977 ruling, allegations of sexual harassment and lawsuits have permeated
virtually every type of industry, and the health-care system is not immune. Indeed, sexual
harassment as well as other types of nonphysical violence are worldwide problems for nurses,
with English-speaking countries exhibiting the highest rates of both physical violence and
sexual harassment in nursing (Examining the Evidence 22.1).
Source: Spector, P. E., Shou, Z. E., & Che, X. X. (2013, February 19). Nurse exposure to physical and nonphysical
violence, bullying, and sexual harassment: A quantitative review. international Journal of Nursing studies. Retrieved
June 23, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/23433725
This research conducted a quantitative review of the nursing violence literature, estimating expos-
ure rates by type of violence, setting, source, and world region. A total of 136 articles provided
data on 151,347 nurses from 160 samples. Categories depended on the availability of at least
five studies. Exposure rates were coded as percentages of nurses in the sample who reported a
given type of violence. Five types of violence were physical, nonphysical, bullying, sexual harass-
ment, and combined (type of violence was not indicated). Setting, time frame, country, and source
of violence were coded.
Overall violence exposure rates were 36.4% for physical violence, 66.9% for nonphysical
violence, 39.7% for bullying, and 25% for sexual harassment, with 32.7% of nurses reporting
having been physically injured in an assault. Rates of exposure varied by world region (Anglo,
Asia, Europe, and the Middle East), with the highest rates for physical violence and sexual harass-
ment in the Anglo region, and the highest rates of nonphysical violence and bullying in the Middle
East. Regions also varied in the source of violence, with patients accounting for most of it in
Anglo and European regions, whereas patients’ families/friends were the most common source
in the Middle East.
About a third of nurses worldwide indicated exposure to physical violence and bullying, about
a third reported injury, about a quarter experienced sexual harassment, and about two-thirds
indicated nonphysical violence. Physical violence was most prevalent in emergency departments,
geriatric, and psychiatric facilities. Physical violence and sexual harassment were most prevalent
in Anglo countries, and nonphysical violence and bullying were most prevalent in the Middle East.
Patients accounted for most physical violence in the Anglo region and Europe, and patients’
family and friends accounted for the most in the Middle East.
Examining the Evidence 22.1
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534 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
While sexual harassment between health-care workers is noted most often in the literature,
it may also come from the patients that nurses care for. On September 6, 2012, EEOC
filed suit against a Virginia long-term care agency under Title VII of the Civil Rights Act,
alleging that the employer failed to protect a female receptionist from sexual harassment by
a resident, which created a “sexually hostile work environment” for her (Boehm, 2013). As
with most harassment lawsuits, the employee alleged that she made numerous complaints to
her supervisor about the harassment, yet the employer failed to take proper corrective action.
Boehm (2013) notes that while sexual harassment is a difficult issue in any employment
setting, many nursing homes have residents who act out inappropriately as a result of
dementia or Alzheimer disease. Nevertheless, these agencies must take steps to address and
minimize the risk of their employees even when it comes from residents.
Indeed, health-care organizations must be alert to sexual harassment and intervene
immediately when it is suspected, regardless of the perpetrator. This requires a proactive
approach on the part of employers to prevent, detect, and correct instances of harassment.
At minimum, organizations must have a plan that outlines temporary steps to deal with such
allegations while they are being investigated as well as permanent remedial steps once the
investigation has been completed, to ensure that the situation does not recur.
Lastly, nurses must take appropriate action when they witness the harassment of others
or when they themselves are the targets of such offenses. When one person makes another
uncomfortable in the workplace by the use of sexual innuendoes or jokes or invades another’s
personal space, this behavior should be recognized and confronted as sexual harassment.
Unfortunately, underreporting of the problem is common and nurses often make light
of sexually harassing incidents. In addition, Rossheim (2013) notes that while hospital
procedure enables direct-care workers to remove themselves from cases where patients are
sexually inappropriate, nurses rarely do.
LEARNING EXERCISE 22.6
Confronting Sexual Harassment
You are a new female employee at Valley Medical Center’s iCU and love your job. although only
25 years old, you have been a nurse for 4 years, and the last two were spent in a small critical
care unit in a rural hospital. You work the 3 pm to 11 pm shift. Ever since you came to work
here, one of the male physicians (dr. Jones) has been especially attentive to you. at first, you
were flattered, but more recently, you have become uncomfortable around him. He sometimes
touches you and seems to be flirting with you. You have no romantic interest in him and know
that he is married. Last night, he asked you to meet him for an after-work drink and you refused.
He is a very powerful man in the unit, and you do not want to alienate him, but you are becoming
increasingly troubled by his behavior.
today, you went to your shift charge nurse and explained how you felt. in response, the nurse
said, “Oh, he likes to flirt with all the new staff, but he is perfectly harmless.” these comments
did not make you feel better. at approximately 7 pm, dr. Jones came to the unit and cornered you
again in a comatose patient’s room and asked you out. You said no again, and you are feeling
more anxious because of his behavior.
Assignment: Outline an appropriate course of action. What options can you identify? What
is your responsibility? What are the driving and restraining forces for action? What support
systems for action can you identify? What responsibility does the organization have? Be creative
and think beyond the obvious. Be able to support your decisions.

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 535
Legislation Affecting Americans with Disabilities
The Rehabilitation Act of 1973 required all employers with government contracts of more
than $25,000 to take affirmative action to recruit, hire, and advance disabled people who
are qualified. Similar but less aggressive affirmative action steps were required for other
companies doing business with the federal government, with specific requirements depending
on the size of the company and the dollar amount of the contract. The Department of Labor
was charged with enforcing this act. Although initially there was very slow progress in getting
companies to hire those with disabilities, steady progress has been made.
In 1990, Congress passed the Americans with Disabilities Act to eliminate discrimination
against Americans with physical or mental disabilities in the workplace and in social life.
Disability is defined as “any physical or mental impairment that limits any major life
activity.” This includes people with obvious physical disabilities as well as those with cancer,
diabetes, HIV or AIDS, and recovering substance abusers.
Veterans Readjustment Assistance Act
The Veterans Readjustment Act provides employment rights and privileges for veterans with
regard to positions that they held before they entered the armed forces. This act was used by some
nurses after the Vietnam War and during the nursing surplus after the Persian Gulf War to gain
reemployment after military service. There is a lesser need for nurses implementing this act when
veterans return from war during a nursing shortage, because jobs are readily available.
The Occupational Safety and Health Act
The manager needs to be particularly cognizant of legislation imposed by the OSHA and
state health licensing boards. OSHA speaks to the employer’s requirements to provide a
place of employment that is free from recognized hazards that may cause physical harm.
The Department of Labor enforces this act. Because it is impossible for the Department of
Labor to physically inspect all facilities, most inspections are brought about by employee
complaint or employer request. The act allows fines to be levied if employers continue with
unsafe conditions.
Since OSHA’s inception, many organizations have vehemently criticized the act, and
specifically its administration. They have charged that the cost of meeting OSHA standards
has excessively burdened American businesses. On the other hand, unions have asserted that
the federal government has never staffed or funded OSHA adequately. They have charged
that the OSHA has been negligent in setting standards for toxic substances, carcinogens, and
other disease-producing agents.
Because the risk of discovery and the fine (if judged guilty) are both low, employers may
choose to ignore unsafe working conditions. Nurse-managers are in a unique position to call
attention to hazardous conditions in the workplace and should communicate such concerns
to a higher authority. Ongoing controversies regarding safety issues include the cost and
effectiveness of universal precautions and immunizations against potential bioterrorism.
Most states also have occupational and safety regulations. Again, the employer must comply
with the more stringent regulations in the case of overlaps. Many state licensing boards have
additional health regulations that differ from the federal regulations.
STATE HEALTH FACILITIES LICENSING BOARDS
In addition to health and safety requirements, many state boards have regulations regarding
staffing requirements. It is the ultimate responsibility of top-level management to meet the
requirements for state licensing. However, all managers are responsible for knowing and
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536 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
meeting the regulations that apply to their unit or department. For example, if the manager of
an ICU has a state staffing level that mandates 12 hours of nursing care per patient per day
and requires that the ratio of RNs to other staff be 2:1, then the supervisor is obligated to staff
at that level or greater. If, during times of short staffing, supervisors are unable to meet this
level of staffing, they must communicate this to the upper-level management so that there
can be a joint resolution.
The variation in state licensing requirements makes a lengthy discussion of them
inappropriate for this book. However, managers must be knowledgeable about state licensing
regulations that pertain to their level of supervision.
INTEGRATING LEADERSHIP SKILLS AND MANAGEMENT FUNCTIONS
WHEN WORKING WITH COLLECTIVE BARGAINING, UNIONIZATION
AND EMPLOYMENT LAWS
Unionization and legal constraints will seem less burdensome if managers remember that
both primarily protect the rights of patients and employees. If managers perform their jobs
well and work for organizations that desire to “do the right thing” by accepting their social
responsibility, they need not fear unionization and legal constraints. If the organization is
not unionized, the manager must use the leadership skills of communication, fairness, and
shared decision-making to ensure that employees do not feel unionization is necessary. The
integrated leader-manager is a role model for fairness, knows unit employees well, and
sincerely seeks to meet their needs.
When making decisions that deal with unions and employment legislation, the effective
leader-manager always seeks to do what is just. Additionally, he or she seeks appropriate
assistance before finalizing decisions that involve sensitive legal or contractual issues. By
using these leadership skills, the manager becomes fairer in personnel management, develops
increased self-awareness, and develops an understanding of the average individual’s need to
seek unionization and of the necessity for employment legislation.
The effective manager maintains the required amount of staffing and ensures a safe
working environment. The rights of the organization and the employee are protected as
the manager uses personnel policies in a nondiscriminatory and consistent manner. The
emphasis is on flexibility and the accommodation of employment legislation and union
contracts.
KEY CONCEPTS
l Historically, union activity increases during times of labor shortages and economic upswings.
l although nurses are still roughly twice as likely to be in a union as other occupations, the percentage of
nurses as well as total number of nurses in unions nationwide is decreasing.
l Union alliances are becoming increasingly commonplace in health care since increased negotiating
power comes with greater membership.
l the aNa acts as a professional association for rNs and as a collective bargaining agent. this dual
purpose poses a conflict in loyalty for some nurses.
l People are motivated to join or reject unions as a result of their numerous needs and values.
l Nurses with less than 10% to 15% (equal to about one shift per pay period) of their time as charge
nurse are considered staff nurses, while nurses working more than 15% of their professional time
as charge nurses are considered supervisors, and therefore, are ineligible for protection under the
NLra.

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 537
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
l although all managers play an important role in establishing and maintaining effective management–
labor relationships, the middle-level manager has the greatest influence on preventing unionization in a
nonunion organization.
l Creating a climate in which labor and management can work together to accomplish mutual goals is possible.
l Labor relation laws concern the rights and duties of unions and employers in their relationship with each other.
l Labor standards are regulations dealing with the conditions of the employee’s work, including physical
conditions, financial aspects, and the number of hours worked.
l state and federal employment legislation often overlap; as a general rule, the employer must abide by
the stricter of the two regulations.
l Much of the human rights legislation concerning employment practices came about because of
documented discrimination in the workplace.
l sexual harassment and other types of nonphysical violence are worldwide problems for nurses, with
English-speaking countries exhibiting the highest rates of both physical violence and sexual harassment
in nursing.
l although some legislation makes the job of managing people more difficult for managers, it has resulted
in increased job fairness and opportunities for women, minorities, the elderly, and the disabled.
LEARNING EXERCISE 22.7
Writing about Employment Laws
Many employment laws generate emotion. Usually, people feel strongly about at least one of
these issues. select one of the following employment laws, and write a 250-word essay on
why you support or disapprove of the law. Choose from the Equal Pay Act of 1963, equal
opportunity laws, affirmative action, sexual harassment, or age discrimination.
LEARNING EXERCISE 22.8
Dilemma Involving an Expired Nursing License
at your long-term care facility, it is a policy that licensed employees have a current, valid
medical license. this is in keeping with the state licensing code. it is always difficult to get
people to bring their license in to verify that it is current.
You have just come from a meeting with the director, who reminded you that you must not have
people performing duties that require a license if the license has expired. You decide to issue a
memo stating that you will suspend all employees who have not verified their licenses with you.
Following this, all of the LVNs/LPNs brought their licenses in for verification. However, one of
the LVNs/LPNs has an expired license. When questioned, the nurse admits that payment for
relicensure was not made until after your memo was received. this nurse delayed payment
because of a financial crisis. You call the licensing board and learn it will be 2 weeks before the
employee will receive the license in the mail or before web verification of the license is possible.
active license status cannot be verified over the telephone.
(Continued )
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538 UNIT VI ROLES AND FUNCTIONS IN DIRECTING
You consider the following facts. it is illegal to perform duties that require a license without one.
the LVN/LPN had prior knowledge of the licensing laws and hospital policy. the LVN/LPN has
been a good employee with no record of prior disciplinary action.
Assignment: decide what you should do. What alternatives do you have? Provide rationale for
your decision.
LEARNING EXERCISE 22.9
How Would You Handle This Petition?
Betty smith, a unit clerk, has come to see you, the nurse-manager of the medical unit, to
complain of flagrant discriminatory practices against female employees of University General
Hospital. she alleges that women are denied promotional and training opportunities comparable
to those made available to men. she shows you a petition with 35 signatures supporting her
allegations. Ms. smith has threatened to forward this petition to the administrator of the hospital,
the press, and the department of Labor unless corrective action is taken at once. Being a
woman yourself, you have some sympathy for Ms. smith’s complaint. However, you believe
overall that employees at University General are treated fairly regardless of their sex.
Ms. smith, a fairly good employee, has worked on your unit for 4 years. However, she has been
creating problems lately. she has been reprimanded for taking too much time for coffee breaks.
Personnel evaluations that recommend pay raises and promotions are due next week.
Assignment: How should you handle this problem? is the personnel evaluation an appropriate
time to address the petition? Outline your plan and explain your rationale.
REFERENCES
American Nurses Association. (2013). About ANA. Retrieved
June 22, 2013, from http://www.nursingworld.org/
Functional MenuCategories/AboutANA.aspx
Boehm, T. (2013, January). Harassment by resident.
Provider. Retrieved June 21, 2013, from http://www
.providermagazine.com/archives/2013_Archives/
Pages/0113/Harassment-By-Resident.aspx
Bump, P. (2013, May 7). Businesses have the right to remain
silent about your right to join a union. Atlantic
Wire. Retrieved August 16, 2013, from http://www
.theatlanticwire.com/national/2013/05/businesses
-have-right-remain-silent-about-your-right-join
-union/64979/
Commins, J. (2012, January 3). Why do nurses join unions?
Because they can. Strategiesfornursingmanagers
.com. Retrieved June 21, 2013, from http://www
.strategiesfornursemanagers.com/ce_detail/275275
.cfm
Hananel, S. (2013, May 7). Appeals court strikes down
union poster rule. Bloomberg Business Week News.
Retrieved June 22, 2013, from http://www
.businessweek.com/ap/2013-05-07/appeals-court
-strikes-down-union-poster-rule
Haugh, R. (2006). The new union strategy: Turning the
community against you. Hospitals and Health
Networks, 80(5), 32–37.
Huston, C. (2014a). Collective bargaining and the
professional nurse. In C. Huston (Ed.), Professional
issues in nursing (3rd ed.). Philadelphia, PA:
Lippincott Williams & Wilkins 278–291.
Huston, C. (2014b). Diversity in the nursing workforce. In C.
Huston (Ed.), Professional issues in nursing (3rd ed.).
Philadelphia, PA: Lippincott Williams & Wilkins
136–155.
Johnstone, M. (2012). Industrial action and patient safety
ethics. Australian Nursing Journal, 19(7), 29.
Liu , E. (2013, January 29). Viewpoint: The decline of unions is
your problem too. Time Ideas. Retrieved June 22, 2013,
from http://ideas.time.com/2013/01/29/viewpoint-why
-the-decline-of-unions-is-your-problem-too/
Matthews, J. (2010). When does delegating make you a
supervisor? Online Journal of Issues in Nursing,
15(2), 3. Retrieved June 23, 2013, from http://
www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Vol152010/No2May2010/
Delegating-and-Supervisors.aspx
Mayer, G., & Shimabukuro, J. O. (2012, July 5). The
definition of “supervisor” under the National Labor
Relations Act. Congressional Research Service.
Retrieved June 23, 2013, from http://www.fas.org/
sgp/crs/misc/RL34350

http://www.nursingworld.org/Functional MenuCategories/AboutANA.aspx

http://www.providermagazine.com/archives/2013_Archives/Pages/0113/Harassment-By-Resident.aspx

http://www.theatlanticwire.com/national/2013/05/businesses-have-right-remain-silent-about-your-right-join-union/64979/

http://www.strategiesfornursemanagers.com/ce_detail/275275.cfm

http://www.businessweek.com/ap/2013-05-07/appeals-court-strikes-down-union-poster-rule

Viewpoint: The Decline of Unions Is Your Problem Too

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegating-and-Supervisors.aspx

http://www.fas.org/sgp/crs/misc/RL34350

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Chapter 22 Collective Bargaining, Unionization, and Employment Laws 539
Moberg, D. (2013, February 20). Are mergers the answer for
fractious nurses unions? In These Times. Retrieved
June 21, 2013, from http://inthesetimes.com/working/
entry/14631/are_mergers_the_answer_for_nurses
_unions/.
National Labor Relations Board. (n.d). Case 09-CA-026348.
Retrieved December 30, 2011, from http://www.nlrb
.gov/case/09-CA-026348#casedetails
NLRB v. Health Care & Retirement Corp. (1994). NLRB v.
Health Care & Retirement Corp., 114 S. Ct. 1778,
May 23, 1994. Retrieved June 23, 2013, from http://
www.law.cornell.edu/supct/html/92-1964.ZS.html
Right to Work, Right to Not Join a Union. (2013). Liberty
Alliance. Retrieved June 22, 2013, from http://
libertyalliance.com/2013/06/right-to-work-right-to
-not-join-a-union/
Robertson, K. (2013, January 4). Unions join forces to fight
nursing cutbacks. Sacramento Business Journal.
Retrieved June 22, 2013, from http://www
.bizjournals.com/sacramento/news/2013/01/04/
unions-join-forces-to-fight-nursing.html?page=all
Rossheim, J. (2013). How nurses can fight sexual
harassment. Allhealthcare. Retrieved June 22, 2013,
from http://allhealthcare.monster.com/benefits/
articles/3458-how-nurses-can-fight-sexual
-harassment?page=2
Selvam, A. (2012). Striking out: Nurses unions go up against
hospitals as year ends. Modern Healthcare, 42(1),
14–15.
Service Employees International Union. (2013). Our union.
Retrieved June 21, 2013, from http://www.seiu.org/
our-union/
Spector, P. E., Shou, Z. E., & Che, X. X. (2013, February
19). Nurse exposure to physical and nonphysical
violence, bullying, and sexual harassment: A
quantitative review. International Journal of Nursing
Studies. Retrieved June 23, 2013, from http://www
.ncbi.nlm.nih.gov/pubmed/23433725
United States Equal Employment Opportunity Commission
(USEEOC). (n.d.-a). Discrimination by type.
Retrieved June 21, 2013, from http://www.eeoc.gov/
laws/types/index.cfm
United States Equal Employment Opportunity Commission
(USEEOC). (n.d.-b). Facts about sexual harassment.
Retrieved June 22, 2013, from http://www.eeoc.gov/
eeoc/publications/fs-sex.cfm
Warner, K. (2013, January 23). The real reason for the
decline of American unions. Bloomberg. Retrieved
June 22, 2013, from http://www.bloomberg.com/
news/2013-01-23/the-real-reason-for-the-decline-of
-american-unions.html
Yamada, D. (2013, May 8). Nurse can proceed with age
discrimination claim against employer seeking
“rising young stars,” federal court holds. Minding
the Workplace. Retrieved June 22, 2013, from http://
newworkplace.wordpress.com/2013/05/08/nurse-can
-proceed-with-age-discrimination-claim-against-employer
-seeking-rising-young-stars-federal-court-holds/
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http://www.nlrb.gov/case/09-CA-026348#casedetails

http://www.law.cornell.edu/supct/html/92-1964.ZS.html

http://libertyalliance.com/2013/06/right-to-work-right-to-not-join-a-union/

http://www.bizjournals.com/sacramento/news/2013/01/04/unions-join-forces-to-fight-nursing.html?page=all

http://allhealthcare.monster.com/benefits/articles/3458-how-nurses-can-fight-sexual-harassment?page=2

http://www.seiu.org/our-union/

http://www.ncbi.nlm.nih.gov/pubmed/23433725

http://www.eeoc.gov/laws/types/index.cfm

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Nurse can proceed with age discrimination claim against employer seeking “rising young stars,” federal court holds

http://inthesetimes.com/working/entry/14631/are_mergers_the_answer_for_nurses_unions/

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Roles and Functions
in Controlling
UNIT VII
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542
Quality Control
… the results that pioneering organizations have achieved in leveraging electronic medical records,
computerized provider order entry, and other clinical information systems to create evidence-based
care processes are demonstrating quite clearly that there is tremendous potential to raise the
standard of care.
—Mark Hagland
… because quality health care is a complex phenomenon, the factors contributing to quality in health
care are as varied as the strategies needed to achieve this elusive goal.
—Carol Huston
CROSSWALK tHis CHapter addresses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient
safety
BSN Essential III: scholarship for evidence-based practice
BSN Essential IV: information management and application of patient care technology
BSN Essential V: Health-care policy, finance, and regulatory environments
BSN Essential VI: interprofessional communication and collaboration for improving patient health
outcomes
MSN Essential II: Organizational and systems leadership
MSN Essential III: Quality improvement and safety
MSN Essential IV: translating and integrating scholarship into practice
MSN Essential V: informatics and health-care technologies
MSN Essential VI: Health policy and advocacy
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: patient-centered care
QSEN Competency: teamwork and collaboration
QSEN Competency: evidence-based practice
QSEN Competency: Quality improvement
QSEN Competency: safety
QSEN Competency: informatics
AONE Nurse Executive Competency I: Communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency V: Business skills
23

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Chapter 23 Quality Control 543
LEARNING OBJECTIVES The learner will:
l determine appropriate criteria or standards for measuring quality
l collect and analyze quality control data to determine whether established standards have
been met
l identify appropriate corrective action to be taken when standards have not been met
l differentiate among process, outcome, structure, and concurrent, retrospective, and
prospective audits
l write nursing criteria for process, outcome, and structure audits
l describe key components of total quality management and the toyota production system
philosophy
l select appropriate quantitative and qualitative tools to measure quality in given situations
l describe the role of organizations such as the Joint Commission (JC), the Centers for
Medicare and Medicaid (CMs), the american Nurses association (aNa), the National
Committee for Quality assurance, and the agency for Healthcare research and Quality
(aHrQ) in establishing standards of practice and clinical practice guidelines for health-care
organizations and health-care professionals
l describe how the work of the Maryland Hospital Association Quality Indicator Project is
contributing to benchmark work in indicator identification and quality measurement
l analyze the impact of diagnosis-related groups and the prospective payment system on the
quality of care of hospitalized patients
l describe national efforts such as Health plan employer data and information set and OrYX
to standardize the collection of quality care data
l identify the purpose of standardized nursing languages and discuss how creating a common
use of terminology/definitions in nursing could improve the quality of patient care
l debate the importance of articulating “nursing-sensitive” outcome measures in measuring the
quality of health care
l identify the four evidence-based standards Leapfrog Groups believes will provide the
greatest impact on reducing medical errors
l describe characteristics of a “just culture” and discuss why having such a culture is critical
to timely and accurate medical error reporting
l analyze (quantitatively and qualitatively) the extent of the quality health-care gains that have
occurred since the publication of To Err Is Human
l empower subordinates and followers to participate in continuous quality improvement efforts
During the controlling phase of the management process, performance is measured against
predetermined standards, and action is taken to correct discrepancies between these standards
and actual performance. Employees who feel that they can influence the quality of outcomes
in their work environment experience higher levels of motivation and job satisfaction.
Organizations also need some control over productivity, innovation, and quality outcomes.
Controlling, then, should not be viewed as a means of determining success or failure but as a
way to learn and grow, both personally and professionally.
This unit explores controlling as the fifth and final step in the management process.
Because the management process—like the nursing process—is cyclic, controlling is
not an end in itself; it is implemented throughout all phases of management. Examples
of management controlling functions include the periodic evaluation of unit philosophy,
mission, goals, and objectives; the measurement of individual and group performance against
pre-established standards; and the auditing of patient goals and outcomes.
Quality control—a specific type of controlling—refers to activities that are used to
evaluate, monitor, or regulate services rendered to consumers. For any quality control
program to be effective, certain components need to be in place (Display 23.1). First, the
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544 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
program needs to be supported by top-level administration; a quality control program cannot
merely be an exercise to satisfy various federal and state regulations. A sincere commitment
by the institution, as evidenced by fiscal and human resource support, will be a deciding
factor in determining and improving quality of services.
1. support from top-level administration.
2. Commitment by the organization in terms of fiscal and human resources.
3. Quality goals reflect search for excellence rather than minimums.
4. process is ongoing (continuous).
DISPLAY 23.1 Hallmarks of Effective Quality Control Programs
Although the organization must be realistic about the economics of rendering services, if
nursing is to strive for excellence, then developed quality control criteria should be pushed
to optimal levels rather than minimally acceptable levels. Finally, the process of quality
control must be ongoing; that is, it must reflect a belief that the search for improvement in
quality outcomes is continuous and that care can always be improved. Although controlling
is generally defined as a management function, effective quality control requires managers to
have skill in both leadership and management. Leadership roles and management functions
inherent in quality control are delineated in Display 23.2.
LEADERSHIP ROLES
1. encourages followers to be actively involved in the quality control process.
2. Clearly communicates expected standards of care to subordinates.
3. encourages the setting of high standards to maximize quality instead of setting minimum safety
standards.
4. embraces and champions quality improvement (Qi) as an ongoing process.
5. Uses control as a method of determining why goals were not met.
6. is active in communicating quality control findings and their implications to other health profes-
sionals and consumers.
7. acts as a role model for followers in accepting responsibility and accountability for nursing
actions.
8. distinguishes between clinical standards and resource utilization standards, ensuring that
patients receive at least minimally acceptable levels of quality care.
9. supports/actively participates in research efforts to identify and measure nursing-sensitive
patient outcomes.
10. Creates a work culture that deemphasizes blame for errors and focuses instead on addressing
factors that lead to and cause near misses, medical errors, and adverse events.
11. encourages the use of six sigma as the benchmark for Qi goals.
12. establishes benchmarks that mirror those of best-performing organizations and that drive a goal
of continuous quality improvement (CQi).
MANAGEMENT FUNCTIONS
1. in conjunction with other personnel in the organization, establishes clear-cut, measurable stan-
dards of care and determines the most appropriate method for measuring if those standards
have been met.
2. selects and uses process, outcome, and structure audits appropriately as quality control tools.
3. accesses appropriate sources of information in data gathering for quality control.
4. determines discrepancies between care provided and unit standards and uses critical event
analysis (Cea) or root cause analysis (rCa) to determine why standards were not met.
5. Uses quality control findings in determining needed areas of staff education or coaching.
DISPLAY 23.2 Leadership Roles and Management Functions Associated with Quality Control

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Chapter 23 Quality Control 545
To understand quality control, the manager must become familiar with the process
and terminology used in quality measurement and improvement activities. This chapter
introduces quality control as a specific and systematic process. Audits are presented as tools
for assessing quality. In addition, the historical impact of external forces on the development
and implementation of quality control programs in health-care organizations is discussed.
Key organizations involved in the establishment and monitoring of quality initiatives in the
United States are discussed. In addition, quality control strategies, quality measurement tools,
benchmarking, and clinical practice guidelines (CPGs) are introduced. Finally, strategies for
creating a culture of safety are identified, as are the challenges of changing a system that all
too often focuses on individual errors rather than on the need to make system-wide changes.
DEFINING QUALITY HEALTH CARE
Quality measurement and outcomes accountability have been buzzwords in health care
since the 1980s and continue to be at the forefront of almost every health-care agenda today.
Defining and measuring quality of care are essential for health-care providers to demonstrate
accountability to insurers, patients, and legislative and regulatory bodies. However, achieving
quality care is not just a matter of better training for providers or delivering more care. The
problem is multidimensional, and its complexity begins with the very definition of quality
care itself.
The Institute of Medicine (IOM) (1994, p. 3) defines health-care quality as “the degree
to which health services for individuals and populations increase the likelihood of desired
health outcomes and are consistent with current professional knowledge.” While this classic
definition is widely accepted, parts of it merit further examination. The first is the assertion
that quality does not exist unless desired health outcomes are attained. Outcomes are only one
indicator of quality. Sometimes, patients receive the best possible care with the information
available and poor outcomes occur. At other times, poor care may still result in good
outcomes. Using outcomes alone as a way to measure quality care then is flawed.
While outcomes are an important measure of quality care, it is dangerous to use them as the
only criteria for quality measurement.
The second implication in the IOM definition is that for care to be considered high quality,
it must be consistent with current professional knowledge. Staying current in terms of
professional knowledge in today’s information firestorm is difficult for even the most
dedicated providers. To complicate the issue even further, how quality of care is defined
and measured often differs between providers and patients. Clearly, it is difficult to find a
common definition of quality health care that represents the viewpoints of all stakeholders in
6. Keeps abreast of current government, accrediting body, and licensing regulations that affect
quality control.
7. actively participates in state and national benchmarking and “best practices” initiatives.
8. Continually assesses the unit or organizational environment to identify and categorize errors
that are occurring and proactively reworks the processes that led to the errors.
9. establishes an environment where research evidence and clinical guidelines based on best
practices drive clinical decision-making and patient care.
10. is accountable to insurers, patients, providers, and legislative and regulatory bodies for quality
outcomes.
11. establishes six sigma methodology as a goal for every aspect of Qi.
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546 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
the health-care system. What is even more difficult, however, is identifying and elucidating
the myriad of factors that play a part in determining whether quality health care exists.
QUALITY CONTROL AS A PROCESS
If defining health-care quality is problematic, then the measurement of health-care quality is
even more difficult. To make the process more effective and efficient, the collection of both
quantitative and qualitative data is used as well as a specific and systematic process. This
process, when viewed simplistically, can be broken down into three basic steps:
1. The criterion or standard is determined.
2. Information is collected to determine if the standard has been met.
3. Educational or corrective action is taken if the criterion has not been met.
The first step, as depicted in Figure 23.1, is the establishment of control criteria or
standards. Measuring performance is impossible if standards have not been clearly established.
Not only must standards exist, but leader-managers must also see that subordinates know
and understand the standards. Because standards vary among institutions, employees must
know the standard expected of them at their organization. Employees must be aware that
Establish control criteria
Identify the information
relevant to the criteria
Compare collected
information with the
established criteria
Reevaluation
Provide information and, if
necessary, take corrective
action regarding findings
Make a judgment
about quality
Collect and analyze
the information
Determine ways to
collect the information
FIGURE 23.1 • steps in auditing quality control. Copyright ® 2006 Lippincott Williams &
Wilkins. instructor’s resource Cd-rOM to accompany Leadership roles and Management
Functions in Nursing, by Bessie L. Marquis and Carol J. Huston.

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Chapter 23 Quality Control 547
their performance will be measured in terms of their ability to meet the established standard.
For example, hospital nurses should provide postoperative patient care that meets standards
specific to their institution. A nurse’s performance can be measured only when it can be
compared with a preexisting standard.
Many organizations have begun using benchmarking—the process of measuring products,
practices, and services against best-performing organizations—as a tool for identifying
desired standards of organizational performance. In doing so, organizations can determine
how and why their performance differs from exemplar organizations, and use the exemplar
organizations as role models for standard development and performance improvement.
Benchmarking is the process of measuring products, practices, and services against best-
performing organizations.
Many states have initiated a best practices program that invites health-care institutions
to submit a description of a program or protocol relating to improvements in quality of
life, quality of care, staff development, or cost-effectiveness practices. Experts review
the submissions, examine outcomes, and then designate a best practice. The difference in
performance between top-performing health-care organizations and the national average is
called the quality gap. While the quality gap is typically small in many industries, it is often
significant in health care.
The second step in the quality control process includes identifying information relevant
to the criteria. What information is needed to measure the criteria? In the example of
postoperative patient care, this information might include the frequency of vital signs,
dressing checks, and neurologic or sensory checks. Often, such information is determined by
reviewing current research or existing evidence.
The third step is determining ways to collect information. As in all data gathering, the
manager must be sure to use all appropriate sources. When assessing quality control of the
postoperative patient, the manager could find much of the information in the patient chart.
Postoperative flow sheets, the physician orders, and the nursing notes would probably be
most helpful. Talking to the patient or nurse could also yield information.
The fourth step in auditing quality control is collecting and analyzing information. For
example, if the standards specify that postoperative vital signs are to be checked every
30 minutes for 2 hours and every hour thereafter for 8 hours, it is necessary to look at how
often vital signs were taken during the first 10 hours after surgery. The frequency with which
vital signs are assessed is listed on the postoperative flow sheet and then is compared with the
standard set by the unit. The resulting discrepancy or congruency gives managers information
with which they can make a judgment about the quality or appropriateness of the nursing care.
If vital signs were not taken frequently enough to satisfy the standard, the manager would
need to obtain further information regarding why the standard was not met and counsel
employees as needed. This is often done using a process known as computer-aided error
analysis (CEA) or root cause analysis (RCA).
In addition to evaluating individual employee performance, quality control provides a
tool for evaluating unit goals. If unit goals are consistently unmet, the leader must reexamine
those goals and determine if they are inappropriate or unrealistic. There is danger here that
the leader, who feels pressured to meet unit goals, may lower standards to the point where
quality is meaningless. This reinforces the need to determine standards first and then evaluate
goals accordingly.
The last step in Figure 23.1 is reevaluation. If quality control is measured on
20 postoperative charts and a high rate of compliance with established standards is found,
the need for short-term reevaluation is low. If standards are consistently unmet or met only
partially, frequent reevaluation is indicated. However, quality control measures need to be
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548 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
ongoing, not put forth simply in response to a problem. Effective leaders ensure that quality
control is proactive by pushing standards to maximal levels and by eliminating problems in
the early stages before productivity or quality is compromised.
Quality control efforts must be proactive, not solely as a reaction to a problem.
LEARNING EXERCISE 23.1
Designing an Audit Tool
You are a public health nurse in a small, nonprofit visiting nurse clinic. the nursing director has
requested that you chair the newly established Qi committee because of your experience with
developing audit criteria. Because a review of the patient population indicates that maternal–
child visits make up the greatest percentage of home visits, the committee chose to develop
a retrospective-process audit tool to monitor the quality of initial postpartum visits. the criteria
specified that the clients to be included in the audit had to have been discharged with an infant
from a birth center or obstetrical unit following uncomplicated vaginal delivery. the home visit
would occur not later than 72 hours after the delivery.
Assignment: design an audit tool appropriate for this diagnosis that would be convenient to
use. specify percentages of compliance, sources of information, and number of patients to
be audited. Limit your process criteria to 20 items. try solving this yourself before reading the
possible solution that appears in the appendix.
THE DEVELOPMENT OF STANDARDS
A standard is a predetermined level of excellence that serves as a guide for practice. Standards
have distinguishing characteristics; they are predetermined, established by an authority, and
communicated to and accepted by the people affected by them. Because standards are used
as measurement tools, they must be objective, measurable, and achievable. There is no one
set of standards. Each organization and profession must set standards and objectives to guide
individual practitioners in performing safe and effective care. Standards for practice define
the scope and dimensions of professional nursing.
The American Nurses Association (ANA) has been instrumental in developing professional
standards for almost 80 years. In 1973, the ANA Congress first established standards for
nursing practice, thereby providing a means of determining the quality of nursing that a
patient receives, regardless of whether such services are provided by a professional nurse
alone or in conjunction with nonprofessional assistants.
The ANA has played a key role in developing standards for the profession.
Currently, the ANA publishes numerous different standards for nursing practice that reflect
different areas of specialty nursing practice (ANA, 2013a). The Scope and Standards of
Practice—originally published by the ANA in 1991 and revised several times since—
provides a foundation for all registered nurses (RNs) in practice. These standards consist
of Standards of Practice and Standards of Professional Performance (Display 23.3). The
most recent updates include significant changes such as the incorporation of competency
statements in the place of measurement criteria under the standards section and an expanded
list of standards of practice (ANA, 2013b).

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Chapter 23 Quality Control 549
In addition, the ANA (2009) publication Nursing Administration: Scope and Standards
of Practice may be of particular interest to nurse-managers. It too includes Standards of
Practice as well as Standards of Professional Performance. These standards are regarded
as authoritative statements describing the duties that nurse administrators are expected to
perform competently (p. vii).
Other developed standards reflect such diverse fields of practice as diabetes nursing,
forensic nursing practice, home health nursing practice, gerontologic nursing, nursing practice
in correctional facilities, parish nursing, oncology nursing, school nursing, psychiatric–
mental health nursing practice, nursing informatics, and public health (ANA, 2013a). All of
these standards exemplify optimal performance expectations for the nursing profession and
have provided a basis for the development of organizational and unit standards nationwide.
Organizational standards outline levels of acceptable practice within the institution. For
example, each organization develops a policy and procedures manual that outlines its specific
standards. These standards may minimize or maximize in terms of the quality of service
expected. Such standards of practice allow the organization to measure unit and individual
performance more objectively.
DISPLAY 23.3 American Nurses Association Scope and Standards of Practice
(2nd Edition) (2010)
STANDARDS OF PRACTICE
1. assessment—the rN collects comprehensive data pertinent to the health-care consumer’s
health or the situation.
2. diagnosis—the rN analyzes the assessment data to determine the diagnoses or issues.
3. Outcomes identification—the rN identifies expected outcomes for a plan individualized to the
health-care consumer or the situation.
4. planning—the rN develops a plan that prescribes strategies and alternatives to attain expected
outcomes.
5. implementation—the rN implements the identified plan.
standard 5a. Coordination of Care—the rN coordinates care delivery.
standard 5B. Health teaching and Health promotion—the rN employs strategies to promote
health and a safe environment.
standard 5C. Consultation.
standard 5d. prescriptive authority and treatment.
6. evaluation—the rN evaluates progress toward the attainment of outcomes.
STANDARDS OF PROFESSIONAL PERFORMANCE
7. ethics—the rN practices ethically.
8. education—the rN attains the knowledge and competency that reflects current nursing practice.
9. evidence-Based practice and research—the rN integrates evidence and research findings
into practice.
10. Quality of practice—the rN contributes to quality nursing practice.
11. Communication—the rN communicates effectively in a variety of formats in all areas of practice.
12. Leadership—the rN demonstrates leadership in the professional practice setting and the profession.
13. Collaboration—the rN collaborates with health-care consumer, family, and others in the
conduct of nursing practice.
14. professional practice evaluation—the rN evaluates her or his own nursing practice in relation
to professional practice standards and guidelines, relevant statutes, rules, and regulations.
15. resource Utilization—the rN utilizes appropriate resources to plan and provide nursing
services that are safe, effective, and financially responsible.
16. environmental Health—the rN practices in an environmentally safe and healthy manner.
Source: American Nurses Association (2010). scope and standards of practice (2nd ed.). Silver Spring, MD:
American Nurses Association.
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550 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
One contemporary effort to establish standards for individual nursing practice has been the
development of clinical practice guidelines (CPGs). CPGs or standardized clinical guidelines
provide diagnosis-based, step-by-step interventions for providers to follow in an effort to
promote high-quality care while controlling resource utilization and costs. CPGs, such as
those developed by the Agency for Healthcare Research and Quality (AHRQ), are developed
following an extensive review of the literature and suggest what interventions, in what order,
will likely lead to the best possible patient outcomes. In other words, CPGs should reflect current
research findings and best practices.
CPGs reflect evidence-based practice; that is, they should be based on cutting edge research
and best practices.
In 1998, the AHRQ and the U.S. Department of Health, in partnership with the American
Medical Association and American Association of Health Plans–Health Insurance Association
of America, launched the National Guideline Clearinghouse (NGC). The NGC is a free,
publicly available comprehensive database of evidence-based CPGs and related documents in
one easy-to-access location (AHRQ, 2013). The Web site for this clearinghouse and the key
features of the NGC are shown in Display 23.4.
1. structured, standardized abstracts (summaries) about each guideline and its development
2. editorial insights on current issues of importance to the guideline and/or measure fields including
perspectives on trends in guideline and/or measure development, reviews/critiques of guidelines/
measures, comments on topics related to evidence-based medicine, or similar themes
3. Guideline syntheses are systematic comparisons of selected guidelines that address similar topic
areas. Key elements of each synthesis include a discussion of areas of agreement and difference,
the major recommendations and the corresponding strength of evidence and recommendation
rating schemes, and a comparison of guideline methodologies. also presented are the source(s)
of funding, the benefits/harms of implementing the guideline recommendations, and any associ-
ated contraindications
4. a guideline matrix/utility for filtering NGC content and for comparing attributes of two or more
guidelines in a side-by-side comparison
5. Guideline resources such as aHrQ evidence reports; hospital-acquired conditions; complemen-
tary Web sites; mobile device resources; and patient education materials
6. annotated bibliographies from more than 7,100 citations for publications and resources about
guidelines. resources are selected from peer-reviewed journals as well as non-journal sources.
Links to pubMed or the original article are provided when available
Source: Agency for Healthcare Research and Quality (2013). National Guideline Clearing House. Retrieved June 23,
2013, from http://www.guideline.gov/about/index.aspx
DISPLAY 23.4 The National Guideline Clearinghouse: Key Components
Newhouse (2010) cautions, however, that many currently endorsed guidelines are largely
based on expert opinion rather than research evidence. In addition, she suggests that some
guidelines do not include the strength of the evidence on which the guideline is based.
This disadvantages the user who assumes that the guidelines are based on credible research
evidence. Finally, Newhouse suggests that some guidelines are not useful because they have
been influenced by potential bias (conflicts of interest) or because they lack flexibility for a
complex and divergent patient population.
In addition, some providers eschew CPGs, arguing that they are “cookbook medicine”;
however, the reality is that they likely serve as the best possible guide in caring for specific
patient populations that exists today. This does not mean that providers cannot deviate from
evidence-based guidelines; they can and do. However, such deviations should be accompanied
by the identification of the unique factors of the individual case that calls for that deviation.
Other barriers to the implementation of CPGs are noted in Examining the Evidence 23.1.

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Chapter 23 Quality Control 551
AUDITS AS A QUALITY CONTROL TOOL
Where standards provide the yardstick for measuring quality care, audits are measurement
tools. An audit is a systematic and official examination of a record, process, structure,
environment, or account to evaluate performance. Auditing in health-care organizations
provides managers with a means of applying the control process to determine the quality
of services rendered. Auditing can occur retrospectively, concurrently, or prospectively.
Retrospective audits are performed after the patient receives the service. Concurrent audits
are performed while the patient is receiving the service. Prospective audits attempt to identify
how future performance will be affected by current interventions. The audits most frequently
used in quality control include the outcome, process, and structure audits.
Outcome Audit
Outcomes can be defined as the end result of care. Outcome audits determine what results, if
any, occurred as a result of specific nursing interventions for patients. These audits assume
that the outcome accurately demonstrates the quality of care that was provided. Many experts
consider outcome measures to be the most valid indicators of quality care, but until the past
decade, most evaluations of hospital care have focused on structure and process.
Outcomes reflect the end result of care or how the patient’s health status changed as a result of
an intervention.
Outcome measurement, however, is not new; Florence Nightingale was advocating the
evaluation of patient outcomes when she used mortality and morbidity statistics to publicize
the poor quality of care during the Crimean War. In today’s era of cost-containment, outcome
research is needed to determine whether managed care processes, restructuring, and other
new clinical practices are producing the desired cost savings without compromising the
quality of patient care.
Outcomes are complex, and it is important to recognize that many factors contribute
to patient outcomes. There is growing recognition, however, that it is possible to separate
the contribution of nursing to the patient’s outcome; this recognition of outcomes that are
nursing-sensitive creates accountability for nurses as professionals and is important in
developing nursing as a profession. Although outcomes traditionally used to measure quality
Source: Facilitators and Barriers to the Use of Clinical Practice Guidelines. (2012). aOrN Journal, 96(6), 668–669.
The increased emphasis on evidence-based practice has led to the development of CPGs and
checklists to help with clinical decision-making and care planning. Guidelines only work if they
are used, however, and they must be reviewed and revised as needed. In this study, the resear-
chers sought to identify factors that facilitate or prevent nurses from using CPGs.
The researchers identified three primary facilitators that encourage CPG use: education/ori-
entation/training; communication; and time/staffing/workload. The three primary barriers to CPG
use were time/staffing/workload; education, orientation, and training; and communication.
The researchers in this study suggested that almost every working staff nurse can identify
with these findings because guidelines and checklists are becoming more prevalent and even
mandatory at many facilities. They noted that additional research is needed to determine whether
electronic CPGs are used more often and promote better patient care than written guidelines.
In addition, nurses should participate in the development of new CPGs, and managers should
ensure adequate education and orientation is provided for every new CPG.
Examining the Evidence 23.1
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552 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
of hospital care include mortality, morbidity, and length of hospital stay, these outcomes are
not highly nursing-sensitive. More nursing-sensitive outcome measures for the acute-care
setting include patient fall rates, nosocomial infection rates, the prevalence of pressure sores,
physical restraint use, and patient satisfaction rates.
Process Audit
Process audits measure how nursing care is provided. The audit assumes a connection
between the process and the quality of care. Critical pathways and standardized clinical
guidelines are examples of efforts to standardize the process of care. They also provide a tool
to measure deviations from accepted best practice process standards.
Process audits are used to measure the process of care or how the care was carried out and
assume that a relationship exists between the process used by the nurse and the quality of care
provided.
Process audits tend to be task-oriented and focus on whether practice standards are being
fulfilled. Process standards may be documented in patient care plans, procedure manuals, or
nursing protocol statements. A process audit might be used to establish whether fetal heart
tones or blood pressures were checked according to an established policy. In a community
health agency, a process audit could be used to determine if a parent received instruction
about a newborn during the first postpartum visit.
In addition, a process audit could be done of the medication reconciliation process used to
prevent medication errors at patient transition points. Medication reconciliation is the process
of comparing the medications a patient is taking (and should be taking) with newly ordered
medications (Joint Commission, 2012). The comparison addresses duplications, omissions,
and interactions, and the need to continue current medications. The types of information
that clinicians use to reconcile medications include (among others) medication name, dose,
frequency, route, and purpose (Joint Commission, 2012).
Structure Audit
Structure audits assume that a relationship exists between quality care and appropriate
structure. A structure audit includes resource inputs such as the environment in which health
care is delivered. It also includes all those elements that exist prior to and separate from
the interaction between the patient and the health-care worker. For example, staffing ratios,
staffing mix, emergency department wait times, and the availability of fire extinguishers in
patient care areas are all structural measures of quality of care.
Structural standards, which are often set by licensing and accrediting bodies, ensure a safe
and effective environment, but they do not address the actual care provided. An example of
a structural audit might include checking to see if patient call lights are in place or if patients
can reach their water pitchers. It also might examine staffing patterns to ensure that adequate
resources are available to meet changing patient needs.
LEARNING EXERCISE 23.2
Identifying Structure, Process, and Outcome Measures
You are a charge nurse on a postsurgical unit. retrospective survey data reveal that many
patients report high levels of postoperative pain in the first 72 hours after surgery. You decide
to make a list of possible structure, process, and outcome variables that may be impacting the
situation. One of the structure measures you identify is that the narcotic medication carts are

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Chapter 23 Quality Control 553
STANDARDIZED NURSING LANGUAGES
One means of better identifying nursing-sensitive outcomes has been the development of
standardized nursing languages. A standardized nursing language provides a consistent
terminology for nurses to describe and document their assessments, interventions, and the
outcomes of their actions. Currently, 12 standardized nursing languages have been approved
by the ANA (National Association of School Nurses, 2012) (see Display 23.5.). Three are
discussed in this chapter.
located some distance from the patient rooms and that may be contributing to a delay in pain
medication administration. One of the process measures you identify is that licensed staff are
inconsistent in terms of how soon they make their initial pain assessments on postoperative
patients as well as the tools they use to assess pain levels. an outcome measure might be the
average wait time from the time a patient requests pain medication until it is administered.
Assignment: identify at least three additional structure, process, and outcome measures
for which you might collect data in an effort to resolve this problem. select at least one of
these measures, and specifically identify how you would collect the data. then, describe how
you would use your findings to increase the likelihood that future practice on the unit will be
evidence-based.
One of the oldest standardized nursing languages is the NMDS. The NMDS—developed
by Werley and Lang—represents efforts lasting more than a decade to standardize the
collection of nursing data. With the NMDS, a minimum set of items of information with
uniform definitions and categories is collected to meet the needs of multiple data users. Thus,
it creates a shared language that can be used by nurses in any care delivery setting as well as
by other health professionals and researchers. This data then can be used to compare nursing
effectiveness, costs, and outcomes across clinical settings and nursing interventions.
Another tool that helps to link nursing interventions and patient outcomes is the NIC
developed by the Iowa Interventions Project, College of Nursing, Iowa City, Iowa. The NIC
DISPLAY 23.5 Standardized Nursing Languages Approved by the American Nurses
Association
1. NaNda international (NaNda-i)
2. Nursing interventions Classification (NiC)
3. Nursing Outcomes Classification (NOC)
4. Clinical Care Classification system (CCC)
5. the Omaha system
6. perioperative Nursing data set (pNds)
7. international Classification for Nursing practice (iCNp)
8. systemized Nomenclature of Medicine Clinical terms (sNOMed Ct)
9. Logical Observation identifiers Names and Codes (LOiNC)
10. Nursing Minimum data sets (NMds)
11. Nursing Management Minimum data sets (NMMds)
12. aBC Codes
Source: National Association of School Nurses (2012). standardized nursing languages. Retrieved June 23, 2013
from http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/
ArticleId/48/Standardized-Nursing-Languages-Revised-June-2012
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554 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
is a research-based classification system that provides a common, standardized language for
nurses; it consists of independent and collaborative interventions of nurses in all specialty
areas and in all settings. With 30 diverse classes of care, such as drug management,
child bearing, community health promotion, physical comfort promotion, and perfusion
management and multiple domains of interventions, the NIC can be linked with the North
American Nursing Diagnosis Association taxonomy, the NMDS, and nursing outcomes to
improve patient outcomes.
Finally, the International Council of Nurses (ICN) has developed the International
Classification for Nursing Practice (ICNP), a compositional terminology for nursing practice
that is applicable globally. The ICNP represents the domain of nursing practice as an essential
and complementary part of professional health services, necessary for decision-making and
policy development aimed at improving health status and health care (ICN, 2009).
QUALITY IMPROVEMENT MODELS
Over the past several decades, the American health-care system has moved from a quality
assurance (QA) model to one focused on quality improvement (QI). The difference between
the two concepts is that QA models target currently existing quality; QI models target
ongoing and continually improving quality. Two models that emphasize the ongoing nature
of QI include total quality management (TQM) and the Toyota Production System (TPS).
Quality assurance models seek to ensure that quality currently exists, whereas QI models
assume that the process is ongoing and quality can always be improved.
Total Quality Management
TQM, also referred to as continuous quality improvement (CQI), is a philosophy developed
by Dr. W. Edward Deming. TQM is one of the hallmarks of Japanese management systems.
It assumes that production and service focus on the individual and that quality can always
be better. Thus, identifying and doing the right things, the right way, the first time, and
problem-prevention planning—not inspection and reactive problem-solving—lead to quality
outcomes.
TQM is based on the premise that the individual is the focal element on which production and
service depend (i.e., it must be a customer-responsive environment) and that the quest for
quality is an ongoing process.
Because TQM is a never-ending process, everything and everyone in the organization
are subject to continuous improvement efforts. No matter how good the product or service
is, the TQM philosophy says that there is always room for improvement. Customer needs
and experiences with the product are constantly evaluated. Workers—not a central QA/QI
department—do this data collection, thus providing a feedback loop between administrators,
workers, and consumers. Any problems encountered are approached in a preventive or
proactive mode so that crisis management becomes unnecessary.
Another critical component of TQM is the empowerment of employees by providing
positive feedback and reinforcing attitudes and behaviors that support quality and productivity.
Based on the premise that employees have an in-depth understanding of their jobs, believe
they are valued, and feel encouraged to improve product or service quality through risk-taking
and creativity, TQM trusts the employees to be knowledgeable, accountable, and responsible
and provides education and training for employees at all levels. Although the philosophy of
TQM emphasizes that quality is more important than profit, the resultant increase in quality
of a well-implemented TQM program attracts more customers, resulting in increased profit

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Chapter 23 Quality Control 555
margins and a financially healthier organization. The 14 quality management principles of
TQM as outlined by Deming (1986) are summarized in Display 23.6.
The Toyota Production System
Another more contemporary, customer-focused QI model is the TPS. TPS is a production
system built on the complete elimination of waste and focused on the pursuit of the most
efficient production method possible (Toyota Motor Company, n.d.). “Toyota members seek
to continually improve their standard processes and procedures in order to ensure maximum
quality, improve efficiency and eliminate waste. This is known as kaizen and is applied to
every sphere of the company’s activities” (para 3).
Health-care organizations that use TPS would have caregivers not only attempt to directly
solve problems at the time they occur, but it would also have them determine the root cause of
the problem, so that the likelihood of the problem recurring would be minimized. TPS argues
that solving individual problems this way, one at a time and where, when, and with whom
they occur, prevents larger problems. Thus, management decisions are based on a long-term
philosophy, even at the expense of short-term financial goals.
Implementing TPS, however, is not easy. It usually requires a change in organizational
culture, values, and roles since responsibility and accountability for solving problems is so
decentralized. In addition, eliminating problems at their root is far different from solving an
immediate problem at hand. Thus, adopting TPS in an organization requires a substantial
commitment of leadership time and resources. It also requires a tremendous amount of staff
preparation and involvement.
1. Create a constancy of purpose for the improvement of products and service.
2. adopt a philosophy of continual improvement.
3. Focus on improving processes, not on inspection of product.
4. end the practice of awarding business on price alone; instead, minimize total cost by working
with a single supplier.
5. Constantly improve every process for planning, production, and service.
6. institute job training and retraining.
7. develop the leadership in the organization.
8. drive out fear by encouraging employees to participate actively in the process.
9. Foster interdepartmental cooperation, and break down barriers between departments.
10. eliminate slogans, exhortations, and targets for the workforce.
11. Focus on quality and not just quantity; eliminate quota systems if they are in place.
12. promote teamwork rather than individual accomplishments. eliminate the annual rating or merit system.
13. educate/train employees to maximize personal development.
14. Charge all employees with carrying out the tQM package.
Source: Deming, W. E. (1986). Out of the crisis. Cambridge, MA: MIT Press.
DISPLAY 23.6 Total Quality Management Principles
LEARNING EXERCISE 23.3
Deming’s 14 Total Quality Management Principles
think back to the organization for which you have worked the longest. How many of deming’s
14 principles for tQM are used in that organization? do you believe some of the 14 principles
are more important than others? Why or why not? Could an organization have a successful
quality management program if only some of the principles are used?
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556 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
WHO SHOULD BE INVOLVED IN QUALITY CONTROL?
Ideally, everyone in the organization should participate in quality control, because each
individual is a recipient of the benefits. Quality control gives employees feedback about
their current quality of care and how the care they provide can be improved. Engagement of
frontline staff appears to be especially critical when implementing or sustaining QI efforts such
as TCAB (Transforming Care at the Bedside)—a new national program developed and led by
the Robert Wood Johnson Foundation and the Institute for Health Improvement (Parkerton
et al., 2009). TCAB engages leaders at all levels of the organization, empowers frontline staff
to improve care processes, and engages family members and patients in decision-making
about their care. The end result is an improvement in patient safety indicators.
Many contemporary organizations, however, designate an individual (frequently a nurse)
to be their patient safety officer. This strategy is risky, as it may create the impression that
the responsibility for quality care is not shared. Therefore, although it is impractical to expect
full staff involvement throughout the quality control process, as many staff as possible should
be involved in determining criteria or standards, reviewing standards, collecting data, or
reporting.
Quality control also requires evaluating the performance of all members of the
multidisciplinary team. Professionals such as physicians, respiratory therapists, dietitians,
and physical therapists contribute to patient outcomes and therefore must be considered
in the audit process. Patients should also be actively involved in the determination of an
organization’s quality of care. It is important to remember, however, that quality care does
not always equate with patient satisfaction.
Patient satisfaction often has little to do with whether a patient’s health improved during a
hospital stay.
For example, the quality of food, provision of privacy, satisfaction with a roommate,
or noisiness of the nursing station may play into a patient’s satisfaction with a hospital
admission. In addition, patient satisfaction may be adversely affected by long waits for call
lights to be answered and for transport to ancillary services such as the radiology department.
Even the friendliness of the staff can impact patient satisfaction and perception of quality
care. Although these factors are an important component of patient comfort, and therefore
quality of care, quality is more encompassing and must always include an examination
of whether the patient received the most appropriate treatment from the most appropriate
provider in a timely manner.
QUALITY MEASUREMENT AS AN ORGANIZATIONAL MANDATE
Organizational accountability for the internal monitoring of quality and patient safety has
increased exponentially the last 30 years. Most health-care organizations today have complete
QI programs and are actively working to improve patient outcomes and promote patient safety.
Changing government regulations regarding quality control, however, continue to influence
QI efforts strongly. Managers must be cognizant of changing government and licensing
regulations that affect their unit’s quality control and standard setting. This awareness allows
the manager to implement proactive rather than reactive quality control.
External Impacts on Quality Control
Although few organizations would debate the significant benefits of well-developed and
implemented quality control programs, quality control in health-care organizations has
evolved primarily from external influences and not as a voluntary monitoring effort. When

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Chapter 23 Quality Control 557
Medicare and Medicaid (government reimbursement for the elderly, disabled, and indigent)
were implemented in the early 1960s, health-care organizations had little need to justify
costs or prove that the services provided met patients’ needs. Reimbursement was based on
the costs incurred in providing the service, and no real ceilings were placed on the amount
that could be charged for services. Only when the cost of these programs skyrocketed did the
government establish regulations requiring organizations to justify the need for services and
to monitor the quality of services.
Professional Standards Review Organizations
Professional Standards Review Board legislation (PL 92-603), established in 1972, was
among the first of the federal government’s efforts to examine cost and quality. Professional
standards review organizations mandated certification of need for the patient’s admission and
continued review of care; evaluation of medical care; and analysis of the patient profile, the
hospital, and the practitioners.
This new kind of surveillance and the existence of external controls had a huge effect
on the industry. Health-care organizations began to question basic values and were forced
to establish new methods for collecting data, keeping records, providing services, and
accounting in general. Because government programs, such as Medicare and Medicaid,
represent such a large group of today’s patients, organizations that were unwilling or unable
to meet these changing needs did not survive financially.
The Prospective Payment System
The advent of diagnosis-related groups (DRGs) in the early 1980s added to the ever-
increasing need for organizations to monitor cost-containment yet guarantee a minimum
level of quality (Chapter 10). As a result of DRGs, hospitals became part of the prospective
payment system (PPS), whereby providers are paid a fixed amount per patient admission
regardless of the actual cost to provide the care. This system has been criticized as promoting
abbreviated hospital stays and services leading to a reduced quality of care. Clearly, DRGs
have resulted in increased acuity levels of hospitalized patients, a decrease in the length of
patient stay, and a perception by many health-care providers that patients are being discharged
prematurely. All of these factors have contributed to growing levels of dissatisfaction by
nurses regarding the quality of care they provide.
Critics of the PPS argue that although DRGs may have helped to contain rising health-care
costs, the associated rapid declines in length of hospital stay and services provided have
resulted in declines in quality of care.
LEARNING EXERCISE 23.4
Quality of Patient Care
How do you define quality of care? is the quality of your care always what you would like it
to be? if not, why not? What factors can you control in terms of providing high-quality care?
(Which are internal and which are external?) in your clinical experience, have drGs affected the
quality of care provided? if so, how? do you see differences in the quality of care provided to
clients based on their ability to pay for that care or the type of insurance that they have?
The Joint Commission
The Joint Commission (JC) (formerly known as the Joint Commission for Accreditation
of Healthcare Organizations [JCAHO])—an independent, not-for-profit organization that
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558 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
accredits more than 20,000 health-care organizations and programs in the United States (Joint
Commission, 2013a)—has historically had a tremendous impact on planning for quality
control in acute-care hospitals. The JC was the first to mandate that all hospitals have a QA
program in place by 1981. These QA programs were to include a review of the care provided
by all clinical departments, disciplines, and practitioners; the coordination and integration of
the findings of quality control activities; and the development of specific plans for known or
suspected patient problems. Again, in 1982, the JC began to require quarterly evaluations of
standards for nursing care as measured against written criteria.
The JC also maintains one of the nation’s most comprehensive databases of sentinel (serious
adverse) events by health-care professionals and their underlying causes. A sentinel event is
defined by the JC (2013c, para 2) as “an unexpected occurrence involving death or serious
physical or psychological injury, or the risk thereof. Serious injury specifically includes loss
of limb or function. The phrase, ‘or the risk thereof’ includes any process variation for which
a recurrence would carry a significant chance of a serious adverse outcome.” Such events
are called “sentinel” because they signal the need for immediate investigation and response.
Information from the JC sentinel database is regularly shared with accredited organizations
to help them take appropriate steps to prevent medical errors (JC, 2013c).
Another JC priority is the development of RCA with a plan of correction for the errors that
do occur. The JC’s (2013c) Sentinel Event Policy provides that organizations that are either
voluntarily reporting a sentinel event or responding to the JC’s inquiry about a sentinel event
submit their related RCA and action plan electronically to the JC whenever such events occur.
The sentinel event data are then reviewed, and recommendations are made. The JC defends
the confidentiality of the information, if necessary, in court.
Similarly, some organizations use a failure mode and effects analysis to examine all
possible failures in a design—including sequencing of events, actual and potential risk, points
of vulnerability, and areas for improvement (American Society for Quality, n.d.).
ORYX
In the late 1990s, the JC instituted its Agenda for Change—a multiphase, multidimensional
set of initiatives directed at modernizing the accreditation process by shifting the focus of
accreditation from organizational structure to organizational performance or outcomes. This
required the development of clinical indicators to measure the quality of care provided. To
further this goal, the JC approved a milestone initiative, known as ORYX, in February 1997.
This initiative integrated outcomes and other performance measures into the accreditation
process with data being publicly reported at a Web site known as Quality Check (www
.qualitycheck.org).
Under ORYX, all organizations accredited by the JC were required to select at least 1 of
60 acceptable performance measurement systems and to begin data collection on specific
clinical measures. Organizations could also volunteer for ORYX Plus, an effort by the JC
to create a national standardized database of 32 performance measures. In addition, the JC
began collecting data on outcome measures, including the sentinel events overall error rate,
the number of reports on possible errors or near misses, hospital readmission rates, and the
rate of hospital-acquired infections in an effort to better measure quality of care.
CORE MEASURES
Finally, the JC implemented its core measures program (also called Hospital Quality
Measures) as part of ORYX in 2002 in an effort to better standardize its valid, reliable,
and evidence-based data sets. Hospitals that choose not to participate in the core measures
initiative receive a reduction of 2% in their Medicare Annual Payment.
The four areas initially targeted for implementation were acute myocardial infarction,
pneumonia, heart failure, and the surgical care improvement project. Other core

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Chapter 23 Quality Control 559
measures have since been added including children’s asthma care, emergency department,
hospital-based inpatient psychiatric services, hospital outpatient, immunization, stroke,
substance use, perinatal services, tobacco treatment, and venous thromboembolism (Joint
Commission, 2013b).
In January 2013, the JC announced that it will expand performance measurement
requirements for accredited general medical/surgical hospitals from four to six core measures.
(The Joint Commission Expands Performance, 2013). The additional requirements will
take effect from January 1, 2014. The current four core measures will be mandatory for all
general medical/surgical hospitals that serve specific patient populations. For hospitals with
1,100 or more births per year, the perinatal care measure set will become the mandatory fifth
measure set. The sixth measure set (or fifth and sixth measure sets, for hospitals with fewer
than 1,100 births per year) will be chosen by all general medical/surgical hospitals from the
approved complement of core measure sets (The Joint Commission Expands Performance,
2013). The JC expects that requirements will increase over time, depending on the national
health-care environment, emerging national measurement priorities, and hospitals’ ever-
increasing capability to electronically capture and transmit data (The Joint Commission
Expands Performance, 2013).
National Patient Safety Goals
To augment the core measures and promote specific improvements in patient safety, the JC
also issues National Patient Safety Goals (NPSGs) annually. For example, the NPSGs for
2013 included such things as identifying patients correctly, improving staff communication,
using medicines safely, preventing infection, identifying patient safety risks, and preventing
mistakes in surgery (The Joint Commission, 2013d). It remains to be seen to what degree
compliance with core measures and the NPSGs actually improves patient outcomes.
Early research findings are mixed with some studies reporting improved patient outcomes
associated with core measures implementation and others finding no difference.
CENTERS FOR MEDICARE AND MEDICAID SERVICES
The Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing
Administration, also plays an active role in setting standards for and measuring quality in
health care. With the introduction of the Medicare Quality Initiative in November 2001
(now called the Hospital Quality Initiative [HQI]), health outcomes were targeted as the
data source. As part of the HQI, easy-to-understand data on health-care quality from nursing
homes, home health agencies, hospitals, and kidney dialysis facilities are made available
to all consumers via a variety of media. The intent is to encourage consumers and their
physicians to discuss and make better-informed decisions on how to get the best hospital care,
create incentives for hospitals to improve care, and support public accountability (Hospital
Quality Initiative, 2008).
Pay for Performance/Quality-Based Purchasing
The CMS, through Medicare, has also established Pay for Performance (P4P), also known as
quality-based purchasing. P4P initiatives were created to align payment and quality incentives
and to reduce costs through improved quality and efficiency. For example, the Physician
Quality Reporting Initiative allows for payments to health professionals who satisfactorily
report quality information to Medicare. In addition, 10 groups began participating in the
4-year Physician Group Practice Demonstration in 2005. For each year of the project, the
groups could receive up to 80% of the savings they generated for Medicare by preventing
complications and hospitalizations. Bonus payments depended on their savings and their
quality of care.
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560 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
Critics of the P4P incentive system suggest, however, that the system has failed to yield the
desired results. They state this has occurred for many reasons, including a focus on provider
improvement and not achievement, the risk adjustment of provider scores may be imprecise
or even inapplicable to certain P4P metrics, small sample sizes result in too few patients who
are eligible to be scored for a given metric, and because patients are often treated by multiple
physicians (Pay for Performance, 2011).
In addition, they suggest that “P4P may result in better documentation of care, without a
concurrent improvement in actual care. In addition, physicians may move their practices to
areas where they believe patients can more effectively manage their own care; coordination
of care could decline, especially for patients with multiple illnesses; physicians might focus
on improving care only in areas addressed by financial rewards; and practice administrative
costs could increase” (Pay for Performance, para 13).
Hospital Consumer Assessment of Healthcare Providers and Systems
Surveys
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
survey is the first national, standardized, publicly reported survey of patients’ perspectives of
hospital care. Developed by a partnership between AHRQ and CMS beginning in 2002, the
27-item HCAHPS (pronounced “H-caps”) survey instrument measures patients’ perceptions
of their hospital experience and can be conducted by mail, telephone, mail with telephone
follow-up, or active interactive voice recognition (HCAHPS Fact Sheet, 2012).
The HCAHPS survey asks medical, surgical, and maternity care patients who have
been recently discharged (between 48 hours and 6 weeks) about aspects of their hospital
experience including “how often” or whether patients experienced a critical aspect of
hospital care, rather than whether they were “satisfied” with the care. Data collected include
how well nurses and doctors communicate with patients, how responsive hospital staff are
to patients’ needs, how well hospital staff help patients manage pain, how well the staff
communicates with patients about medicines, and whether key information is provided
at discharge (see Examining the Evidence 23.2). In addition, the survey addresses the
Source: Study Links HCAHPS, Readmission Rates. (2013). Hospital Case Management, 21(2), 25.
This study by Press Ganey, a South Bend, IN, health-care performance improvement organiza-
tion, analyzed hospitals’ readmission penalty data and compared it with their performance on the
CMS value-based purchasing measures. The study found a strong correlation between 30-day
readmissions and performance on the HCAHPS portion of the Value-Based Purchasing Program
with 30-day readmission rates decreasing as HCAHPS scores increased.
Press Ganey noted that good communication with patients and family members is a major fac-
tor in performance on patient perception of care measures as well as on the hospital’s success
in preventing 30-day readmissions. The HCAHPS survey asked patients to rate communication
with nurses and physicians, responsiveness of the hospital staff, and discharge information, along
with questions about cleanliness and quietness of the hospital environment, and pain manage-
ment. Many of the questions focused on communication and the hospital’s effectiveness in enga-
ging patients—factors that also affect patients’ ability to care for themselves after discharge and
avoid being readmitted.
The researchers concluded that case managers should start discharge planning on admission
and communicate frequently with patients and family members during their hospital stay. This will
reduce the hospital readmissions that occur as a result of patients not following their discharged
instructions, failing to take their medication correctly, and not having the community resources
they need to manage after discharge, all of which indicate gaps in communication.
Examining the Evidence 23.2

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Chapter 23 Quality Control 561
cleanliness and quietness of patients’ rooms, the patients’ overall rating of the hospital, and
whether they would recommend the hospital to family and friends. Ten HCAHPS measures
are publicly reported on the Hospital Compare Web site (www.hospitalcompare.hhs.gov) for
each participating hospital.
While many hospitals collected information on patient satisfaction for their own
internal use, until HCAHPS there were no common metrics and no national standards
for collecting and publicly reporting information about patient experience of care. Since
2008, HCAHPS data have been reported publicly making, valid comparisons possible
across hospitals locally, regionally, and nationally. This public reporting has created
new incentives for hospitals to improve quality of care and has enhanced accountability
in health care by increasing transparency of the quality of hospital care (HCAHPS Fact
Sheet, 2012).
National Committee for Quality Assurance
Another external force assessing quality control in health-care organizations is the National
Committee for Quality Assurance (NCQA). The NCQA, a private nonprofit organization
that accredits managed care organizations, has developed the Health Plan Employer Data
and Information Set (HEDIS) to compare the quality of care in managed care organizations.
HEDIS 2013 consists of 75 measures across 8 domains of care, which provide numerical and
descriptive information about the quality of care, patient outcomes, access and availability
of services, utilization, premiums, and the plan’s financial stability and operating policies
(NCQA, 2013). Future versions are expected to have an even greater number of performance
indicators as the growing Medicaid and Medicare segment of the population enrolled in
managed care adds more specific performance indicators.
One of the most significant weaknesses of NCQA accreditation, however, is that such
accreditation is voluntary. Since 1999, however, Medicare and Medicaid have contracted their
managed care plans only with health plans that are accredited by the NCQA. More employers
are also adopting this policy with the result that most managed care organizations will need
this accreditation in the future to survive fiscally.
Maryland Hospital Association Quality Indicator Project
Another major initiative to measure quality in acute-care settings is the Maryland Hospital
Association Quality Indicator Project (QI Project). The QI Project—a research project that
began in 1985 with 7 acute-care hospitals in Maryland—currently has more than 1,800
acute-care hospitals and other health-care facilities participating. Among facilities accredited
by the JC, the QI Project is the performance measurement system most frequently selected
for meeting the ORYX requirement. Nearly 1,000 of the project’s participants use their QI
Project data to meet this JCAHO requirement (Wisconsin Hospital Association, 2003–2013).
It is important though to remember that the QI Project is still considered a research project,
and as such, the project is not intended to be used to establish performance thresholds or
standards of care; however, its benchmark work in indicator identification and measurement
is invaluable.
Multistate Nursing Home Case Mix and Quality Demonstration
There has also been a major move to develop quality indicators in long-term care settings. One
of the most significant efforts has been the Multistate Nursing Home Case Mix and Quality
demonstration, funded by the CMS. This demonstration seeks to develop and implement both
a case mix classification system to serve as the basis for Medicare and Medicaid payment
and a quality-monitoring system to assess the impact of case mix payment on quality and to
provide better information to the nursing home survey process.
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562 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
Report Cards
In response to the demand for objective measures of quality, a number of health
plans, health-care providers, employer purchasing groups, consumer information
organizations, and state governments have begun to formulate health-care quality report
cards. Most states have laws requiring providers to report some type of data. AHRQ
has also been exploring the development of a report card for the nation’s health-care
delivery system.
However, many current report cards do not contain information about the quality of care
rendered by specific clinics, group practices, or physicians in a health plan’s network. In
addition, some critics of health-care report cards point out that health plans may receive
conflicting ratings on different report cards. This is a result of using different performance
measures and how each report card chooses to pool and evaluate individual factors. In
addition, report cards may not be readily accessible or may be difficult for the average
consumer to understand.
MEDICAL ERRORS: AN ONGOING THREAT TO QUALITY OF CARE
Many studies over the past 2 decades suggest that medical errors are rampant in the health-
care system. The most well known of these studies was likely the 1999 IOM report called To
Err Is Human (Kohn, Corrigan, & Donaldson, 2000). This report found that between 44,000
and 98,000 Americans die each year as a result of medical errors, making medical errors the
eighth leading cause of death in this country, even when the lower estimate was used. The
IOM study also looked at the type of errors that were occurring. Medication errors stood out
as a particularly high risk, since these errors can lead to patient injuries, often called adverse
drug events.
Perhaps the most significant contribution of the IOM report, however, was the conclusion
that most of these errors did not occur from individual recklessness. Instead, they occurred
because of basic flaws in the way that the health delivery system is organized and delivered.
The current focus in medical error research is on fixing these flaws and creating and/
or fostering environments that minimize the likelihood of errors occurring. Strategies to
create such environments include better reporting of the errors that do occur, the Leapfrog
initiatives, reform of the medical liability system, and other point-of-care strategies such as
bar coding, smart IV pumps, and medication reconciliation.
Reporting and Analyzing Errors
One critical strategy for addressing errors in the health-care system is the need to increase
both the mandatory and voluntary reporting of medical errors. At the unit level, organizational
cultures must be created that remove blame from the individual and, instead, focus on how
the organization itself can be modified to reduce the likelihood of such errors occurring in
the future. Only then will health-care workers feel they can report the errors and near misses
they see occurring every day in their clinical practice.
This does not, however, remove individual practitioner responsibility and accountability
to do everything they can to provide safe and competent care. This need to find a middle
ground between a blame-free culture, which attributes all errors to system failure and says no
individual is held accountable, and an overly punitive culture, where individuals are blamed
for all mistakes, has been labeled a “just culture” (Landro, 2010). Developed by engineer
David Marx, a just culture emphasizes finding the middle ground between the two extremes.
It also seeks to separate unavoidable error from reckless behavior and unjustifiable risk
(Landro).

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Chapter 23 Quality Control 563
Ignoring the problem of medical errors, denying their existence, or blaming the individuals
involved in the processes does nothing to eliminate the underlying problems.
Legislation is also occurring at the national level to promote both the mandatory and
voluntary reporting of medical errors. For example, the Patient Safety and Quality
Improvement Act was signed into law in 2005. This bill protects medical error information
voluntarily submitted to new private organizations (patient safety organizations) from being
subpoenaed or used in legal discovery and generally requires that the information is treated
as confidential.
Federal legislation has also been proposed to protect the voluntary reporting of ordinary
injuries and “near misses”—errors that did not cause harm this time but easily could the next
time. This would be like what is done in aviation, in which near misses are confidentially
reported and can be analyzed by anyone.
Health-care organizations also need to do a better job of identifying what errors are
occurring, categorizing those errors, and examining and reworking the processes that led to
the errors. It is the leader-manager who bears the responsibility for proactively creating a
work environment that minimizes these risks.
The Leapfrog Group
In addition, to help minimize risks to patients, the standards and expectations of oversight
groups, insurers, and professional groups have been raised. One such effort is the Leapfrog
Group, a growing conglomeration of non–health-care Fortune 500 company leaders who
are committed to modernizing the current health-care system. Based on current research,
the Leapfrog Group has identified four evidence-based standards that they believe will
provide the greatest impact on reducing medical errors: computerized physician–provider
order entry (CPOE), evidence-based hospital referral (EHR), ICU (intensive care unit)
physician staffing (IPS), and the use of Leapfrog Safe Practices scores (Leapfrog Group,
2013). These strategies and the evidence supporting their use are described more fully in
Display 23.7.
Scientific evidence indicates that these Leapfrog initiatives will reduce preventable
medical errors. Their implementation is already underway or feasible in the short term;
COMPUTERIZED PHYSICIAN–PROVIDER ORDER ENTRY
requires primary care providers to enter orders into a computer instead of handwriting them. this
reduces medication errors based on inaccurate transcription. it also gives providers vital clinical
decision support via access to information tools that support a health-care provider in decisions
related to diagnosis, therapy, and care planning of individual patients.
Evidence: CpOe has been shown to reduce serious prescribing errors in hospitals by more than
50%.
EVIDENCE-BASED HOSPITAL REFERRAL
suggests that patients with high-risk conditions should be treated at hospitals with characteristics
shown to be associated with better outcomes.
Evidence: referring patients needing certain complex medical procedures to hospitals offering
the best survival odds based on scientifically valid criteria, such as the number of times a hospital
performs these procedures each year or other process or outcomes data, reduces the patient’s risk
of dying up to 40%.
DISPLAY 23.7 Evidence-Based Leapfrog Initiatives
(Continued )
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564 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
consumers can appreciate their value; and health plans, purchasers, or consumers can easily
ascertain their presence or absence in selecting health-care providers.
Leapfrog has also endorsed the use of bar coding to reduce point-of-care medication
errors. As set forth by the U.S. Food and Drug Administration (FDA), all prescription and
over-the-counter medications used in hospitals must contain a national drug code number,
which indicates its dosage forms and strength. The FDA suggests that a bar code system
coupled with a CPOE system would greatly enhance the ability of all health-care workers to
follow the “five rights” of medication administration—that the right person receives the right
drug in the right dose via the right route at the right administration time.
In addition, hospitals are increasingly turning to so-called smart pumps for intravenous
(IV) therapy infusions. These smart pumps have safety software inside an advanced infusion
therapy system that prevents IV medication errors through minimum and maximum dose
limits as well as preset limits that cannot be overridden at a clinician’s discretion.
A Six Sigma Approach
Another approach that has been taken to create a culture of safety management at the
institutional level has been the implementation of a Six Sigma approach. Sigma is a statistical
measurement that reflects how well a product or process is performing. Higher sigma values
indicate better performance. Historically, the health-care industry has been comfortable
striving for three sigma processes (all data points fall within 3 standard deviations) in terms
of health-care quality, instead of six (Huston, 2014). This is one reason why health care
has more errors than the banking or airline industries, where Six Sigma is the expectation.
Organizations should aim for this target by carefully applying the Six Sigma methodology to
every aspect of QI.
The safety record in health care is a far cry from the enviable record of the similarly complex
aviation industry.
Reforming the Medical Liability System
Finally, if quality health care is to be achieved, the medical liability system and our litigious
society must be recognized as potential barriers to systematic efforts to uncover and learn from
mistakes that are made in health care. Organizational cultures need to change for employees
and patients to be comfortable in reporting hazards that can affect patient safety without fear
INTENSIVE CARE UNIT PHYSICIAN STAFFING
examines the level of training of iCU medical personnel and suggests that quality of care in hospital
iCUs is strongly influenced by (a) whether intensivists (doctors with special training in critical care
medicine) are providing care and (b) the staff organization in the iCU.
Evidence: ips has been shown to reduce the risk of patients dying in the iCU by 40%.
LEAPFROG SAFE PRACTICES SCORES
The National Quality Forum (NQF) endorsed safe practices, which if utilized would reduce the risk
of harm in certain processes, systems, or environments of care. included in the 34 practices are
the 3 initiatives noted above. this fourth initiative assesses a hospital’s progress on the remaining
31 NQF safe practices.
Source: Collated from Leapfrog Group. (2013). the Leapfrog Group fact sheet. Retrieved June 24, 2013, from http://
www.leapfroggroup.org/about_us/leapfrog-factsheet and Huston, C. (2014). Medical errors: An ongoing threat to
quality health care. In C. Huston (Ed.), professional issues in nursing: Challenges and opportunities (3rd ed.),
Philadelphia, PA: Lippincott Williams & Wilkins.

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Chapter 23 Quality Control 565
of personal risk. Many experts have argued that the culture in health-care organizations must
shift from one of blame to one in which errors are identified and responded to in a timely
manner.
Are We Making Progress?
Gaps continue to exist between the care that patients should receive and the care they actually
receive. This has been borne out in numerous studies including the follow-up IOM study
Crossing the Quality Chasm: A New Health System for the 21st Century, which found large
gaps between the preventive, acute, and chronic care that people should get and what they
actually received.
Similarly, a large study by Healthgrades (2008) of 41 million Medicare patient records
between 2004 and 2006 in virtually all of the nation’s nearly 5,000 nonfederal hospitals
reported 238,337 potentially preventable deaths. The overall incident rate was approximately
3% of all Medicare admissions, accounting for 1.1 million patient safety incidents during the
3 years studied. Medicare patients who experienced a patient safety incident had a one-in-five
chance of dying as a result of the incident. The study concluded that if all of the hospitals had
performed at the level of Distinguished Hospitals for Patient Safety, approximately 220,106
patient safety incidents and 37,214 Medicare deaths could have been prevented, saving the
US $2.0 billion during the study period.
More recent data from Healthgrades (2013), however, was more encouraging. Hospital
quality, as measured by mortality and complication rates, saw significant improvement from
2005 to 2011, although this varied by condition and procedure. For example, from 2005
through 2011, the nation’s average in-hospital risk-adjusted mortality rate improved 22%
across 16 of the common procedures and conditions studied by Healthgrades, such as chronic
obstructive pulmonary disease (COPD), heart failure, and stroke.
Changes in hospital performance during this time frame varied widely by procedure and
condition, ranging from a 3.5% increase in the risk-adjusted mortality rate for gastrointestinal
surgeries and procedures (performance decline) to a 34.1% improvement in risk-adjusted
mortality rate for COPD. Hospital quality also varied significantly across the United States
with certain states performing exceptionally well (California and Delaware) and some
performing poorly (Alabama and Pennsylvania) (Healthgrades, 2013).
It is clear then that despite all the interventions that have come out from the IOM studies
and the multitude of organizations dedicated to QI in health care, progress in addressing the
problem of medical errors is limited. Indeed, Wachter (2010) affirms that QI gains in health
care in the 15 years since the publication of To Err Is Human have been slow to materialize,
and he suggests that future changes will also likely be incremental. Yet, he also suggests
that we have learned much from the missteps we have taken and that new important and
unaddressed areas are now being placed on the patient safety agenda.
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
WITH QUALITY CONTROL
Quality control provides managers with the opportunity to evaluate organizational
performance from a systematic, scientific, and objective viewpoint. To do so, managers must
determine what standards will be used to measure quality care in their units and then develop
and implement quality control programs that measure results against those standards. All
managers are responsible for monitoring the quality of the product that their units produce; in
health-care organizations, that product is patient care. Managers too must assess and promote
patient satisfaction whenever possible.
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566 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
The manager, however, cannot operate in a vacuum in determining what quality is and
how it should be measured. This determination should come from research-based evidence.
Demands for hard data on quality have increased as regulatory bodies, patients, payers,
and hospital managers have required justification for services provided. Managers must
be cognizant of rapidly changing quality control regulations and proactively adjust unit
standards to meet these changing needs. Until 2 decades ago, limited attention was given to
quality measurement in health care. As we enter the 21st century, however, there is an ever-
increasing focus on the quality of care and the standardization of quality data collection and
an increased accountability for outcomes from the system level to the individual provider.
Inspiring subordinates to establish and achieve high standards of care is a leadership
skill. Leaders are a role model for high standards in their own nursing care and encourage
subordinates to seek maximum rather than minimum standards. One way that this can be
accomplished is by involving subordinates in the quality control process. By studying direct
cause–effect relationships, subordinates learn to modify individual and group performance to
improve the quality of care provided.
Vision is another leadership skill inherent in quality control. The visionary leader
looks at what is and determines what should be. This future focus allows leaders to shape
organizational goals proactively and improve the quality of care. Moreover, the integrated
leader-manager in quality control must be willing to be a risk-taker and to be accountable. In
an era of limited resources and cost-containment, there is great pressure to sacrifice quality
in an effort to contain costs. The self-aware leader-manager recognizes this risk and seeks
to achieve a balance between quality and cost-containment that does not violate professional
obligations to patients and subordinates.
Winning the war to improve health care will require sustained public interest to create the
momentum to systematically change the health-care system in a way that improves quality.
Increasing consumer knowledge and participation in health care will be imperative in this
effort. In addition, change agents must be able to successfully address the disconnection that
still exists between consumers’ perceptions of the quality of their own care and the actual
quality provided. This dialogue has only just begun.
KEY CONCEPTS
l Controlling is implemented throughout all phases of management.
l Quality control refers to activities that are used to evaluate, monitor, or regulate services rendered to
consumers.
l a standard is a predetermined baseline condition or level of excellence that constitutes a model to be
followed and practiced.
l Because there is no one set of standards, each organization and profession must set standards and
objectives to guide individual practitioners in performing safe and effective care.
l CpGs provide diagnosis-based, step-by-step interventions for nurses to follow in an effort to promote
evidence-based, high-quality care and yet control resource utilization and costs.
l Benchmarking is the process of measuring products, practices, and services against those of best-
performing organizations.
l the difference in performance between top-performing health-care organizations and the national
average is called the quality gap. While the quality gap is typically small in industries such as
manufacturing, aviation, and banking, wide variation is the norm in health care.
l Cea and rCa help to identify not only what and how an event happened but why it happened, with the
end goal being to ensure that a preventable negative outcome does not recur.

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Chapter 23 Quality Control 567
l Outcome audits determine what results, if any, followed from specific nursing interventions for
patients.
l process audits are used to measure the process of care or how the care was carried out.
l structure audits monitor the structure or setting in which patient care occurs (such as the finances,
nursing service structure, medical records, and environmental structure).
l there is growing recognition that it is possible to separate the contribution of nursing to the patient’s
outcome; this recognition of outcomes that are nursing-sensitive creates accountability for nurses as
professionals and is important in developing nursing as a profession.
l standardized nursing languages provide a consistent terminology for nurses to describe and document
their assessments, interventions, and the outcomes of their actions.
l Quality assurance models seek to ensure that quality currently exists, whereas Qi models assume that
the process is ongoing and that quality can always be improved.
l Quality control in health-care organizations has evolved primarily from external forces and not as a
voluntary effort to monitor the quality of services provided.
l Critics of the pps argue that although drGs may have helped to contain rising health-care costs, the
associated rapid declines in length of hospital stay and services provided have resulted in declines in
quality of care.
l the JC is the major accrediting body for health-care organizations and programs in the United states.
it also administers the OrYX initiative and collects data on core measures in an effort to better
standardize data collection across acute-care hospitals.
l the CMs plays an active role in setting standards for and measuring quality in health care including the
HQi and p4p.
l the 27-item HCaHps survey is the first national, standardized, publicly reported survey of patients’
perspectives of hospital care. it measures recently discharged patients’ perceptions of their hospital
experience.
l the NCQa, a private nonprofit organization that accredits managed care organizations, also developed
the Hedis to compare quality of care in managed care organizations.
l ideally, everyone in an organization should participate in quality control activities.
l in response to the demand for objective measures of quality, a number of health plans, health-care
providers, employer purchasing groups, consumer information organizations, and state governments
have begun to formulate health-care quality report cards.
l a plethora of studies across the past 2 decades suggest that medical errors continue to be rampant in
the health-care system.
l the patient safety and Quality improvement act, signed into law in 2005, protects medical error
information that is voluntarily submitted to new private organizations (patient safety organizations) from
being subpoenaed or used in legal discovery and generally requires that the information is treated as
confidential.
l the Leapfrog Group identified four evidence-based standards that they believe will provide the
greatest impact on reducing medical errors: CpOe, eHr, ips, and the use of Leapfrog safe practices
scores.
l the Fda has suggested that a drug bar code system coupled with a computerized order entry system
would greatly decrease the risk of medication errors.
l Historically, the health-care industry has been comfortable with striving for three sigma processes
(all data points fall within 3 standard deviations) in terms of health-care quality instead of six (that are
adopted by the highest-performing organizations in terms of quality).
l as direct caregivers, staff nurses are in an excellent position to monitor nursing practice by identifying
problems and implementing corrective actions that have the greatest impact on patient care.
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568 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
LEARNING EXERCISE 23.5
Identifying Nursing-Sensitive Outcome Criteria
some patients get better despite nursing care, not as a result of it. However, the quality of
nursing care can affect patient outcomes tremendously. do you believe that quality nursing care
makes a difference in patients’ lives? identify five criteria that you would use to define quality
nursing care. these criteria should reflect what you believe nurses do (nursing-sensitive) that
makes the difference in patient outcomes. are the criteria you listed measurable?
LEARNING EXERCISE 23.7
Examining Mortality Rates
You have been the nursing coordinator of cardiac services at a medium-sized urban hospital for
the last 6 months. among the hospital’s cardiac services are open-heart surgery, invasive and
noninvasive diagnostic testing, and a comprehensive rehabilitation program. the open-heart
surgery program was implemented a little over a year ago. during the last 3 months, you have
begun to feel uneasy about the mortality rate of postoperative cardiac patients at your facility.
an audit of medical records shows a unit mortality rate that is approximately 30% above national
norms. You approach the unit medical director with your findings. He becomes defensive and
LEARNING EXERCISE 23.6
Working Short Staffed—Again
You are a staff nurse at Mercy Hospital. the hospital’s patient census and acuity have been very
high for the last 6 months. Many of the nursing staff have resigned; a coordinated recruitment effort
to refill these positions has been largely unsuccessful. the nursing staff is demoralized, and staff
frequently call in sick or fail to show up for work. today, you arrive at work and find that you are again
being asked to work short-handed. You will be the only rN on a unit with 30 patients. although
you have two licensed professional nurses/licensed vocational nurses and two certified nursing
assistants assigned to work with you, you are concerned that patient safety could be compromised.
a check with the central nursing office ascertains that no additional help can be obtained.
You feel that you have reached the end of your rope. the administration at Mercy Hospital has
been receptive to employee feedback about the acute staffing shortage, and you believe that they
have made some efforts to try to alleviate the problem. You also believe, however, that the efforts
have not been at the level they should have been and that the hospital will continue to expect
nurses to work short-handed until some major force changes things. although you have thought
about quitting, you really enjoy the work that you do and feel morally obligated to your coworkers,
the patients, and even your superiors. today, it occurs to you that you could anonymously phone
the state licensing bureau and turn in Mercy Hospital for consistent understaffing of nursing
personnel, leading to unsafe patient care. You believe that this could be the impetus needed to
improve the quality of care. You are also aware of the action’s political risks.
Assignment: discuss whether you would take this action. What is your responsibility to the
organization, to yourself, and to patients? How do you make decisions such as this one, which
have conflicting moral obligations?

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Chapter 23 Quality Control 569
states that there have been a few freakish situations to skew the results but that the open-heart
program is one of the best in the state. When you question him about examining the statistics
further, he becomes very angry and turns to leave the room. at the door, he stops and says,
“remember that these patients are leaving the operating room alive. they are dying on your unit.
if you stir up trouble, you are going to be sorry.”
Assignment: Outline your plan. identify areas in your data gathering that may have been
misleading or that may have skewed your findings. if you believe action is still warranted, what
are the personal and professional risks involved? How well developed is your power base to
undertake these risks? to whom do you have the greatest responsibility?
LEARNING EXERCISE 23.8
Weighing Conflicting Obligations
You are the unit supervisor of a medical–surgical unit. shauna, an rN on your unit, who
graduated 3 years ago from nursing school, has made a number of small errors in the past
few months, all of which she has voluntarily reported. these errors included things like missing
medications, giving medications late, and on one occasion, giving medications to the wrong
patient. No apparent harm has occurred to her patients as a result of these errors and on each
occasion, shauna has responded to your coaching efforts with an assertion that she will be
more attentive and careful in the future.
today, however, shauna came to your office to admit that she flushed a patient’s iV line with
10,000 units of heparin rather than with the 100 units that was ordered. the vials looked
similar and she failed to notice the dosing on the label. shauna reported the error to the
patient’s physician and filled out the adverse incident report form required by the hospital on all
medication errors. at this point, the patient is demonstrating no ill effects from the overdosing,
but will need to be monitored closely for the next 24 hours.
You recognize that shauna’s pattern of repetitive medication errors is placing patients at risk. You
have some reservations, however, about dealing with shauna in a punitive way since she openly
reports the errors she makes and because none of her errors until today had really jeopardized patient
safety. You are also aware, however, that you have an obligation to make sure that the staff caring for
your patients are competent and that patients are protected from harm. You are also attempting to
establish a unit culture that encourages open reporting, not “shame and blame,” so you are aware that
your staff are watching closely how you will respond to yet another error on shauna’s part.
Assignment: What will you do to address this error as well as the errors shauna has made in the
past few months? What options are available to you? What obligations do you have to shauna, to
the organization, and to the patients on your unit? How will you create a culture that encourages
the open reporting of errors and yet protects patients from potentially unsafe practitioners?
LEARNING EXERCISE 23.9
Avoiding Adverse Events and Medication Errors
Assignment: interview the patient safety officer or the manager of the risk management
department at your local hospital. Use the following questions as a guide to begin the interview.
present a report to your peers regarding your findings.
1. What are the most common causes of medication errors in this facility?
(Continued )
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570 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
2. Which medications are more commonly involved in medication errors? What factors has this
agency identified that cause these errors to occur?
3. What are the most common adverse events affecting patients? What precipitating factors
have been identified as increasing the possibility of these adverse events?
4. What new technologies have been adopted to increase patient safety? examples might be iV
smart pumps, bar coding of medications, and computerized physician–provider order entry.
5. How are medication errors or adverse events reported? What safeguards have been built
in to encourage voluntary reporting of errors? do disincentives exist that would discourage
someone from reporting such an error?
6. are staff included in the quality control process? if so, how?
7. For which of the JC core measures are data being collected? What is the process for this
data collection?
LEARNING EXERCISE 23.10
Quality Topics for Group Discussion
Assignment: select one of the topics below for small or large group debate. Generate as many
perspectives as possible.
● support or oppose the proposition that quality in health care should be quantitatively measurable.
● support or oppose the proposition that public and private sector initiatives during the past
3 decades have been successful in lowering health-care costs while maintaining quality.
● support or oppose the proposition that traditional natural science study designs, such as
the experimental method, are the most appropriate models for testing hypotheses about
quality and health-care delivery.
● support or oppose the proposition that quality in health care should be measured more by
client satisfaction than by traditional outcome measures.
● support or oppose the proposition that downsizing (layoffs of professional rNs) and the
increased use of unlicensed assistive personnel are currently affecting the quality of patient
care negatively.
LEARNING EXERCISE 23.11
Tracking Down an Infection through Root Cause Analysis
You work in a small, long-term care facility and are often the only rN working on the unit. Many of
your patients have indwelling Foley catheters. recently, several patients have developed bladder
infections, after having a unit nosocomial urinary tract infection (Uti) rate of less than 1% for the
past year. in fact, the facility has always prided itself on carefully following established evidence-
based policies and procedures, both in catheter insertion and in routine catheter care. When
you talk to the Chief Nursing Officer about the problem, she asks you to investigate the problem
and report back to her. You decide to sit down and make a list of the structure and process
indicators you could examine in an attempt to find the cause of the problem.
Assignment: identify at least eight process and structure variables you could use to determine
the cause(s) of the spike in nosocomially acquired Utis in the facility. then develop a quality
evaluation plan for one of these variables. What data will you collect? What steps will you
implement to carry out this quality audit?

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Chapter 23 Quality Control 571
REFERENCES
Agency for Healthcare Research and Quality. (2013).
National guideline clearing house. Retrieved June 23,
2013, from http://www.guideline.gov/about/
index.aspx
American Nurses Association. (2010). Scope and standards
of practice (2nd ed.). Silver Spring, MD: American
Nurses Association.
American Nurses Association. (2009). Nursing administration.
Scope & standards of practice. Silver Springs, MD:
Nursesbooks.org
American Nurses Association. (2013a). Nursing
standards. Retrieved June 24, 2013, from
http://nursingworld.org/MainMenuCategories/
ThePracticeofProfessionalNursing/NursingStandards
.aspx
American Nurses Association. (2013b). Call for public
comment. Nursing: Scope & standards of practice.
Retrieved June 23, 2013, from http://www
.nursingworld.org/HomepageCategory/
NursingInsider/Archive_1/2010-NI/Jan10-NI/Public
-Comment-Nursing-Scope-Standards.aspx
American Society for Quality. (n.d.). Quality tools. Failure
modes and effects analysis (FMEA). Retrieved June
23, 2013, from http://asq.org/learn-about-quality/
process-analysis-tools/overview/fmea.html
Deming, W. E. (1986). Out of the crisis. Cambridge, MA:
MIT Press.
Facilitators and Barriers to the Use of Clinical Practice
Guidelines. (2012). AORN Journal, 96(6), 668–669.
HCAHPS Fact Sheet. (2012). CAHPS–A registered
trademark of AHRQ. Retrieved June 24, 2013, from
http://www.hcahpsonline.org/files/HCAHPS%20
Fact%20Sheet%20May%202012
Healthgrades. (2008, April 8). Medical errors cost
U.S. $8.8 billion, result in 238,337 potentially
preventable deaths according to HealthGrades
Study. Retrieved March 14, 2010, from http://
www.healthgrades.com/media/DMS/pdf/
HealthGradesPatientSafetyRelease2008
Healthgrades. (2013). American Hospital Quality
Outcomes 2013: Healthgrades report to the
nation Executive summary. Retrieved June 24,
2013, from http://c773731.r31.cf2.rackcdn
.com/d0/ce/09b1df7b4fb4960b69dcb50313e3/
Healthgrades%20American%20Hospital%20
Quality%20Report%202013
Hospital Quality Initiative Overview. (2008, July).
Centers for Medicare & Medicaid Services.
Retrieved June 24, 2013, from http://www
.cms.hhs.gov/HospitalQualityInits/Downloads/
Hospitaloverview
Huston, C. (2014). Medical errors: An ongoing threat to
quality health care. In C. Huston (Ed.), Professional
issues in nursing: Challenges and opportunities
(3rd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins 228–248.
Institute of Medicine. (1994). America’s health in transition:
Protecting and improving quality. Washington, DC:
National Academy Press.
International Council of Nurses. (2009, January 26).
International Classification for Nursing Practice
(ICNP®) now included as a related classification in
the WHO Family of International Classifications.
Retrieved June 23, 2013, from http://www.icn.ch/
images/stories/documents/news/press_releases/
2009_PR_03_ICNP_now_included_as_a_Related
_Classification_in_the_WHO_Family_of_International
_Classifications
(The) Joint Commission. (2013a). Facts about the joint
commission. Retrieved June 24, 2013, from http://
www.jointcommission.org/about_us/fact_sheets.aspx
(The) Joint Commission. (2013b). Facts about ORYX® for
hospitals (National Hospital Quality Measures).
Retrieved June 24, 2013, from http://www
.jointcommission.org/facts_about_oryx_for_hospitals/
(The) Joint Commission. (2013c). Sentinel event policy and
procedures. Retrieved June 24, 2013, from http://
www.jointcommission.org/Sentinel_Event_Policy
_and_Procedures/
(The) Joint Commission. (2013d). 2013 hospital national
patient safety goals. Retrieved June 25, 2013, from
http://www.jointcommission.org/assets/1/6/2013
_HAP_NPSG_final_10-23
(The) Joint Commission. (2012). Using national patient
safety goals effective January 1, 2013. Retrieved
June 24, 2013, from http://www.jointcommission.org/
assets/1/18/NPSG_Chapter_Jan2013_HAP
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.)
(2000). Executive summary In: To err is human:
Building a safer health system (pp. 1–6). Retrieved
August 22, 2013, from http://www.nap.edu/openbook
.php?record_id=9728&page=R1
Landro, L. (2010, March 16). New focus on averting
errors: Hospital culture. Wall Street Journal–Digital
Network. Health. Retrieved March 17, 2010, from
http://online.wsj.com/article/SB10001424052748704
588404575123500096433436.html?mod=WSJ_hps
_MIDDLEThirdNews.
Leapfrog Group. (2013). The Leapfrog Group fact sheet.
Retrieved June 24, 2013, from http://www
.leapfroggroup.org/about_us/leapfrog-factsheet
National Association of School Nurses. (2012).
Standardized nursing languages. Retrieved
June 23, 2013, from http://www.nasn.org/
PolicyAdvocacy/PositionPapersandReports/
NASNPositionStatementsFullView/tabid/462/
ArticleId/48/Standardized-Nursing-Languages
-Revised-June-2012
National Committee for Quality Assurance. (2013).
HEDIS and performance measurement. Measuring
performance. Retrieved June 23, 2013, from http://
www.ncqa.org/tabid/59/Default.aspx
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http://www.guideline.gov/about/index.aspx

http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards.aspx

http://www.nursingworld.org/HomepageCategory/NursingInsider/Archive_1/2010-NI/Jan10-NI/Public-Comment-Nursing-Scope-Standards.aspx

http://asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html

http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet%20May%202012

http://www.healthgrades.com/media/DMS/pdf/HealthGradesPatientSafetyRelease2008

http://c773731.r31.cf2.rackcdn.com/d0/ce/09b1df7b4fb4960b69dcb50313e3/Healthgrades%20American%20Hospital%20Quality%20Report%202013

http://www.cms.hhs.gov/HospitalQualityInits/Downloads/Hospitaloverview

http://www.icn.ch/images/stories/documents/news/press_releases/2009_PR_03_ICNP_now_included_as_a_Related_Classification_in_the_WHO_Family_of_International_Classifications

http://www.jointcommission.org/about_us/fact_sheets.aspx

http://www.jointcommission.org/facts_about_oryx_for_hospitals/

http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/

http://www.jointcommission.org/assets/1/6/2013_HAP_NPSG_final_10-23

http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP

http://www.nap.edu/openbook.php?record_id=9728&page=R1

http://online.wsj.com/article/SB10001424052748704588404575123500096433436.html?mod=WSJ_hps_MIDDLEThirdNews

http://www.leapfroggroup.org/about_us/leapfrog-factsheet

http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/48/Standardized-Nursing-Languages-Revised-June-2012

http://www.ncqa.org/tabid/59/Default.aspx

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572 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
Newhouse, R. P. (2010, February). Clinical guidelines
for nursing practice. Are we there yet? Journal of
Nursing Administration, 40(2), 57–59.
Parkerton, P. H., Needleman, J., Pearson, M. L., Upenieks,
V. V., Soban, L. M., & Yee, T. (2009, November).
Lessons from nursing leaders on implementing
TCAB. American Journal of Nursing, 109(11),
71–76.
Pay for Performance: An Overview. (January 20, 2011).
Healthcare economist. Retrieved June 23, 2013, from
http://healthcare-economist.com/2011/01/20/pay-for
-performance-an-overview/
Study Links HCAHPS, Readmission Rates. (2013). Hospital
Case Management, 21(2), 25.
The Joint Commission Expands Performance Measurement
Requirements. (2013). Healthcare Purchasing News,
37(1), 6.
Toyota Motor Company (n.d.). Toyota production system.
Toyota Motor Corporation. Retrieved June 24, 2013,
from http://www.toyota.com.au/toyota/company/
operations/toyota-production-system
Wachter, R. (2010, January). Patient safety at ten:
Unmistakable progress, troubling gaps. Health
Affairs, 29(1), 165–173.
Wisconsin Hospital Association. (2003–2013). What is
the Maryland quality indicator project? Retrieved
June 24, 2013, from http://www.wha.org/
marylandQIP.aspx

http://www.toyota.com.au/toyota/company/operations/toyota-production-system

http://www.wha.org/marylandQIP.aspx

Pay-for-Performance: An Overview

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573
24
Performance Appraisal
… it is a paradoxical but profoundly true and important principle of life that the most likely way to
reach a goal is to be aiming not at that goal itself but at some more ambitious goal beyond it.
—Arnold Toynbee
… performance stands out like a ton of diamonds. Non-performance can always be explained away.
—Harold S. Geneen
CROSSWALK THiS cHApTer AddreSSeS:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
MSN Essential II: Organizational and systems leadership
MSN Essential VII: interprofessional collaboration for improving patient and population health
outcomes
QSEN Competency: Teamwork and collaboration
QSEN Competency: Safety
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency II: A knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l identify and use appropriate performance appraisal tools for measuring professional nursing
performance
l identify factors that increase the likelihood that a performance appraisal will develop and
motivate staff
l provide feedback regarding peer performance in a constructive and assertive manner
l avoid the halo effect, horns effect, and central tendency errors in conducting performance
appraisals
l recognize subjectivity as an ever-present limitation of the performance appraisal process
l describe coaching techniques that promote employee growth in work performance
l gather data for performance appraisals in a systematic manner that is fair and objective
l develop an awareness of biases that influence a person’s ability to complete a fair and
objective performance appraisal
l differentiate between performance appraisal tools such as rating scales, checklists, essays,
self-appraisal, and management by objectives (MBOs)
l identify what conditions should be present before, during, and after the performance
appraisal that increase the likelihood of a positive outcome
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574 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
An important managerial controlling responsibility is determining how well employees
carry out the duties of their assigned jobs. This is done through performance appraisals,
in which work performance is reviewed. Performance appraisals let employees know the
level of their job performance as well as any expectations that the organization may have of
them. Performance appraisals also generate information for salary adjustments, promotions,
transfers, disciplinary actions, and terminations.
In performance appraisals, actual performance, not intent, is evaluated.
None of the manager’s actions is as personal as appraising the work performance of others.
Because work is an important part of one’s identity, people are very sensitive to opinions about
how they perform. For this reason, performance appraisal becomes one of the greatest tools
an organization has to develop and motivate staff. When used correctly, it can encourage staff
and increase retention and productivity; however, in the hands of an inept or inexperienced
manager, the appraisal process may significantly discourage and demotivate workers.
In addition, because a manager’s opinions and judgments are used for far-reaching
decisions regarding the employee’s work life, they must be determined in an objective,
systematic, and formalized manner as possible. Using a formal system of performance review
reduces, but does not eliminate, the appraisal’s subjectivity. In addition, the more professional
a group of employees is, the more complex and sensitive the evaluation process becomes. The
skilled leader-manager who uses a formalized system for the appraisal is better able to build
a team approach to patient care.
This chapter focuses on the relationship between performance appraisal and motivation
and discusses how performance appraisals can be used to determine the developmental needs
of the staff. Emphasis is placed on appropriate data gathering and the types of performance
appraisal tools available. The performance appraisal interview is explored, and strategies are
presented for reducing appraiser bias and increasing the likelihood that the appraisal itself
will be growth-producing. Finally, performance management is introduced as an alternative
to the traditional annual performance appraisal. The leadership roles and management
functions inherent in successful performance appraisal are shown in Display 24.1.
DISPLAY 24.1 Leadership Roles and Management Functions Associated with
Performance Appraisal
LEADERSHIP ROLES
1. Uses the appraisal process to motivate employees and promote growth.
2. Uses appropriate techniques to reduce the anxiety inherent in the appraisal process.
3. involves employees in all aspects of performance appraisal.
4. is aware of own biases and prejudices so as to eliminate their influence in the performance
appraisal process.
5. develops employee trust by being honest and fair when evaluating performance.
6. encourages the peer review process among professional staff.
7. Uses appraisal interviews to facilitate two-way communication.
8. provides ongoing support to employees who are attempting to correct performance deficiencies.
9. Uses coaching techniques that promote employee growth in work performance.
10. individualizes performance goals and the appraisal interview as needed to meet the unique
needs of a culturally diverse staff.
MANAGEMENT FUNCTIONS
1. Uses a formalized system of performance appraisal.
2. Gathers fair and objective data throughout the evaluation period to use in employee’s perfor-
mance appraisals.

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Chapter 24 Performance Appraisal 575
USING THE PERFORMANCE APPRAISAL TO MOTIVATE EMPLOYEES
Although systematic employee appraisals have been used in management since the 1920s,
using the appraisal as a tool to promote employee growth did not begin until the 1950s. This
evolution of performance appraisals is reflected in its changing terminology. At one time,
the appraisal was called a merit rating and was tied fairly closely to salary increases. More
recently, it was termed performance evaluation, but because the term evaluation implies that
personal values are being placed on the performance review, that term is used infrequently.
Some organizations continue to use both of these terms or others, such as competency
assessment, effectiveness report, and service rating. Most health-care organizations, however,
use the term performance appraisal, because this term implies an appraisal of how well
employees perform the duties of their job as delineated by the job description or some other
prespecified criteria.
An important point to consider, if the appraisal is to have a positive outcome, is how the
employee views the appraisal. Indeed, Mulvaney, McKinney, and Grodsky (2012) note that
both employees and management often view the performance appraisal process as frustrating
and unfair. These frustrations are largely attributed to a reliance on performance appraisal
instruments that are not job related; have confusing or unclear rating levels; and are viewed
as subjective and biased by staff. The result is that both the administration and staff often
come to view the performance appraisal process as a painful, annual exercise (Mulvaney et
al.). Price (2013) concurs, noting that many managers feel the annual performance appraisal
is treated as something of a paper exercise.
Management research has shown that various factors influence whether the appraisal
ultimately results in increased motivation and productivity. Some of these factors include the
following:
• The employee must believe that the appraisal is based on a standard to which other
employees in the same classification are held accountable. This standard must be
communicated clearly to employees at the time they are hired and may be a job
description or an individual goal set by staff for the purpose of performance appraisal.
• The employee must believe that the appraisal tool adequately and accurately assesses
performance criteria directly related to his or her job. For example, Olmstead, Falcone,
Lopez, Sharpe, and Michna (2012) shared the story of an Indiana hospital that used
a hospital-wide evaluation tool related to the hospital mission statement goals. This
tool rated employees on vague criteria such as dignity, quality, and compassion. As
a result, the employees regularly challenged managers’ evaluations, arguing that the
rating categories in the evaluation tool had little to do with actual performance or job
requirements.
• The employee should have some input into developing the standards or goals on which
his or her performance is judged. This is imperative for the professional employee.
• The employee must know in advance what happens if the expected performance
standards are not met.
3. Uses the appraisal process to determine staff education and training needs.
4. Bases performance appraisal on documented standards.
5. is as objective as possible in performance appraisal.
6. Maintains appropriate documentation of the appraisal process.
7. Follows up on identified performance deficiencies.
8. conducts the appraisal interview in a manner that promotes a positive outcome.
9. provides frequent informal feedback on work performance.
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576 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
• The employee needs to know how information will be obtained to determine
performance. The appraisal tends to be more accurate if various sources and types of
information are solicited. Sources could include peers, coworkers, nursing care plans,
patients, and personal observation. Employees should be told which sources will be used
and how such information will be weighted.
• The appraiser should be one of the employee’s direct supervisors. For example, the
charge nurse who works directly with the staff nurse should be involved in the appraisal
process and interview. It is appropriate and advisable in most instances for the head
nurse and supervisor also to be involved. However, employees must believe that the
person doing the major portion of the review has actually observed their work.
• The performance appraisal is more likely to have a positive outcome if the appraiser is
viewed with trust and professional respect. This increases the chance that the employee
will view the appraisal as a fair and accurate assessment of his or her work performance.
A summary of the factors influencing the effectiveness of appraisals can be seen in
Display 24.2.
If employees believe that the appraisal is based on their job description rather than on whether
the manager approves of them, they are more likely to view the appraisal as relevant.
Appraisal should be based on a standard.
The appraisal tool must adequately and accurately assesses job performance.
employee should have input into development of the standard.
employee must know the standard in advance.
employee must know the sources of data gathered for the appraisal.
Appraiser should be someone who has observed the employee’s work.
Appraiser should be someone who the employee trusts and respects.
DISPLAY 24.2 Factors Influencing Effective Performance Appraisal
LEARNING EXERCISE 24.1
Writing about Performance Appraisals
during your lifetime, you probably have had many performance appraisals. These may have been
evaluations of your clinical performance during nursing school or as a paid employee. reflect on
these appraisals. How many of them encompassed the six recommendations listed in display
24.2? How did the inclusion or exclusion of these recommendations influence your acceptance
of the results?
Assignment: Select one of the above six recommendations about which you feel strongly. Write
a three-paragraph essay about your personal experience as it relates to these recommendations.
STRATEGIES TO ENSURE ACCURACY AND FAIRNESS IN THE PERFORMANCE
APPRAISAL
If the goal of the performance appraisal is to satisfy the requirements of the organization,
then the performance appraisal is a waste of time. On the other hand, if the employee views
the appraisal as valuable, valid and growth-producing, it can have many positive effects.
Information obtained during the performance appraisal can be used to develop the employee’s

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Chapter 24 Performance Appraisal 577
potential, to assist the employee in overcoming difficulties that he or she has in fulfilling the
job’s role, to point out strengths of which the employee may not be aware, and to aid the
employee in setting goals.
A performance appraisal wastes time if it is merely an excuse to satisfy regulations and the goal
is not employee growth.
Because inaccurate and unfair appraisals are negative and can demotivate, it is critical that the
manager use strategies that increase the likelihood of a fair and accurate appraisal. Although
some subjectivity is inescapable, the following strategies will assist the manager in arriving
at a fairer and more accurate assessment:
1. The appraiser should develop an awareness of his or her own biases and prejudices.
This helps to guard against subjective attitudes and values influencing the appraisal.
The appraiser must always recognize though that all employee reviews involve some
subjectivity and Bacal (2013) suggests that we need to stop pretending that our ways
of evaluating employee performance are objective.
2. Consultation should be sought frequently. Another manager should be consulted when
a question about personal bias exists and in many other situations. For example, it
is very important that new managers solicit assistance and consultation when they
complete their first performance appraisals. Even experienced managers may need to
consult with others when an employee is having great difficulty fulfilling the duties
of the job. Consultation must also be used when employees work several shifts so that
information can be obtained from all of the shift supervisors.
3. Data should be gathered appropriately. Many different sources should be consulted
about employee performance and the data gathered needs to reflect the entire time
period of the appraisal. Frequently, managers gather data and observe an employee
just before completing the appraisal, which gives an inaccurate picture of performance.
Because all employees have periods when they are less productive and motivated, data
should be gathered systematically and regularly.
4. Accurate record-keeping is another critical part of ensuring accuracy and fairness in
the performance appraisal. Information about subordinate performance (both positive
and negative) should be recorded and not trusted to memory. The recording of both
positive and negative performance behavior throughout the performance period is also
known as critical incident recording. The manager should make a habit of keeping
notes about observations, others’ comments, and his or her periodic review of charts
and nursing care plans. Taking regular notes on employee performance is a way to
avoid the recency effect, which favors appraisal of recent performance over less recent
performance during the evaluation period.
When ongoing anecdotal notes are not maintained throughout the evaluation period, the
appraiser is more apt to experience the recency effect, where recent issues are weighed more
heavily than past performance.
5. Collected assessments should contain positive examples of growth and achievement and
areas where development is needed. Nothing delights employees more than discovering
that their immediate supervisor is aware of their growth and accomplishments and can
cite specific instances in which good clinical judgment was used. Too frequently,
collected data concentrate on negative aspects of performance. Bacal (2013) agrees,
noting that the performance appraisal should move away from “evaluating” the past
and move toward improving success in the future.
6. Some effort must be made to include the employee’s own appraisal of his or her work.
Self-appraisal may be performed in several appropriate ways. Employees can be
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578 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
instructed to come to the appraisal interview with some informal thoughts about their
performance, or they can work with their managers in completing a joint assessment.
One advantage of management by objectives (MBOs)—the use of personalized goals
to measure individual performance—is the manner in which it involves the employee
in assessing his or her work performance and in goal-setting.
7. The appraiser needs to guard against three common pitfalls of assessment: the halo
effect, the horns effect, and central tendency. The halo effect occurs when the appraiser
lets one or two positive aspects of the assessment or behavior of the employee unduly
influence all other aspects of the employee’s performance. The horns effect occurs
when the appraiser allows some negative aspects of the employee’s performance
to influence the assessment to such an extent that other levels of job performance
are not accurately recorded. Mackenzie (2013, p. 453) notes that “rating employees
more severely than their performance merits will frustrate and discourage workers
who will resent unfair assessment of their performance. Likewise, rating employees
more favorably than their performance merits cheats them and the department of the
benefits of exploring areas for improvement and the opportunities for developing and
coaching.”
The manager who falls into the central tendency trap is hesitant to risk true
assessment and therefore rates all employees as average. These appraiser behaviors
lead employees to discount the entire assessment of their work. Accel-Team (2013)
states that some managers equivocate on performance appraisal ratings for fear that
subordinates given a high rating may expect immediate rewards and that employees
given low ratings will cause trouble. “In such instances, formal performance
evaluation reviews have negative consequences, in that they don’t just summarize past
performance, they can shape future performance” (Accel-Team, para 6).
8. Finally, reviewers need to guard against a bias known as the Matthew effect. The
Matthew effect is said to occur when employees receive the same appraisal results, year
after year. Those who performed well early in their employment are likely to do well.
Those who struggled will continue to struggle. Often the Matthew effect is compared
with the adage “the rich get richer and the poor get poorer.” Thus, past appraisals
prejudice an employee’s future attempts to improve. Display 24.3 provides a summary
of performance appraisal strategies.
LEARNING EXERCISE 24.2
Planning an Employee’s First Performance Appraisal
Mrs. Jones is a new licensed vocational nurse (LVN)/licensed practical nurse (LpN) and has
been working the 3 pm to 11 pm shift on the long-term care unit where you are the evening
charge nurse. it is time for her 3-month performance appraisal. in your facility, each employee’s
job description is used as the standard of measure for performance appraisal. essentially, you
develop self-awareness regarding own biases and prejudices.
Use appropriate consultation.
Gather data adequately over time.
Keep accurate anecdotal records for the length of the appraisal period.
collect positive data and identify areas where improvement is needed.
include employee’s own appraisal of his or her performance.
Guard against the halo effect, horns effect, central tendency trap, and Matthew effect.
DISPLAY 24.3 Strategies to Ensure Performance Appraisal Accuracy

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Chapter 24 Performance Appraisal 579
PERFORMANCE APPRAISAL TOOLS
Since the 1920s, many appraisal tools have been developed, all of which have been popular at
different times. Since the early 1990s, the Joint Commission has been advocating the use of an
employee’s job description as the standard for performance appraisal. Bacal (2013) cautions,
however, that job descriptions may be a poor source for setting employee goals since they
are often outdated by the time they are on paper. Instead Bacal suggests that employees be
allowed to flesh out job description tasks and to set goals which more specifically address the
employee’s specific strengths and weaknesses.
The Joint Commission also suggests that employers must be able to demonstrate that
employees know how to plan, implement, and evaluate care specific to the ages of the patients
they care for. This continual refinement of critical competencies for professional nursing
practice has a tremendous impact on the tools used in the appraisal process. It is important
to remember, however, that competence assessments are not the same as performance
evaluations. A competence assessment evaluates skill and knowledge; a performance
evaluation evaluates execution of a task or tasks.
A competence assessment evaluates whether an individual has the knowledge, education, skills,
or experience to perform the task, whereas a performance evaluation examines how well that
individual actually completes that task.
The effectiveness of a performance appraisal system is only as good as the tools used to create
those assessments. An effective competence assessment tool should allow the manager to
focus on the priority measures of performance. The following is an overview of some of the
appraisal tools commonly used in health-care organizations.
Trait Rating Scales
A trait rating scale is a method of rating a person against a set standard, which may be the
job description, desired behaviors, or personal traits. The trait rating scale has been one of
the most widely used of the many available appraisal methods. Rating personal traits and
behaviors is the oldest type of rating scale. Many experts argue, however, that the quality or
quantity of the work performed is a more accurate performance appraisal method than the
employee’s personal traits and that trait evaluation invites subjectivity. Rating scales are also
subject to central tendency and halo- and horns-effect errors and thus are not used as often
believe that Mrs. Jones is performing her job well, but you are somewhat concerned because
she still relies on the registered nurses (rNs) even for minor patient care decisions. Although
you are glad that she does not act completely on her own, you would like to see her become
more independent. The patients have commented favorably to you on Mrs. Jones’s compassion
and on her follow-through on all their requests and needs.
Mrs. Jones gets along well with the other LVNs/LpNs, and you sometimes believe that they
take advantage of her hard-working and pleasant nature. On a few occasions, you believe
that they inappropriately delegated some of their work to her. When preparing for Mrs. Jones’s
upcoming evaluation, what can you do to make the appraisal as objective as possible? You want
Mrs. Jones’s first evaluation to be growth-producing.
Assignment: plan how you will proceed. What positive forces are already present in this
scenario? What negative forces will you have to overcome? Support your plan with readings
from references at the end of this chapter.
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580 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
today as they were in the past. Instead, many organizations use two other rating methods,
namely, the job dimension scale and the behaviorally anchored rating scale (BARS).
Display 24.4 shows a portion of a trait rating scale with examples of traits that might be
expected in an RN.
Job Knowledge
Serious gaps in
essential knowledge
Satisfactory
knowledge of
routine
Adequately
informed on most
phases of the job
Good knowledge
of all phases of
the job
excellent
understanding of
the job
1 2 3 4 5
Judgment
decisions are often
wrong on issues
Makes some
decision errors
Good decisions Sound and
logical thinker
Makes good,
complex decisions
1 2 3 4 5
Attitude
resents suggestions,
no enthusiasm, new
ideas accepted
reluctantly
disengaged but
cooperative
and accepting
Generally
cooperative and
accepting of new
ideas
Openly
cooperates and
accepts new
ideas
consistently
helpful and offers
new ideas
1 2 3 4 5
DISPLAY 24.4 Sample Trait Rating Scale
Job Dimension Scales
Job dimension scales require that a rating scale be constructed for each job classification.
The rating factors are taken from the context of the written job description. Although job
dimension scales share some of the same weaknesses as trait scales, they do focus on job
requirements rather than on ambiguous terms such as “quantity of work.” Display 24.5 shows
an example of a job dimension scale for an industrial nurse.
JOB DIMENSION 5 4 3 2 1
renders first aid and treats job-related injuries and illnesses
Holds fitness classes for workers
Teaches health and nutrition classes
performs yearly physicals on workers
Keeps equipment in good working order and maintains inventory
Keeps appropriate records
dispenses medication and treatment for minor injuries
(5 = excellent; 4 = good; 3 = satisfactory; 2 = fair; 1 = poor)
DISPLAY 24.5 Sample Job Dimension Rating Scale for an Industrial Nurse
Behaviorally Anchored Rating Scales
BARS, sometimes called behavioral expectation scales, overcome some of the weaknesses
inherent in other rating systems. As in the job dimension method, the BARS technique
requires that a separate rating form be developed for each job classification. Then, as in
the job dimension rating scales, employees in specific positions work with management to
delineate key areas of responsibility. However, in BARS, many specific examples are defined
for each area of responsibility; these examples are given various degrees of importance by
ranking them from 1 to 9. If the highest-ranked example of a job dimension is being met, it
is less important than a lower-ranked example that is not.

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Chapter 24 Performance Appraisal 581
Appraisal tools firmly grounded in desired behaviors can be used to improve performance
and keep employees focused on the vision and mission of the organization. However,
because separate BARS are needed for each job, the greatest disadvantage in using this tool with
large numbers of employees is the time and expense. Additionally, BARS are primarily
applicable to physically observable skills rather than to conceptual skills. Yet, this is an
effective tool, because it focuses on specific behaviors, allows employees to know exactly
what is expected of them, and reduces rating errors.
Although all rating scales are prone to weaknesses and interpersonal bias, they do have
some advantages. Many may be purchased, and although they must be individualized to
the organization, there is little need for expensive worker hours to develop them. Rating
scales also force the rater to look at more than one dimension of work performance, which
eliminates some bias.
Checklists
There are several types of checklist appraisal tools. The weighted scale, the most frequently
used checklist, is composed of many behavioral statements that represent desirable job
behaviors. Each of these behavior statements has a weighted score attached to it. Employees
receive an overall performance appraisal score based on behaviors or attributes. Often, merit
raises are tied to the total point score (i.e., the employee needs to reach a certain score to
receive an increase in pay).
Another type of checklist, the forced checklist, requires the supervisor to select an
undesirable and a desirable behavior for each employee. Both desirable and undesirable
behaviors have quantitative values, and the employee again ends up with a total score on
which certain employment decisions are made.
Another type of checklist is the simple checklist. The simple checklist comprises numerous
words or phrases describing various employee behaviors or traits. These descriptors are often
clustered to represent different aspects of one dimension of behavior, such as assertiveness or
interpersonal skills. The rater is asked to check all those that describe the employee on each
checklist. A major weakness of all checklists is that there are no set performance standards.
In addition, specific components of behavior are not addressed. Checklists do, however, focus
on a variety of job-related behaviors and avoid some of the bias inherent in the trait rating
scales.
Essays
The essay appraisal method is often referred to as the free-form review. The appraiser
describes in narrative form an employee’s strengths and areas where improvement or growth
is needed. Although this method can be unstructured, it usually calls for certain items to be
addressed. This technique does appropriately force the appraiser to focus on positive aspects
of the employee’s performance. However, a greater opportunity for personal bias undoubtedly
exists. In addition, Mackenzie (2013) notes it is complex and time-consuming and the
quality of the content may be more reflective of the writing skills of the appraiser than the
performance of the employee.
Many organizations combine various types of appraisals to improve the quality of their
review processes. Because the essay method does not require exhaustive development, it can
quickly be adapted as an adjunct to any type of structured format. This gives the organization
the ability to decrease bias and focus on employee strengths.
Self-Appraisals
Employees are increasingly being asked to submit written summaries or portfolios of
their work-related accomplishments and productivity as part of the self-appraisal process.
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582 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
Portfolios often provide examples of continuing education, professional certifications,
awards, and recognitions. The portfolio also generally includes the employee’s goals and an
action plan for accomplishing these goals.
There are advantages and disadvantages to using self-appraisal as a method of performance
review. Although introspection and self-appraisal result in growth when the person is self-
aware, even mature people require external feedback and performance validation. Some
employees look forward to their annual performance review in anticipation of positive
feedback. Asking these employees to perform their own performance appraisal would
probably be viewed negatively rather than positively.
Some employees look on their annual performance review as an opportunity to receive positive
feedback from their supervisor, especially if the employee receives infrequent praise on a day-
to-day basis.
Some employees undervalue their own accomplishments or feel uncomfortable giving
themselves high marks in many areas. In an effort to avoid this potential influence on their
rating, managers may wish to complete the performance appraisal tool before reading the
employee’s self-analysis, or they should view the self-appraisal as only one of a number
of data sources that should be collected when evaluating worker performance. When self-
appraisal is not congruent with other data available, the manager may wish to pursue the
reasons for this discrepancy during the appraisal conference. Such an exchange may provide
valuable insight regarding the worker’s self-awareness and ability to view himself or herself
objectively.
Management by Objectives
MBO is an excellent tool for determining an individual employee’s progress because it
incorporates both the employee’s assessments and the organization. The focus in this chapter,
however, is on how these concepts are used as an effective performance appraisal method
rather than on their use as a planning technique.
Although seldom used in health care, MBO is an excellent method to appraise the
performance of the employee in a manner that promotes individual growth and excellence.
The following steps delineate how MBO can be used effectively in performance appraisal:
1. The employee and supervisor meet and agree on the principal duties and
responsibilities of the employee’s job. This is done as soon as possible after beginning
employment.
2. The employee sets short-term goals and target dates in cooperation with the supervisor
or manager, and the manager guides the process so that it relates to the position’s
duties. It is important that the subordinate’s goals not be in conflict with the goals of
the organization. In setting these goals, the manager must remember that one’s values
and beliefs simply reflect a single set of options among many. This is especially true
in working with a multicultural staff. Professional expectations and values can vary
greatly among cultures, and the manager must be careful to resist judgmental reactions
and allow for cultural differences in goal-setting.
3. Both parties agree on the criteria that will be used for measuring and evaluating the
accomplishment of goals. In addition, a time frame is set for completing the objectives,
which depends on the nature of the work being planned. Common time frames used in
health-care organizations vary from 1 month to 1 year.
4. Regularly, but more than once a year, the employee and supervisor meet to discuss
progress. At these meetings, some modifications can be made to the original goals
if both parties agree. Major obstacles that block completion of objectives within the
stipulated time frame are identified. In addition, the resources and support needed from
others are identified.

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Chapter 24 Performance Appraisal 583
5. The manager’s role is supportive, assisting the employee to reach goals by coaching
and counseling.
6. During the appraisal process, the manager determines whether the employee has met
the goals.
7. The entire process focuses on outcomes and results and not on personal traits.
One of the many advantages of MBO is that the method creates a vested interest in the
employee to accomplish goals because employees are able to set their own goals. Additionally,
defensive feelings are minimized, and a spirit of teamwork prevails. MBO as a performance
appraisal method also has its disadvantages. Highly directive and authoritarian managers find
it difficult to lead employees in this manner. Also, the marginal employee frequently attempts
to set easily attainable goals. However, research has shown that MBO, when used correctly,
is a very effective method of performance appraisal.
LEARNING EXERCISE 24.3
Using Management by Objective as a Part of Performance Appraisal
it is time for Nancy irwin’s annual performance appraisal. She is an rN on a postsurgical unit,
dealing with complex trauma patients requiring high-level nursing intensity. You are the evening
charge nurse and have worked with Ms. irwin for the 2 years since she graduated from nursing
school. Last year, in addition to the regular 1 to 5 rating scale for job expectations, all of the
charge nurses added an MBO component to the performance appraisal form. in collaboration
with his or her charge nurse, each employee developed five goals that were supposed to have
been carried out over a 1-year period.
in reviewing Ms. irwin’s performance, you use several sources, including your written notes and
her charting, and your conclusion is that with her strengths and weaknesses, overall she is a
better-than-average nurse. However, you believe that she has not grown much as an employee
over the past 6 months. This observation is confirmed by a review of the following:
Objective Result
1. conduct a mini in-service or patient care
conference twice monthly for the 12 mo.
Met goal for the first 2 mo. in the last 10 mo, she
conducted only six conferences.
2. Will attend five educational classes
related to work; at least one of these will
be given by an outside agency.
Attended one surgical nursing wound conference in the
city and one in-house conference on TpN.
3. Will become an active member of a
nursing committee at the hospital.
Became an active member of the policies and procedures
committee and regularly attends meetings.
4. reduce the number of late arrivals at
work by 50% (from 24 per year to 12).
First 3 mo: not late. Second 3 mo: three late arrivals. Third
3 mo: six late arrivals. Last 3 mo: six late arrivals.
5. ensure that all patients discharged have
discharge instructions documented in
their charts.
Anecdotal notes show that Ms. irwin still frequently forgets
to document these nursing actions.
Assignment: As Ms. irwin’s charge nurse what can you do to ensure that the current appraisal
results in greater growth for her? What went wrong with last year’s MBO plan? devise a plan
for the performance appraisal. Try solving this yourself before reading the possible solution that
appears in the Appendix.
Peer Review
When peers rather than supervisors carry out monitoring and assessing work performance,
it is referred to as peer review. Most likely, the manager’s review of the employee is not
complete unless some type of peer review data is gathered. Peer review provides feedback
that can promote growth. It can also provide learning opportunities for the peer reviewers.
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584 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
The concept of collegial evaluation of nursing practice is closely related to maintaining
professional standards.
Although the prevailing practice in most organizations is to have managers evaluate
employee performance, there is much to be said for collegial review. Peer review is widely
used in medicine and academe; however, health-care organizations have been slow to adopt
peer review for the following five reasons:
1. Staff are often poorly oriented to the peer review method and many first-level
managers, including team leaders, have had little training in how to conduct a growth-
producing performance appraisal. In fact, Keegal (2013) suggests that first-level
managers like team leaders often have to learn these skills on the job, supported only
by brief management courses with minimal leadership theory.
2. Peer review is viewed as very threatening when inadequate time is spent orienting
employees to the process and when necessary support is not provided throughout the
process.
3. Peers feel uncomfortable sharing feedback with people with whom they work closely,
so they omit needed suggestions for improving the employee’s performance. Thus, the
review becomes more advocacy than evaluation. Randall and Sharples (2012) agree,
noting that leniency in performance appraisal is common and difficult to reduce.
This leniency is typically driven by raters’ motivation to avoid conflicts with ratees
(Examining the Evidence 24.1).
Source: Randall, R., & Sharples, D. (2012). The impact of rater agreeableness and rating context on the evaluation
of poor performance. Journal of Occupational & Organizational psychology, 85(1), 42–59.
Participants were 230 government employees responsible for administering welfare benefits.
Participant agreeableness was measured using the 20 agreeableness items from Goldberg’s
International Personality Inventory Pool. Example items included “I am easy to satisfy” and “I
suspect hidden motives in others.”
Participants were informed that they were testing an appraisal system developed for a small
local manufacturing company and that they would rate the performance of one of the managers
from this company using a competency framework. Participants were told by the researcher that
they would be required to provide face-to-face feedback individually to the ratee. Participants
then received training, completed two practice rating exercises, and were introduced to, but did
not interact with, the ratee who vacated the room after being introduced.
The study found that significantly higher ratings were given by raters when raters thought they
had to meet face-to-face with the ratees. Raters did not, however, generally give lenient ratings
when exposed to inflated self-ratings if future collaboration was not anticipated. The resear-
chers concluded that rater agreeableness exerts a largely independent effect on rating behavior,
since the higher the rater’s agreeableness the higher the ratings that were given. These effects
appeared to be driven by raters’ motivation to avoid conflict with ratees.
Examining the Evidence 24.1
4. Peer review is viewed by many as more time-consuming than traditional superior–
subordinate performance appraisals.
5. Because much socialization takes place in the workplace, friendships often result in
inflated evaluations, or interpersonal conflict may result in unfair appraisals.
6. Because peer review shifts the authority away from management, the insecure manager
may feel threatened.

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Chapter 24 Performance Appraisal 585
Peer review has its shortcomings, as evidenced by some university teachers receiving
unjustified tenure or the failure of physicians to maintain adequate quality control among
some individuals in their profession. Additionally, peer review involves much risk-taking, is
time-consuming, and requires a great deal of energy. However, nursing as a profession should
be responsible for setting the standards and then monitoring its own performance. Because
performance appraisal may be viewed as a type of quality control, it seems reasonable to
expect that nurses should have some input into the performance evaluation process of their
profession’s members.
Peer review can be carried out in several ways. The process may require the reviewers
to share the results only with the person being reviewed, or the results may be shared with
the employee’s supervisor and the employee. The review would never be shared only with
the employee’s supervisor. The results may or may not be used for personnel decisions. The
number of observations, number of reviewers, qualification and classification of the peer
reviewer, and procedure need to be developed for each organization. If peer review is to
succeed, the organization must overcome its inherent difficulties by doing the following before
implementing a peer review program:
• Peer review appraisal tools must reflect standards to be measured, such as the job
description.
• Staff must receive a thorough orientation to the process before its implementation. The
role of the manager should be clearly defined.
• Ongoing support, resources, and information must be made available to the staff during
the process.
• Data for peer review need to be obtained from predetermined sources, such as
observations, charts, and patient care plans.
• A decision must be made about whether anonymous feedback will be allowed. This is
controversial and needs to be addressed in the procedure.
• Decisions must be reached on whether the peer review will affect personnel decisions
and, if so, in what manner.
Peer review has the potential to increase the accuracy of performance appraisal. It can also
provide many opportunities for increased professionalism and learning. The use of peer review
in nursing should continue to expand as nursing increases its autonomy and professional
status. Display 24.6 provides a summary of types of performance appraisal tools.
The 360-Degree Evaluation
An adaptation of peer review, and a relatively new addition to performance appraisal tools,
the 360-degree evaluation, includes an assessment by all individuals within the sphere of
Trait rating scales: rates an individual against some standard.
Job dimension scales: rates the performance on job requirements.
Behaviorally anchored rating scales: rates desired job expectations on a scale of importance to the
position.
Checklists: rates the performance against a set list of desirable job behaviors.
Essays: A narrative appraisal of job performance.
Self-appraisals: An appraisal of performance by the employee.
Management by objectives: employee and management agree upon goals of performance to be
reached.
Peer review: Assessment of work performance carried out by peers.
DISPLAY 24.6 Summary of Performance Appraisal Tools
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586 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
influence of the individual being appraised. “The idea is to look at how the employee is
perceived by multiple layers of people. This includes physicians, patients, the employees,
coworkers, whoever they report to, and employees from other departments with whom they
work” (Gallo, Minsley, & Wright, 2009, p. 110). For example, a 360-degree evaluation of
a ward clerk or unit secretary might include feedback from the nursing staff, from patients,
and from staff from other departments who interact with that individual on a regular basis. In
addition, most 360-degree feedback tools include a self-assessment.
Getting feedback from multiple individuals provides a broader, more accurate perspective
of the employee’s work performance. This divergent thinking suggests that involving
additional individuals in the appraisal process provides unique and valuable perspectives that
might otherwise not be considered. Luse (2013) notes that no more than 12 individuals should
be involved in the process and that it should ideally be done in an online format. Nowack
and Mashihi (2012) concur that inviting more, rather than fewer reviewers to participate in
the process, makes findings more relevant and useful. In fact, recent research suggests that
when two or fewer respondents provide data, rater responses may be inadequate for reliable
measurement. The risk, however, with large numbers of reviewers is that it may be difficult
to interpret important differences by different raters and to decide what to do with discrepant
results. Nowack and Mashihi note the importance of coaches helping ratees fully understand
and interpret the meaning of such differences.
DecisionWise (2013) concurs, suggesting that some type of coaching is generally
indicated for the individual who receives 360-degree feedback results. Those individuals who
receive some type of coaching on their feedback and set goals for development, experience
significantly greater performance improvement than those who simply participate in the
360-degree feedback process and receive their feedback reports (DecisionWise).
3D Group (2013) sounds a warning, however, that 360-degree ratings can become tainted
by bias if raters know the results could have an affect on the recipient’s position in a company.
Therefore, some individuals argue it should be used only for developmental purposes. Others
argue that if feedback recipients are not held accountable for making behavioral changes based
on the results, the 360-degree feedback program loses some of its impact (3D Group).
LEARNING EXERCISE 24.4
Addressing Mary’s Change in Behavior
even in organizations that have no formal peer review process, professionals must take some
responsibility for colleagues’ work performance, even if informally. The following scenario
illustrates the need for peer involvement.
You have worked at Memorial Hospital since your graduation from nursing school. Your school
roommate, Mary, has also worked at Memorial since her graduation. For the first year, you and
Mary were assigned to different units, but you were both transferred to the oncology unit 6 months
ago. You and Mary work the 3 pm to 11 pm shift, and it is the policy for the charge nurse duties
to alternate among three rNs assigned to the unit on a full-time basis. Both of you are among
the nurses assigned to rotate to the charge position. You have noticed lately that when Mary is in
charge, her personality seems to change; she barks orders and seems tense and anxious.
Mary is an excellent clinical nurse, and many of the staff seek her out in consultation about
patient care problems. You have, however, heard several of the staff grumbling about Mary’s
behavior when she is in charge. As Mary’s good friend, you do not want to hurt her feelings, but
as her colleague, you feel a need to be honest and open with her.
Assignment: A very difficult situation occurs when personal and working relationships are
combined. describe what, if anything, you would do.

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Chapter 24 Performance Appraisal 587
PLANNING THE APPRAISAL INTERVIEW
The most accurate and thorough appraisal will fail to produce growth in employees if the
information gathered is not used appropriately. Many appraisal interviews have negative
outcomes because the manager views them as a time to instruct employees only on what they
are doing wrong rather than looking at strengths as well.
Managers often dislike the appraisal interview more than the actual data gathering.
One of the reasons managers dislike the appraisal interview is because of their own
negative experiences when they have been judged unfairly or criticized personally.
Indeed, some managers are so uncomfortable with conducting performance appraisals
that they find reasons not to do them at all. Stonehouse (2013) notes that at times, it
may be that other priorities must take precedence, but the message that is imparted when
appraisals are frequently cancelled or postponed is that they are unimportant.
Clearly, both parties in the appraisal process tend to be anxious before the interview; thus,
the appraisal interview remains an emotionally charged event. For many employees, past
appraisals have been traumatizing. Although little can be done to eliminate the often-negative
emotions created by past experiences, the leader-manager can manage the interview in such
a manner that people will not be traumatized further.
OVERCOMING APPRAISAL INTERVIEW DIFFICULTIES
Feedback, perhaps the greatest tool a manager has for changing behavior, must be given in
an appropriate manner. There is a greater chance that the performance appraisal will have
a positive outcome if certain conditions are present before, during, and after the interview.
Before the Interview
• Make sure that the conditions mentioned previously have been met (e.g., the employee
knows the standard by which his or her work will be evaluated), and he or she has a copy
of the appraisal form.
• Select an appropriate time for the appraisal conference. Do not choose a time when the
employee has just had a traumatic personal event or is too busy at work to take the time
needed for a meaningful conference.
• Give the employee 2 to 3 days of advance notice of the scheduled appraisal conference
so that he or she can prepare mentally and emotionally for the interview.
• Be prepared mentally and emotionally for the conference yourself. If something should
happen to interfere with your readiness for the interview, it should be canceled and
rescheduled.
LEARNING EXERCISE 24.5
The 360-Degree Evaluation
Think of a role you have held which was important to you and which you worked hard at to be
successful. This could be a personal role such as being a parent, boyfriend, or girlfriend, or a
specific job you have held in the past or at present. identify at least six individuals you would
have chosen to complete a 360-degree evaluation of you in that role. Why did you select these
individuals? Might their perceptions have been in conflict? Would these individuals have been
likely to give you honest appraisal feedback? if so, how might their feedback have altered how
you approached the role or the goals you were trying to achieve?
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588 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
• Schedule uninterrupted appraisal time. Hold the appraisal in a private, quiet, and
comfortable place. Forward your telephone calls to another line, and ask another
manager to answer any pages that you may have during the performance appraisal.
• Plan a seating arrangement that reflects collegiality rather than power. Having the person
seated across a large desk from the appraiser denotes a power–status position; placing
the chairs side by side denotes collegiality.
During the Interview
• Greet the employee warmly, showing that the manager and the organization have a
sincere interest in his or her growth.
• Begin the conference on a pleasant, informal note.
• Ask the employee to comment on his or her progress since the last performance
appraisal.
• Avoid surprises in the appraisal conference. The effective leader coaches and
communicates informally with staff on a continual basis, so there should be little new
information at an appraisal conference. Indeed, Keegal (2013) notes that managers
should not wait for the annual appraisal to deal with poor performance, as this allows
bad habits to become entrenched and team resentment to grow.
• Use coaching techniques throughout the conference.
• When dealing with an employee who has several problems—either new or long-
standing—do not overwhelm him or her at the conference. If there are too many
problems to be addressed, select the major ones.
• Conduct the conference in a nondirective and participatory manner. Input from the
employee should be solicited throughout the interview; however, the manager must
recognize that employees from some cultures may be hesitant to provide this type of
input. In this situation, the manager must continually reassure the employee that such
input is not only acceptable but is also desired.
• Listen carefully to what the employee has to say and give them your full attention.
• Focus on the employee’s performance and not on his or her personal characteristics.
• Avoid vague generalities, either positive or negative, such as “your skills need a little
work” or “your performance is fine.” Be prepared with explicit performance examples.
Be liberal in the positive examples of employee performance; use examples of poor
performance sparingly. Use several examples only if the employee has difficulty with
self-awareness and requests specific instances of a problem area.
• When delivering performance feedback, be straightforward and state concerns directly
so as not to retard communication or cloud the message.
Indirectness and ambiguity are more likely to inhibit communication than enhance it, and the
employee is left unsure about the significance of the message.
• Mackenzie (2013) suggests that since most employees are waiting for the “bad news,”
it is probably most effective to describe areas for improvement first, followed by the
employee’s strengths.
• Never threaten, intimidate, or use status in any manner. Differences in power and
status interfere with the ability of professionals to form meaningful and constructive
relationships. This is not to say that managers should not maintain an appropriate
authority–power gap with their employees; it simply suggests that power and status

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Chapter 24 Performance Appraisal 589
issues should be minimized as much as possible so that the performance appraisal can
appropriately focus on the subordinate’s performance and needs.
• Let the employee know that the organization and the manager are aware of his or her
uniqueness, special interests, and valuable contributions to the unit. Remember that all
employees make some special contribution to the workplace.
• Make every effort to ensure that there are no interruptions during the conference.
• Use terms and language that are clearly understood and carry the same meaning for both
parties. Avoid words that have a negative connotation. Do not talk down to employees
or use language that is inappropriate for their level of education.
• Mutually set goals for further growth or improvement in the employee’s performance.
Decide how goals will be accomplished and evaluated and what support is needed.
• Plan on being available for employees to return retrospectively to discuss the appraisal
review further. There is frequently a need for the employee to return for elaboration if the
conference did not go well or if the employee was given unexpected new information.
This is especially true for the new employee.
After the Interview
• Both the manager and the employee need to sign the appraisal form to document that
the conference was held and that the employee received the appraisal information. This
does not mean that the employee is agreeing to the information in the appraisal; it merely
means that the employee has read the appraisal. An example of such a form is shown
in Display 24.7. There should be a place for comments by both the manager and the
employee.
performance appraisal for
Name:
Unit:
prepared by:
reason:
(Merit, terminal, end of probation, general reviews)
date of appraisal conference:
comments by employee:
employee’s signature:
(Signature of employee denotes that the appraisal has been read. it does not signify acceptance
or agreement. Space is provided for any comments the employee wishes to make.) comments by
appraiser.
(These comments are to be written at the time of the appraisal conference and in the presence of
the employee.)

employee’s signature (date) evaluator’s signature (date)
DISPLAY 24.7 Performance Appraisal Documentation Form
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590 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
• End the interview on a pleasant note.
• Document the goals for further development that have been agreed on by both parties.
The documentation should include target dates for accomplishment, support needed, and
when goals are to be reviewed. This documentation is often part of the appraisal form.
• If the interview reveals specific long-term coaching needs, the manager should develop
a method of follow-up to ensure that such coaching takes place.
PERFORMANCE MANAGEMENT
Some experts in human resource management have suggested that annual performance
appraisals should be replaced by ongoing performance management. In performance
management, appraisals are eliminated, and the manager places his or her efforts into ongoing
coaching, mutual goal-setting, and the leadership training of subordinates. This focus requires
the manager to spend more regularly scheduled face-to-face time with subordinates.
In contrast to the annual performance review, which is often linked to an employee’s hire
date, the performance management calendar is generally linked to the organization’s business
calendar. This way, performance planning is coordinated throughout the entire organization,
as strategic goals for the year can be identified and subordinates’ roles to achieve those
goals can be openly discussed and planned. Some organizations, however, view performance
management as a continuous cycle. Regardless, all performance-managed organizations
identify role-based competency expectations for every employee, regardless of job
description. Then, employees can determine how these qualities translate into performance
in specific jobs.
COACHING: A MECHANISM FOR INFORMAL PERFORMANCE APPRAISAL
Coaching is described in the literature as “a process through which an individual is provided
with one-on-one interaction to either address specific developmental issues and receive
feedback on strengths and opportunities for involvement or to receive support and guidance
during times of transition in their personal role or throughout the organization” (Karsten
& Baggot, 2010, p. 140). In other words, coaching conveys the spirit of leaders’ and
managers’ roles in informal day-to-day performance appraisals, which promote improved
work performance and team building. Coaching can guide others into increased competence,
commitment, and confidence as well as help them to anticipate options for making vital
connections between their present and future plans.
Day-to-day feedback regarding performance is one of the best methods for improving work
performance and building a team approach.
Manthey (2001) uses the terms reflective practice and clinical coaching to describe a
management strategy that fuses both performance coaching and performance management.
In clinical coaching, the manager or mentor meets with an employee regularly to discuss
aspects of his or her work. Both individuals determine the agenda jointly with the goal of an
environment of learning that can span the personal and professional aspects of the employee’s
experience. During clinical coaching, employees can discuss things that have made them
feel angry or discouraged. They can also get new ideas and information about how to deal
with situations from someone who often has experienced the same problems and issues. This
shared connection between the manager and the employee makes the employee feel validated
and part of a larger team. When coaching is combined with informal performance appraisal,
the outcome is usually a positive modification of behavior. For this to occur, however, the
leader must establish a climate in which there is a free exchange of ideas.

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Chapter 24 Performance Appraisal 591
BECOMING AN EFFECTIVE COACH
The following tactics will assist managers in becoming more effective coaches:
• Be specific, not general, in describing behavior that needs improvement.
• Be descriptive, not evaluative, when describing what was wrong with the work performance.
• Be certain that the feedback is not self-serving but meets the needs of the employee.
• Direct the feedback toward behavior that can be changed.
• Use sensitivity in timing the feedback.
• Make sure that the employee has clearly understood the feedback and that the employee’s
communication has also been clearly heard.
When employees believe that their manager is interested in their performance and personal
growth, they will have less fear of the work performance appraisal. When that anxiety is
reduced, the formal performance interview process can be used to set mutual performance goals.
USING LEADERSHIP SKILLS AND MANAGEMENT FUNCTIONS IN CONDUCTING
PERFORMANCE APPRAISALS
Performance appraisal is a major responsibility in the controlling function of management. The
ability to conduct meaningful, effective performance appraisals requires an investment of time,
effort, and practice on the part of the manager. Although performance appraisal is never easy, if used
appropriately, it produces growth in the employee and increases productivity in the organization.
To increase the likelihood of successful performance appraisal, managers should use a
formalized system of appraisal and gather data about employee performance in a systematic
manner, using many sources. The manager should also attempt to be as objective as possible,
using established standards for the appraisal. The result of the appraisal process should provide
the manager with information for meeting training and educational needs of employees. By
following up conscientiously on identified performance deficiencies, employees’ work
problems can be corrected before they become habits.
Integrating leadership into this part of the controlling phase of the management process
provides an opportunity for sharing, communicating, and growing. The integrated leader-
manager is self-aware regarding his or her biases and prejudices. This self-awareness leads to
fairness and honesty in evaluating performance. This, in turn, increases trust in the manager
and promotes a team spirit among employees.
The leader also uses day-to-day coaching techniques to improve work performance and
reduce the anxiety of performance appraisal. When anxiety is reduced during the appraisal
interview, the leader-manager is able to establish a relationship of mutual goal-setting, which
has a greater potential to result in increased motivation and corrected deficiencies. The result
of the integration of leadership and management is a performance appraisal that facilitates
employee growth and increases organizational productivity.
KEY CONCEPTS
l The employee performance appraisal is a sensitive and important part of the management process,
requiring much skill.
l When accurate and appropriate appraisal assessments are performed, outcomes can be very positive.
l performance appraisals are used to determine how well employees are performing their job. Therefore,
appraisals measure actual behavior and not intent.
(Continued )
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592 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
l Job descriptions often produce objective criteria for use in the performance appraisal.
l There are many different types of appraisal tools and methods, and the most appropriate one to use
varies with the type of appraisal to be done and the criteria to be measured.
l The employee must be involved in the appraisal process and view the appraisal as accurate and fair.
l MBO has been shown to increase productivity and commitment in employees.
l peer review has great potential for developing professional accountability but is often difficult to implement.
l Unless the appraisal interview is carried out in an appropriate and effective manner, the appraisal data
will be useless.
l Because of past experiences, performance appraisal interviews are highly charged, emotional events for
most employees.
l Showing a genuine interest in the employee’s growth and seeking his or her input at the interview will
increase the likelihood of a positive outcome from the appraisal process.
l performance appraisals should be signed to show that feedback was given to the employee.
l informal work performance appraisals are an important management function.
l Leaders should routinely use day-to-day coaching to empower subordinates and improve work performance.
l in performance management, appraisals are eliminated. instead, the manager places his or her efforts
into ongoing coaching, mutual goal-setting, and the leadership training of subordinates.
LEARNING EXERCISE 24.6
Requesting Feedback from Employees
You are the director of a home health agency. You have just returned from a management course and
have been inspired by the idea of requesting input from your subordinates about your performance
as a manager. You realize that there are some risks involved but believe that the potential benefits
from the feedback outweigh the risks. However, you want to provide some structure for the
evaluation, so you spend some time designing your appraisal tool and developing your plan.
Assignment: What type of tool will you use? What is your overall goal? Will you share the
results of the appraisal with anyone else? How will you use the information obtained? Would
you have the appraisal forms signed or have them be anonymous? Who would you include in
the group that is evaluating you? Be able to support your ideas with appropriate rationale.
LEARNING EXERCISE 24.7
Making Appraisal Interviews Less Traumatic
You are the new night-shift charge nurse in a large intensive care unit composed of an all-rN
staff. When you were appointed to the position, your supervisor told you that there had been
some complaints regarding the manner in which the previous charge nurse had handled
evaluation sessions. Not wanting to repeat the mistakes, you draw up a list of things that you
could do to make the evaluation interviews less traumatic. Because the evaluation tool appears
adequate, you believe that the problems must lie with the interview itself. At the top of your list,
you write that you will make sure each employee has advance notice of the evaluation.

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Chapter 24 Performance Appraisal 593
LEARNING EXERCISE 24.8
Helping a Seasoned Employee to Grow
patty Brown is an LVN/LpN who has been employed by your unit for 10 years. She is an older
woman and is very sensitive to criticism. Her work is generally of high quality, but in reviewing
her past performance appraisals, you notice that during the last 10 years, at least seven times
she has been rated unsatisfactory for not being on duty promptly and eight times for not
attending staff development programs. Because you are the new charge nurse, you would like
to help patty grow in these two areas. You have given patty a copy of the evaluation tool and
her job description and have scheduled her appraisal conference for a time when the unit will
be quiet. You can conduct the appraisal in the conference room.
Assignment: How would you conduct this performance appraisal? Outline your plan. include
how you would begin. What innovative or creative way would you attempt to provide direction
or improvement in the areas mentioned? How would you terminate the session? Be able to give
rationale for your decisions.
LEARNING EXERCISE 24.9
Could This Conflict Have Been Prevented?
Mr. Jones, a 49-year-old automobile salesman, was admitted with severe back pain. As his
primary care nurse, you have established a rapport with Mr. Jones. He has a type A personality
and has been very critical of much of his hospitalization. He was also very upset by the level
and duration of his pain following his laminectomy. You agreed to ambulate him on your shift
three times (at 4:00 pm, 7:00 pm, and 10:30 pm) so that he would need to be ambulated only
once during the day shift. He does not care for many of the day staff and feels that you help to
ambulate him better than anyone else. You noted the ambulating routine on his nursing orders.
Yesterday, Joan Martin, a day nurse, believed that his bowel sounds were somewhat diminished.
She urged him to ambulate more on the day shift, but he refused to do so. (The doctor had
ordered ambulation q.i.d.) When Mr. Jones’s physician visited, Nurse Martin told him that
Mr. Jones ambulated only once on the shift. She did not elaborate further to the doctor. The
physician proceeded to talk very sternly with Mr. Jones, telling him to get out of bed three times
today. Nurse Martin did not mention this incident to you in the report.
By the time you arrived on duty and received the report, Mr. Jones was very angry. He threatened
to sign himself out against medical advice. You talked with his doctor, got the order changed,
and finally managed to calm Mr. Jones down. You then wrote a nursing order that read, “Nurse
Martin is not to be assigned to Mr. Jones again.” When Joan Martin came on duty this morning,
the night shift pointed out your notation. She was very angry and went to see the head nurse.
(Continued )
Assignment: How much advance notice should you give? What additional criteria would
you add to the list to help eliminate much of the trauma that frequently accompanies
performance appraisal (even when the appraisal is very good)? Add six to nine items to the
list. explain why you think that each of these would assist in alleviating some of the anxiety
associated with performance appraisals. do not just repeat the guidelines listed in this
chapter. You may make the guidelines more specific or use references for assistance in
developing your own list.
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594 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
Assignment: Should you have done anything differently? if so, what? could the evaluation
of clinical performance by you and Nurse Martin have been done in a manner that would not
have resulted in conflict? if you were Nurse Martin, what could you have done to prevent the
conflict? Be able to discuss this case in relation to professional trust, peer review, and assertive
communication.
LEARNING EXERCISE 24.10
Addressing Sally’s Errors in Judgment
You are a senior baccalaureate nursing student. This is your sixth week of a medical–surgical
advanced practicum. Your instructor assigns two students to work together in caring for four to
six patients. The students alternate fulfilling leader and follower roles and providing total patient
care. This is the second full day that you have worked as a team with Sally Brown.
Last week, when you were assigned with Sally, she was the leader and made numerous errors
in judgment. She got a patient up who was on strict bed rest. She made an iV medication error
by giving a medication to the wrong patient. She gave morphine too soon because she forgot
to record the time in the medication record, and she frequently did not seem to know what was
wrong with her patients.
Today, you have been the leader and have observed her contaminate a dressing and forget to
check armbands twice when she was giving medications. When you asked her about checking
the placement of the nasogastric tube, she did not know how to perform this skill. You have
heard some of the other students complain about Sally.
Assignment: What is your obligation to your patients, your fellow students, the clinical agency,
and your instructor? Outline what you would do. provide the rationale for your decisions.
REFERENCES
3D Group. (2013). January 2013—Future of 360 degree
feedback: New study finds increased HR influence.
Retrieved June 26, 2013, from http://www.3dgroup
.net/january-2013-future-of-360-degree-feedback
-new-study-find-increased-hr-influence.html
Accel-Team (2013). Self assessment. A system to set your
own performance goals. Retrieved June 27, 2013,
from http://www.accel-team.com/techniques/
employee_evaluation.html
Bacal, R. (2013). 10 ways to modernize performance
management and appraisal for 2013. Performance
Management Health Center. Retrieved June 26,
2013, from http://performance-appraisals.org/
Bacalsappraisalarticles/articles/tenways.htm
DecisionWise (2013). What is 360-degree feedback.
Retrieved June 25, 2013, from http://www.decision
-wise.com/what-is-360-degree-feedback.html
Gallo, C. L., Minsley, M. A., & Wright, J. (2009, October).
Do patients say good, or not so good, things about
your access staff? Hospital Access Management,
28(10), 109–112.
Karsten, M., & Baggot, D. (2010, March). Professional
coaching as an effective strategy to retaining frontline
managers. Journal of Nursing Administration, 40(3),
140–144.
Keegal, T. (2013, May). Poor performance: Managing the
first informal stages. Primary Health Care, 23(4),
31–38.
Luse, K. A. (2013, March/April). Managerial strategies for
creating an effective work environment. Radiologic
Technology, 84(4), 383–397.
Mackenzie, R. (2013, June 1). Supervision and appraisal:
How to support staff performance. Nursing &
Residential Care, 15(6), 452–454.
Manthey, M. (2001). Reflective practice. Creative Nursing,
7(2), 3–5.
Mulvaney, M. A., McKinney, W. R., & Grodsky, R. (2012).
The development of a pay-for-performance appraisal
system for municipal agencies: A case study. Public
Personnel Management, 41(3), 505–533.
Nowack, K. M., & Mashihi, S. (2012). Evidence-based
answers to 15 questions about leveraging 360-degree

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IS4059
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Chapter 24 Performance Appraisal 595
feedback. Consulting Psychology Journal: Practice
& Research, 64(3), 157–182.
Olmstead, J., Falcone, D., Lopez, J., Sharpe, L., & Michna,
J. (2012). Perioperative employee annual evaluations:
A 30-second process. AORN Journal, 96(6), 627–633.
Price, B. (2013). Preparing for your annual staff appraisal:
Part 2. Nursing Standard, 27(21), 42–48.
Randall, R., & Sharples, D. (2012). The impact of rater
agreeableness and rating context on the evaluation
of poor performance. Journal of Occupational &
Organizational Psychology, 85(1), 42–59.
Stonehouse, D. (2013). Appraisal and its benefits for the
support worker. British Journal of Healthcare
Assistants, 7(5), 246–249.
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596
Problem Employees: Rule Breakers,
Marginal Employees, and the Chemically
or Psychologically Impaired
… as patient advocates, nurse leaders must help ensure fitness for duty.
—Richard Hader
… difficult employees can make you question why you became a manager in the first place.
—Mark Pipkin
CROSSWALK tHis cHaPteR addResses:
BSN Essential II: Basic organizational and systems leadership for quality care and patient safety
BSN Essential V: Health-care policy, finance, and regulatory environments
BSN Essential VIII: Professionalism and professional values
MSN Essential II: Organizational and systems leadership
MSN Essential III: Quality improvement and safety
QSEN Competency: teamwork and collaboration
QSEN Competency: safety
AONE Nurse Executive Competency I: communication and relationship building
AONE Nurse Executive Competency II: a knowledge of the health-care environment
AONE Nurse Executive Competency III: Leadership
AONE Nurse Executive Competency IV: Professionalism
AONE Nurse Executive Competency V: Business skills
LEARNING OBJECTIVES The learner will:
l identify the “hot stove” rules described by McGregor to make discipline as fair and growth-
producing as possible
l describe the usual steps in progressive discipline
l differentiate between constructive and destructive discipline
l identify factors that must be present to foster a climate of self-discipline in employees
l seek to eliminate rules that are outdated or no longer appropriate in the environments in
which they function
l compare and contrast how the disciplinary process may vary between unionized and
nonunionized organizations
l analyze situations in which discipline is required and identify appropriate strategies for
constructively modifying behavior
l determine appropriate levels of discipline for rule-breaking in specific situations
l develop strategies that assist marginal employees to be contributing members of the
workforce
25

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 597
l describe the risk factors that result in an increased risk of chemical addiction in the nursing
profession
l identify behaviors and actions that may signify chemical impairment in an employee or
colleague
l analyze how personal feelings, values, and biases regarding chemical impairment may alter
one’s ability to confront and/or help the chemically impaired employee
l recognize the importance of the manager not assuming the role of counselor or treatment
provider for employees who are chemically or psychologically impaired
Employees’ perceptions vary as to what they owe the organization and what they owe
themselves. At times, organizational and individual needs, wants, and responsibilities are
in conflict. The coordination and cooperation needed to meet organizational goals require
leader-managers to control individual subordinates’ urges that are counterproductive to these
goals. Subordinates do this by self-control. Managers meet organizational goals by enforcing
established rules, policies, and procedures. Leaders do this by creating a supportive and
motivating climate and by coaching.
Luse (2013) notes that problem behavior can assume many forms, including blatant
insubordination such as an employee refusing to perform a task, not reporting to work on
time, or showing disrespect to coworkers or others. Highly problematic behavior is often
more subtle, but equally serious. This includes behavior such as undermining fellow team
members (e.g., by spreading gossip or participating in exclusionary activities) and creating
an unwelcome or hostile workplace.
When employees are unsuccessful in meeting organizational goals, managers must attempt
to identify the reasons for this failure and counsel employees accordingly. If employees
fail because they are unwilling to follow rules or established policies and procedures or
they are unable to perform their duties adequately despite assistance and encouragement,
the manager has an obligation to take disciplinary action. However, progressive discipline
is inappropriate for employees who are impaired as a result of disease or degree of ability.
These employees have special problems and needs that require active coaching, support, and,
often, professional counseling to maintain productivity. For employees to be managed most
appropriately, managers must be able to distinguish between employees in need of discipline
and those who are impaired.
Regardless of the cause, however, supervisors should promptly address inappropriate
conduct and poor work performance. Delay only exacerbates such situations. Luse
(2013) agrees, noting that employees become disenchanted with their positions and work
environment for varied and unique reasons. The disenchantment of a single employee can
spread, affecting otherwise satisfied and highly valued employees. When someone is not
performing well, everyone knows it. And when management refuses to act, employees may
perceive that their leaders lack the resolve necessary to make the organization successful.
Not disciplining an employee who should be disciplined jeopardizes an organization’s morale.
This chapter focuses on discipline, coaching, and referral as tools in promoting subordinates’
growth and meeting organizational goals. The normal progression of steps taken in
disciplinary action and strategies for administering discipline fairly and effectively are
delineated. Formal and informal grievances are discussed.
The chapter also focuses on two types of employees with special needs: the marginal
employee and the impaired employee. Marginal employees are those employees who disrupt
unit functioning because the quantity or quality of their work consistently meets only minimal
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598 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
standards at best. This chapter identifies the challenges inherent in working with marginal
employees and presents managerial strategies for dealing with these problem employees.
Impaired employees are those who are unable to accomplish their work at the expected
level as a result of chemical or psychological disease. While the emphasis in this chapter is
on chemical impairment (impairment resulting from drug or alcohol addiction), psychological
impairment is increasingly recognized as a significant problem for employees. The strategies
used to deal with both types of impairment typically overlap. This chapter profiles chemical
addiction among nurses as well as behaviors common to chemically impaired nurses. Steps
in the recovery process and the reentry of the recovering chemically impaired nurse into the
workforce are also discussed. Leadership roles and management functions appropriate for use
with problem employees are shown in Display 25.1.
DISPLAY 25.1 Leadership Roles and Management Functions in Dealing with
Problem Employees
LEADERSHIP ROLES
1. Recognizes and reinforces the intrinsic self-worth of each employee and the role of successful
work performance in maintaining a positive self-image.
2. encourages employees to be self-disciplined in conforming to established rules and regulations.
3. Understands group norms and is able to work within those norms to mold group behavior.
4. assists employees to identify with organizational goals, thus increasing the likelihood that the
standards of conduct deemed acceptable by the organization will be accepted by its employees.
5. is self-aware regarding the power and responsibility inherent in having formal authority to set
rules and discipline employees.
6. serves in the role of coach in performance deficiency coaching or problem-centered coaching.
7. assures that the rights and the responsibilities of both the manager and the employee are
considered in addressing worker grievances.
8. is self-aware regarding values, biases, and beliefs about chemical abuse.
9. Uses active listening as a support tool in working with chemically and psychologically impaired
subordinates but recognizes own limitations in counseling and refers impaired employees to
outside experts for appropriate counseling.
10. examines the work environment for stressors that contribute to substance abuse and elimi-
nates those stressors whenever possible.
11. Keeps patient safety first and foremost when considering how best to intervene with problem
employees.
12. Recognizes that all employees have intrinsic worth and assists them in reaching their maximal
potential.
MANAGEMENT FUNCTIONS
1. discusses clearly all written rules and policies with subordinates, explains the rationale for the
existence of the rules and policies, and encourages questions.
2. clearly identifies performance expectations for all employees and confronts employees when
those expectations are not met.
3. Uses formal authority as judiciously as possible so that subordinates have the opportunity to
invoke self-discipline.
4. Uses formal authority to administer discipline using a progressive model when employees
continue to fail to meet expected standards of achievement.
5. thoroughly investigates the situation before employee discipline is administered.
6. consults with either a superior or the human resources department before dismissing an
employee.
7. Maintains clear, objective, and comprehensive written records regarding the problem employ-
ee’s behavior and attempts to counsel.
8. Uses organizational transfers appropriately.

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 599
CONSTRUCTIVE VERSUS DESTRUCTIVE DISCIPLINE
Discipline involves training or molding the mind or character to bring about desired
behaviors. Discipline is often considered a form of punishment but is not quite the same
thing as punishment. Punishment is an undesirable event that follows unacceptable behavior.
Although discipline can have negative consequences, it can be a powerful motivator for
positive change since it has an educational component as well as a corrective one.
Scientific management theory viewed discipline as a necessary means for controlling an
unmotivated and self-centered workforce. Because of this traditional philosophy, managers
primarily used threats and fear to control behavior. This “big stick” approach to management
focused on eliminating all behaviors that could be considered to conflict with organizational
goals. Although this approach may succeed on a short-term basis, it is usually demotivating
and reduces long-term productivity because people will achieve goals only up to the level
that they believe is necessary to avoid punishment. This approach is also destructive because
discipline is often arbitrarily administered and is unfair either in the application of rules or in
the resulting punishment.
In contrast to punishment, discipline is called constructive discipline when it assists
employee growth. Punishment is frequently inferred when defining discipline, but discipline
can also be defined as training, educating, or molding. In fact, the word discipline comes
from the Latin term disciplina, which means teaching, learning, and growing. In constructive
discipline, punishment may be applied for improper behavior, but it is carried out in a
supportive and corrective manner. Employees are reassured that the punishment given is
because of their actions and not because of who they are.
Constructive discipline uses discipline as a means of helping the employee grow, not as a
punitive measure.
9. seeks out and completes extensive education about chemical abuse in the work setting;
provides these same opportunities to staff.
10. acts as a resource to chemically or psychologically impaired employees regarding professional
services or agencies that provide counseling and support services.
11. collects and records adequate objective data when suspicious of employee chemical
impairment.
12 Focuses employee confrontations on performance deficits and not on the cause of the underly-
ing problem or addiction.
13. Works with the rule breaker, chemically impaired, and/or marginal employee to develop a reme-
dial plan for action; ensures that the employee understands the performance expectations of
the organization and the consequences of not meeting these expectations.
LEARNING EXERCISE 25.1
Thinking about Growth-Producing versus Destructive Discipline
think back to when someone in authority such as a parent, teacher, or boss sets limits or
enforced rules in such a way that you became a better child, student, or employee. What made
this disciplinary action growth-producing instead of destructive? What was the most destructive
disciplinary action that you ever experienced? did it modify your behavior in any way?
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600 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
SELF-DISCIPLINE AND GROUP NORMS
The highest level and most effective form of discipline is self-discipline. When employees
feel secure, validated, and affirmed in their essential worth, identity, and integrity, self-
discipline is forthcoming. Ideally, all employees have adequate self-control and are
self-directed in their pursuit of organizational goals. However, this is not always the case.
Instead, group norms often influence individual behavior and make self-discipline difficult.
Group norms are group-established standards of expected behavior that are enforced by social
pressure. The leader, who understands group norms, is able to work within those norms to
mold group behavior. This modification of group norms, in turn, affects individual behavior
and thus self-discipline.
Although self-discipline is internalized, the leader plays an active role in developing an
environment that promotes self-discipline in employees. It is impossible for employees to
have self-control if they do not understand the acceptable boundaries for their behavior,
nor can they be self-directed if they do not understand what is expected of them. Therefore,
managers must discuss clearly all written rules and policies with subordinates, explain the
rationale for the existence of the rules and policies, and encourage questions.
Self-discipline is possible only if subordinates know the rules and accept them as valid.
Self-discipline also requires an atmosphere of mutual trust. Managers must believe that
employees are capable of and actively seek self-discipline. Likewise, employees must respect
their managers and perceive them as honest and trustworthy. Employees lack the security to
have self-discipline if they do not trust their managers’ motives. Finally, for self-discipline to
develop, formal authority must be used judiciously. If formal discipline is quickly and widely
used, subordinates do not have the opportunity to invoke self-discipline.
FAIR AND EFFECTIVE RULES
Several guidelines must be followed if discipline is to be perceived by subordinates as
growth-producing. This does not imply that subordinates enjoy being disciplined or that
discipline should be a regular means of promoting employee growth. However, discipline,
if implemented correctly, should not permanently alienate or demoralize subordinates.
McGregor (1967) developed four rules to make discipline as fair and growth-producing as
possible (Display 25.2). These rules are called “hot stove” rules, because they can be applied
to someone touching a hot stove.
Four elements must be present to make discipline as fair and growth-producing as possible:
1. Forewarning
2. immediate consequences
3. consistency
4. impartiality
1. all employees must be forewarned that if they touch the hot stove (break a rule), they will be
burned (punished or disciplined). they must know the rule beforehand and be aware of the
punishment.
2. if the person touches the stove (breaks a rule), there will be immediate consequences (getting
burned). all discipline should be administered immediately after rules are broken.
3. if the person touches the stove again, he or she will again be burned. therefore, there is consis-
tency; each time the rule is broken, there are immediate and consistent consequences.
4. if any other person touches the hot stove, he or she also will get burned. discipline must be
impartial, and everyone must be treated in the same manner when the rule is broken.
DISPLAY 25.2 McGregor’s Hot Stove Rules for Fair and Effective Discipline

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 601
Most rule-breaking is not enforced using McGregor’s rules. For example, many people
exceed the speed limit when driving. Generally, people are aware of speed limit regulations,
and signs are posted along the roadway as reminders of the rules; thus, there is forewarning.
There is no, however, immediacy, consistency, or impartiality. Many people exceed the
speed limit for long periods before they are stopped and disciplined, or they may never be
disciplined at all. Likewise, a person may be stopped and disciplined one day and not the
next even though the same rule is broken. Finally, the punishment is inconsistent because
some people are punished for their rule-breaking, but others are not. Even the penalty varies
among people.
Imagine what would happen if automobiles were developed that alarmed every time
a driver exceeded the speed limit and then transmitted this rule violation to local law
enforcement so that a speeding ticket could be issued. The incidence of speeding would
decrease dramatically. In addition, drivers would likely accept greater accountability for the
speeding tickets they received since they would have been forewarned of the consequences
of breaking the speed limit rule and they would know that this rule would be enforced
consistently and impartially for all drivers.
If a rule or regulation is worth having, it should be enforced. When rule-breaking is
allowed to go unpunished, other people tend to replicate the behavior of the rule-breaker.
Likewise, the average worker’s natural inclination to obey rules can be dissipated by lax or
inept enforcement policies because employees develop contempt for managers who allow
rules to be disregarded. The enforcement of rules using McGregor’s hot stove rules keeps
morale from breaking down and allows structure within the organization.
An organization should, however, have as few rules and regulations as possible.
A leadership role involves regularly reviewing all rules, regulations, and policies to
see if they should be discarded or modified in some way. If managers find themselves
spending much of their time enforcing one particular rule, it would be wise to reexamine
the rule and consider whether there is something wrong with the rule or how it is
communicated.
LEARNING EXERCISE 25.2
Rule Breakers and Outdated Rules
Part 1: think back to “rule breakers” you have known. Were they a majority or minority in the
group? How great was their impact on group behavior? What characteristics did they have
in common? did the group modify the rule breaker’s behavior, or did the rule breaker modify
group behavior?
Part 2: Rules quickly become outdated and need to be deleted or changed in some way. think
of a policy or rule that needs to be updated. Why is the rule no longer appropriate? What
could you do to update this rule? does the rule need to be replaced with a new one?
DISCIPLINE AS A PROGRESSIVE PROCESS
Managers have the formal authority and responsibility to take progressively stronger forms
of discipline when employees fail to meet expected standards of achievement. However,
inappropriate discipline (too much or too little) can undermine the morale of the whole team.
Determining appropriate disciplinary action, then, is often difficult, and many factors must
be considered.
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602 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
Discipline is generally administered using a progressive model. This is especially true in
unionized organizations. However, even in nonunion organizations, managers should have a
disciplinary procedure that is written and well communicated.
Action must be taken when employees continue undesirable conduct, either by breaking rules or
by not performing their job duties adequately.
Generally, the first step of the progressive disciplinary process is an informal reprimand or
verbal admonishment. This reprimand includes an informal meeting between the employee
and the manager to discuss the broken rule or performance deficiency. The manager suggests
ways in which the employee’s behavior might be altered to keep the rule from being broken
again. Often, an informal reprimand is all that is needed for behavior modification.
The second step is a formal reprimand or written admonishment. If rule-breaking recurs
after verbal admonishment, the manager again meets with the employee and issues a written
warning about the behaviors that must be corrected. This written warning is very specific
about what rules or policies have been violated, the potential consequences if behavior is
not altered to meet organizational expectations, and the plan of action that the employee is
expected to take to achieve expected change.
Both the employee and the manager should sign the warning to signify that the problem
or incident was discussed. The employee’s signature does not imply that the employee agrees
with everything on the report, only that it has been discussed. The employee must be allowed
to respond in writing to the reprimand, either on the form or by attaching comments to the
disciplinary report; this allows the employee to air any differences in perception between
the manager and the employee. One copy of the written admonishment is then given to
the employee, and another copy is retained in the employee’s personnel file. Display 25.3
presents a sample written reprimand form.
employee name

Position date of hire
Person completing report
Position date report completed
date of incident(s) time rule.
description of incident(s):
Prior attempts to counsel employee regarding this behavior (cite date and results of disciplinary
conferences):
disciplinary contract (plan for correction) and time lines:
consequences of future repetition:
employee comments (additional documentation or rebuttal may be attached):

signature of individual making the report employee signature
date date
date and time of follow-up appointment to review disciplinary contract:
DISPLAY 25.3 Sample Written Reprimand Form
The third step in progressive discipline is usually a suspension from work, either with
or without pay. If the employee continues the undesired behavior despite verbal and
written warnings, the manager should remove the employee from his or her job for a brief
time, generally a few days to several weeks. Such a suspension gives the employee the
opportunity to reflect on the behavior and to plan how he or she might modify the behavior
in the future.

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 603
The last step in progressive discipline is involuntary termination or dismissal. In reality,
many people terminate their employment voluntarily before reaching this step, but the
manager cannot count on this happening. Termination should always be the last resort
when dealing with poor performance. However, if the manager has given repeated warnings
and rule-breaking or policy violations continue, then the employee should be dismissed.
Although this is difficult and traumatic for the employee, the manager, and the unit, the cost
in terms of managerial and employee time and unit morale of keeping such an employee is
enormous.
When using progressive discipline, the steps are followed only for repeated infractions
of the same. At the end of a predesignated period, the slate is wiped clean. For example,
although an employee may have previously received a formal reprimand for unexcused
absences, discipline for a first-time offense of tardiness should begin at the first step of the
process. Also, remember that although discipline is generally administered progressively,
some rule-breaking is so serious that the employee may be suspended or dismissed with the
first infraction. Table 25.1 presents a progressive discipline guide for managers.
When using progressive discipline in all but the most serious infractions, the slate should be
wiped clean at the end of a predesignated period.
Offense First Infraction Second Infraction
Third
Infraction
Fourth
Infraction
Gross mistreatment of
a patient
dismissal
discourtesy to a patient Verbal admonishment Written admonishment suspension dismissal
insubordination Written admonishment suspension dismissal
Use of intoxicants while
on duty
dismissal
Neglect of duty Verbal admonishment Written admonishment suspension dismissal
theft or willful damage
of property
Written admonishment dismissal
Falsehood Verbal admonishment Written admonishment dismissal
Unauthorized absence Verbal admonishment Written admonishment dismissal
abuse of leave Verbal admonishment Written admonishment suspension dismissal
Violation of safety rules Verbal admonishment Written admonishment dismissal
inability to maintain
work standards
Verbal admonishment Written admonishment suspension dismissal
excessive unexcused
tardinessa
Verbal admonishment Written admonishment dismissal
aThe first, second, and third infractions do not mean the first, second, and third time an employee is late but the
first, second, and third time that unexcused tardiness becomes excessive as determined by the manager.
TABLE 25.1 Guide to Progressive Discipline
LEARNING EXERCISE 25.3
Deciding Upon Disciplinary Action
You are a supervisor in a neurologic care unit. One morning, you receive a report from the
night-shift registered nurses (RNs), Nurse caldwell and Nurse Jones. Neither of the nurses
reports anything out of the ordinary, except that a young head-injury patient has been particularly
belligerent and offensive in his language. this young man was especially annoying because he
appeared rational and then would suddenly become abusive. His language was particularly
(Continued )
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604 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
DISCIPLINARY STRATEGIES FOR THE NURSE-MANAGER
It is vital that managers recognize their power in evaluating and correcting employees’
behavior. Because a person’s job is very important to him or her—often as a part of self-
esteem and as a means of livelihood—disciplining or taking away a person’s job is a very
serious action and should not be undertaken lightly. The manager can implement several
strategies to increase the likelihood that discipline will be fair and produce growth.
The first strategy the manager must use is to thoroughly investigate the situation that has
prompted the employee discipline. A supervisor must investigate all allegations of misconduct
even if the misconduct is anonymously reported or initially appears to have no basis.
The manager might ask the following questions: Was the rule clear? Did this employee
know that he or she was breaking a rule? Is culture a factor in this rule-breaking? Has this
employee been involved in a situation like this before? Was he or she disciplined for this
behavior? What was his or her response to the corrective action? How serious or potentially
serious is the current problem or infraction? Who else was involved in the situation? Does
vulgar. You recognize that this is fairly normal behavior in a patient with a head injury, but
yesterday morning, his behavior was so offensive to his neurosurgeons that one of them
threatened to wash his mouth out with soap.
after both night nurses leave the unit, you receive a phone call from the house night supervisor
who relates the following information: When the supervisor made the usual rounds to the neuro
unit, Nurse caldwell was on a coffee break and Nurse Jones was in the unit with two licensed
vocational nurses/licensed professional nurses. Nurse Jones reported that Nurse caldwell
became very upset with the head-injury patient because of his abusive and vulgar language
and had taped his mouth shut with a 4” piece of adhesive tape. Nurse Jones had observed the
behavior and had gone to the patient’s bedside and removed the piece of tape and suggested
that Nurse caldwell go get a cup of coffee.
the supervisor observed the unit several times following this, and nothing else appeared to be
remiss. stating that no harm had come to the patient, Nurse Jones was reluctant to report the
incident but believed that perhaps one of the supervisors should counsel Nurse caldwell. You
thank the night supervisor and consider the following facts in this case:
● Nurse caldwell has been an excellent nurse but is occasionally judgmental.
● Nurse caldwell is a very religious young woman and has led a rather sheltered life.
● taping a patient’s mouth with a 4” piece of adhesive tape is very dangerous, especially for
someone with questionable chest and abdominal injuries and neurologic injuries.
● Nurse caldwell has never been reprimanded before.
You call the physician and explain what happened. the physician believes that no harm was
done and agrees with you that it is up to you whether to discipline the employee and to what
degree. However, the physician believes that most of the medical staff would want the nurse
fired.
You phone the nurse and arrange for a conference with her. she tearfully admits what she did.
she states that she lost control. she asks you not to fire her, although she agrees this is a
dischargeable offense. You consult with the administration, and everyone agrees that you should
be the one to decide the disciplinary action in this case.
Assignment: decide what you would do. You have a duty to your patients, the hospital, and
your staff. List at least four possible courses of action. select from among these choices, and
justify your decision.

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 605
this employee have a history of other types of disciplinary problems? What is the quality of
this employee’s performance in the work setting? Have other employees in the organization
also experienced the problem? How were they disciplined? Could there be a problem with
the rule or policy? Were there any special circumstances that could have contributed to the
problem in this situation? What disciplinary action is suggested by organization policies for
this type of offense? Has precedent been established? Will this type of disciplinary action
keep the infraction from recurring? The wise manager will ask all these questions so that a
fair decision can be reached regarding an appropriate course of action.
Another strategy that the manager should use is to always consult with either a superior
or the human resources department before dismissing an employee. Most organizations
have very clear policies about which actions constitute grounds for dismissal and how that
dismissal should be handled. To protect themselves from charges of willful or discriminatory
termination, managers should carefully document the behavior that occurred and any attempts
to counsel the employee. Managers also must be careful not to discuss with one employee
the reasons for discharging another employee or to make negative comments about past
employees, which may discourage other employees or reduce their trust in the manager.
Performance Deficiency Coaching
Performance deficiency coaching is another strategy that the manager can use to create a
disciplined work environment. This type of coaching may be ongoing or problem-centered.
Problem-centered coaching is less spontaneous and requires more managerial planning than
ongoing coaching. In performance deficiency coaching, the manager actively brings areas of
unacceptable behavior or performance to the attention of the employee and works with him or
her to establish a plan to correct deficiencies. Because the role of a coach is less threatening
than that of an enforcer, the manager becomes a supporter and helper. Performance deficiency
coaching helps employees, over time, to improve their performance to the highest level
of which they are capable. As such, the development, use, and mastery of performance
deficiency coaching should result in improved performance for all. The scenario depicted in
Display 25.4 is an example of performance deficiency coaching.
Coach: i am concerned that you have been regularly coming into report late. this interrupts the other
employees who are trying to hear report and creates overtime because the night shifts must stay
and repeat report on the patients you missed. it also makes it difficult for your modular team mem-
bers to prioritize their plan of care for the day if the entire team is not there and ready to begin at
0700. Why is this problem occurring?
Employee: i’ve been having problems lately with an unreliable babysitter and my car not starting. it
seems like it’s always one thing or another, and i’m upset about not getting to work on time, too.
i hate starting my day off behind the eight ball.
Coach: this hospital has a long-standing policy on attendance, and it is one of the criteria used to
judge work performance on your performance appraisal.
Employee: Yes, i know. i’m just not sure what i can do about it right now.
Coach: What approaches have you tried in solving these problems?
Employee: Well, i’m buying a new car, so that should take care of my transportation problems. i’m
not sure about my babysitter, though. she’s young and not very responsible, so she’ll call me at
the last minute and tell me she’s not coming. i keep her, though, because she’s willing to work
the flexible hours and days that this job requires, and she doesn’t charge as much as a formal
daycare center would.
Coach: do you have family in the area or close friends you can count on to help with childcare on
short notice?
DISPLAY 25.4 Performance Deficiency Coaching Scenario
(Continued )
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606 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
The Disciplinary Conference
When coaching is unsuccessful in modifying problem behavior, the manager must take more
aggressive steps and use more formal measures, such as a disciplinary conference. After
thoroughly investigating an employee’s offenses, managers must confront the employee with
their findings. This occurs in the form of a disciplinary conference. The following steps are
generally part of the disciplinary conference.
Reason for Disciplinary Action
Begin by clearly specifying why the employee is being disciplined. The manager must not be
hesitant or apologetic. The role of the manager includes authority. Despite the assignment of
Employee: Yes, my mother lives a few blocks away and is always glad to help, but i couldn’t count
on her on a regular basis.
Coach: there are employment registry lists at the local college for students interested in providing
childcare. Have you thought about trying this option? Often, students can work flexible hours and
charge less than formal daycare centers.
Employee: that’s a good idea. in fact, i just heard about a childcare referral service that also could
give me a few ideas. i’ll stop there after work. i realize that my behavior has affected unit function-
ing, and i promise to try to work this out as soon as possible.
Coach: i’m sure these problems can be corrected. Let’s have a follow-up visit in 2 weeks to see
how things are going.
LEARNING EXERCISE 25.4
Writing a Performance Deficiency Coaching Plan
You are the professional staff coordinator of a small emergency-care clinic. Historically, the
clinic is busiest on weekend evenings when most drunk-driving injuries, stabbings, and gunshot
wounds occur. Many also come to the clinic on weekends to take care of nonemergency
medical needs that were not addressed during regular physician office hours. Jane has been an
RN at the clinic since it opened 2 years ago. she is well liked by all the employees and provides
a sense of humor and lightheartedness in what is usually a highly stressful environment.
Jane has a reputation for being a “party animal.” she is known to begin partying after work on
Friday night and close down the bars saturday morning. during the last 3 months, Jane has
called in sick five of the seven saturday evenings that she was scheduled to work. the other
employees have worked understaffed on what is generally the busiest night of the week, and
they are becoming angry. they have asked you to talk to Jane or to staff an additional employee
on those saturday evenings that Jane is assigned to work.
Assignment: You have decided to begin performance deficiency coaching with Jane. Write a
possible coaching scenario that includes the following:
● the problem stated in behavioral terms
● an explanation to the employee of how the problem is related to organizational functioning
● a clear statement of the possible consequences of the unwanted behavior
● a request for input from the employee
● employee participation in the problem solving
● a plan for follow-up on the problem
Disciplinary problems, if unrecognized or ignored, generally do not go away; they only get worse.

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 607
authority, novice managers often feel uncomfortable with the disciplinary process and may
provide unclear or mixed messages to the employee regarding the nature or seriousness of a
disciplinary problem. A major responsibility in this role is evaluating employee performance
and suggesting appropriate action for improved or acceptable performance.
In the disciplinary conference, managers must assume the authority given to them by their role.
Levoy (2012) notes, however, that great caution should be used in suggesting the problem is
an employee’s “attitude” since this presumes the manager can read the mind of the problem
employee. Instead, focus on the behaviors that are measurable and specific that provide
evidence of that attitude.
Employee’s Response to Action
Give the employee the opportunity to explain why the rule was not followed. Allowing
employees feedback in the disciplinary process ensures them recognition as human beings.
It also reassures them that your ultimate goal is to be fair and promote their growth.
Rationale for Disciplinary Action
Explain the disciplinary action that you are going to take and why you are going to take it.
Although the manager must keep an open mind to new information that may be gathered
in the second step, preliminary assessments regarding the appropriate disciplinary action
should already have been made. This discipline should be communicated to the employee.
The employee who has been counseled at previous disciplinary conferences should not be
surprised at the punishment, as it should have been discussed at the last conference.
Clarification of Expectations for Change
Describe the expected behavioral change and list the steps needed to achieve this change.
Explain the consequences of failure to change. Again, do not be apologetic or hesitant;
otherwise, the employee will be confused about the seriousness of the issue. Because they
may lack self-control, employees who have repeatedly broken rules need firm direction.
It must be very clear to the employee that timely follow-up will occur.
Agreement and Acceptance of Action Plan
Get agreement and acceptance of the plan. Give support, and let the employee know that you
are interested in him or her as a person. Remember too that the leader-manager administers
discipline to promote employee growth rather than to impose punishment. Although the
expected standards must be very clear, leaders impart a sense of genuine concern for and
desire to help the employee grow. This approach helps the employee to recognize that the
discipline is directed at the offensive behavior and not at the individual. The leader must be
cautious, however, not to relinquish the management role in an effort to nurture and counsel.
The leadership role is to provide a supportive environment and structure so that the employee
can make the necessary changes.
Besides understanding what should be covered in the disciplinary conference, the leader
must be sensitive to the environment in which discipline is given. Although the employee
must receive feedback about his or her rule-breaking or inappropriate behavior as soon as
possible after it has occurred, the manager should implement discipline privately, never
in front of patients or peers. If more than an informal admonishment is required, the
manager should inform the employee of the unacceptable action, and then schedule a formal
disciplinary conference later.
All discipline, even informal admonishments, should be conducted in private.
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608 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
All formal disciplinary conferences should be scheduled in advance at a time agreeable
to both the employee and the manager. Both will want time to reflect on the situation that
has occurred. Allowing time for reflection should reduce the situation’s emotionalism and
promote employee self-discipline, because employees often identify their own plan for
keeping the behavior from recurring.
In addition to privacy and advance scheduling, the length of the disciplinary conference
is important. It should not be so long that it degenerates into a debate, nor so short that both
the employee and the manager cannot provide input. If the employee seems overly emotional
or if great discrepancies exist between the manager and the employee’s perceptions, an
additional conference can be scheduled. Employees often need time to absorb what they have
been told and to develop a plan that is not defensive.
Clearly, identifying the need for and conducting disciplinary conferences can be as stressful
for the manager as it is for the employee, especially when the unit manager is relatively new or
inexperienced in this role. Research conducted by O’donnell, Livingston, and Bartram (2012)
underscores the emotional component experienced by frontline managers in addressing
performance deficits and disciplining employees (Examining the Evidence 25.1).
Source: O’donnell, D. M., Livingston, P. M., & Bartram, T. (2012). Human resource management activities on the front
line: A nursing perspective. contemporary Nurse: a Journal for the australian Nursing Profession, 41(2), 198–205.
Purposive sampling was used to recruit two groups of nurses from one acute hospital within Eastern
Health, the second largest public health service located in Victoria, Australia. Group 1 consisted of
nurse unit managers employed within the role for a minimum of 4 weeks. Group 2 consisted of five
Ward/Unit nursing staff who had worked a minimum of 6 months, to see if those issues identified by
the nurse unit managers were also experienced by those staff who reported directly to them. Overall,
nine managers participated in the first focus group and five RNs participated in the second.
Two prominent themes emerged as the key human resource management challenges facing
the unit managers in their everyday practice. The first was the management of staff behaviors
requiring disciplinary intervention, and the second, retention of staff through staff satisfaction.
Participants described a variety of behaviors and actions displayed by nursing staff and groups
of nursing staff that required some form of disciplinary action to be commenced by the front-
line manager. These behaviors included arriving late to work, manipulation, threats, underperfor-
mance, general negativity, bitterness, inappropriate comments/actions, and excluding individual
staff nurses from group factions. In some cases, and complicating efforts to modify behavior, the
erring behavior was influenced by mental illness and/or substance abuse. All of these behaviors
were perceived as placing colleagues and patients at risk.
The term “performance management” was used by participants to describe a range of disci-
plinary activities aimed at modifying or eliminating problem behavior. The process of performance
management was described by the unit managers as “long” and “tedious,” an “endless” process
that is drawn out over months with an unsatisfactory resolution that tends to benefit the individual
at the expense of their colleagues. This intensive process was often complicated by the inclusion
of union representation at the request of the erring nurse.
Nurse unit managers recognized that they undertook human resource issues, such as per-
formance management “well some days and not others.” The dependent variables included “the
baggage [the nurse manager] you bring to work” and their exposure and experience within the
role. It was noted that the most junior unit manager felt that as a result of her inexperience, she
was perceived as a target by some of the staff with strong and challenging behaviors.
The researchers concluded that future frontline management development opportunities
should address the foundational knowledge and skill deficits experienced by nurse-managers
prior to or during the transition from clinician to manager. Special attention should be paid to the
process of managing undesirable behaviors displayed by staff nurses and developing strategies
to assist unit managers to cope with stressors experienced during disciplinary interventions.
Examining the Evidence 25.1

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 609
The Termination Conference
At times, the disciplinary conference must be a termination conference. Although many of the
principles are the same, the termination conference differs from a disciplinary conference in
that planning for future improvement is eliminated. The following steps should be followed
in the termination conference:
1. Calmly state the reasons for dismissal. The manager must not appear angry or
defensive. Although managers may express regret that the outcome is termination of
employment, they must not dwell on this or give the employee reason to think that the
decision is not final. The manager should be prepared to give examples of the behavior
in question.
2. Explain the employment termination process. State the date on which employment is
terminated as well as the employee’s and organization’s role in the process.
3. Ask for employee input. Termination conferences are always tense; raw, spontaneous,
emotional reactions are common. Listen to the employee, but do not allow yourself to
be drawn emotionally into his or her anger or sorrow. Always stay focused on the facts
of the case and attempt to respond without reacting.
4. End the meeting on a positive note, if possible. The manager should also inform the
employee what, if any, references will be supplied to prospective employers. Finally, it
is usually best to allow the employee who has been dismissed to leave the organization
immediately. If the employee continues to work on the unit after dismissal has been
discussed, it can be demoralizing for all the employees who work on that unit.
TRANSFERRING THE PROBLEM EMPLOYEE
A transfer may be defined as a reassignment to another job within the organization. In a strict
business sense, a transfer usually implies similar pay, status, and responsibility. Because of
the variety of positions available for nurses in any health-care organization, coupled with the
lack of sufficient higher-level positions available, two additional terms have come into use:
lateral transfer and downward transfer.
A lateral transfer describes one staff person moving to another unit, to a position with a
similar scope of responsibilities, within the same organization. A downward transfer occurs
when someone takes a position within the organization that is below his or her previous level.
It may be in a nurse’s interest to consider a downward transfer because it can increase the
chances of long-term career success.
Downward transfers also should be considered when nurses are experiencing periods of
stress or role overload. Self-aware nurses often request such transfers. In some circumstances,
the manager may need to intervene and use a downward transfer to alleviate temporarily
a nurse’s overwhelming stress. Another type of downward transfer may accommodate
employees in the later stages of their career. In many cases, valued employees who wish to
reduce their career roles may be accommodated by a manager’s assistance with locating a
suitable position for their talent and stature in the profession.
Managers often assist valuable employees who desire a reduced role in their careers to locate a
position that will use their talents and still allow them a degree of status.
These accommodating transfers generally allow someone to receive a similar salary but with
a reduction in energy expenditure. For example, a long-time employee might be given a
position as ombudsman to use his or her expertise and knowledge of the organization and at
the same time assume a status position that is less physically demanding.
Finally, there is the inappropriate transfer. Some managers solve unit personnel problems
by transferring problem employees to another unsuspecting department. Such transfers are
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610 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
harmful in many ways. They contribute to decreased productivity, are demotivating for all
employees, and are especially destructive for the employee who is transferred.
This is not to say that employees who do not “fit” in one department will not do well in a
different environment. Before such transfers, however, both the manager and the employee
must speak candidly regarding the employee’s capabilities and the manager’s expectations.
All types of transfers should be individually evaluated for appropriateness.
It is not uncommon for an employee to struggle in one department yet improve his or her
performance in a new department or unit.
GRIEVANCE PROCEDURES
Growth can only occur when employees perceive that feedback and discipline are fair and
just. When employees and managers perceive “fair” and “just” differently, the discrepancy
can usually be resolved by a more formal means called a grievance procedure. The grievance
procedure is essentially a statement of wrongdoing or a procedure to follow when one believes
that a wrong has been committed. This procedure is not limited to resolving discipline
discrepancies; employees can use it any time they believe that they have not been treated fairly
by management. This chapter, however, focuses specifically on grievances that result from the
disciplinary process. Most grievances or conflicts between employees and management can
be resolved informally through communication, negotiation, compromise, and collaboration.
Generally, even informal resolution has well-defined steps that should be followed.
Formal Process
If the employee and management cannot resolve their differences informally, a formal
grievance process begins. The steps of the formal grievance process are generally outlined
in all union contracts or administrative policy and procedure manuals. Generally, these steps
include the progressive lodging of formal complaints up the chain of command. If resolution
does not occur at any of these levels, a formal hearing is usually held. A group of people is
impaneled—much in the same way as a jury—to make a determination of what should be
done. Such groups are often at risk for favoring the individual employee over the all-powerful
institution. This tendency reinforces the need for the manager to have clear, objective, and
comprehensive written records regarding the problem employee’s behavior and attempts to
counsel.
Arbitration
If the differences cannot be settled through a formal grievance process, the matter may
finally be resolved in a process known as arbitration. In arbitration, both sides agree on the
selection of a professional mediator who will review the grievance, complete fact-finding,
and interview witnesses before coming to a decision.
Although grievance procedures extract a great deal of time and energy from both
employees and managers, they serve several valuable purposes. Grievance procedures can
settle some problems before they escalate into even larger ones. The procedures are also
a source of data to focus attention on ambiguous contract language for labor–management
negotiation at a later date.
Perhaps the most important outcome of a grievance is the legitimate opportunity that it provides
for employees to resolve conflicts with their superiors.
Employees who are not given an outlet for resolving work conflicts become demoralized,
angry, and dissatisfied. These emotions affect unit functioning and productivity. Even if the

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 611
outcome is not in the favor of the person filing the grievance, the employee will know that
the opportunity was given to present the case to an objective third party, and the chances of
constructive conflict resolution are greatly increased. In addition, managers tend to be fairer
and more consistent when they know that employees have a method of redress for arbitrary
managerial action.
Rights and Responsibilities in Grievance Resolution
Employees and managers have some separate and distinct rights and responsibilities in
grievance resolution, but many rights and responsibilities overlap. Although it is easy to
be drawn into the emotionalism of a grievance that focuses on one’s perceived rights, the
manager and employee must remember that they both have rights and that these rights have
concomitant responsibilities. For example, although both parties have the right to be heard,
both parties are equally responsible to listen without interrupting. The employee has the
right to a positive work environment but has the responsibility to communicate needs and
discontent to the manager. The manager has the right to expect a certain level of productivity
from the employee but has the responsibility to provide a work environment that makes
this possible. The manager has the right to expect employees to follow rules but has the
responsibility to see that these rules are clearly communicated and fairly enforced.
Both the manager and the employee must show goodwill in resolving grievances. This
means that both parties must be open to discussing, negotiating, and compromising and must
attempt to resolve grievances as soon as possible. The ultimate goal of the grievance should
not be to win but to seek a resolution that satisfies both the person and the organization.
In many cases, the manager can eliminate or reduce his or her risk of being involved
in a grievance by fostering a work environment that emphasizes clear communication and
fair, constructive discipline. Employees can also eliminate or reduce their risk of being
involved in a grievance by being well informed about the labor contract, policies and
procedures, and organizational rules. If both the employee and the employer recognize their
rights and responsibilities, the incidence of grievances in the workplace should decrease.
When mutual problem-solving, negotiation, and compromise are ineffective at resolving
conflicts, the grievance process can provide a positive and growth-producing resolution to
disciplinary conflict.
DISCIPLINING THE UNIONIZED EMPLOYEE
It is essential that all managers be fair and consistent in disciplining employees regardless
of whether a union is present. The presence of a union does, however, usually entail more
procedural, legalistic safeguards in administering discipline and a well-defined grievance
process for employees who believe that they have been disciplined unfairly. Usually, the
manager of nonunionized employees has greater latitude in selecting which disciplinary
measure is appropriate for a specific infraction. Although this gives the manager more
flexibility, discipline among employees may be inconsistent.
On the other hand, unionized employees generally must be disciplined according to
specific, preestablished steps and penalties within an established time frame. For example,
the union contract may be very clear that excessive unexcused absences from work must be
disciplined first by a written reprimand, then a 3-day work suspension, and then termination.
This type of discipline structure is generally fairer to the employee but allows the manager
less flexibility in evaluating each case’s extenuating circumstances.
Another aspect of discipline that may differ between unionized and nonunionized
employees is following due process in disciplining union employees. Due process means that
management must provide union employees with a written statement outlining disciplinary
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612 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
charges, the resulting penalty, and the reasons for the penalty. Employees then have the right
to defend themselves against such charges and to settle any disagreement through formal
grievance hearings.
Another difference between unionized and nonunionized employee discipline lies in
the burden of proof, which typically is the responsibility of the employee without union
membership but is the responsibility of the manager of the employee who belongs to a
union. This means that managers who discipline union employees must keep detailed records
regarding misconduct and counseling attempts.
In disciplinary situations with nonunionized employees, the burden of proof typically falls on
the employee. With union employees, the burden of proof for the wrongdoing and need for
subsequent discipline falls on management.
Another common difference between unionized and nonunionized employees is that most
nonunion employees are classified as at-will, meaning that they are subject to dismissal
“at the will” of the employer. The at-will doctrine, which is applicable in many states,
permits an employer to terminate employment for any or no reason and at the discretion
of the supervisor. In states that do not subscribe to the employment-at-will doctrine or in
organizations that have union representation for employees, employers must have good and
legal cause to dismiss an employee.
It must be noted, however, that even when the employment-at-will doctrine is applicable,
there are numerous exceptions, and an employer must be knowledgeable of each exception.
Such exceptions where at-will dismissal would not apply might include when employment
is being terminated based on membership in a protected legal group such as race, sex,
pregnancy, national origin, religion, disability, age, or military status.
The contract language used by unions regarding discipline may be quite specific or quite
general. Most contracts recognize the right of management to discipline, suspend, or dismiss
employees for just cause. Just cause can be defined as having appropriate rationale for the
actions taken. For just cause to exist, the manager must be able to prove that the employee
violated established rules, that corrective action or penalty was warranted, and that the
penalty was appropriate for the offense. These contracts also generally recognize the right of
the employee to submit grievances when he or she believes that these actions have been taken
unfairly or are discriminatory in some way.
Managers are responsible for knowing all union contract provisions that affect how
discipline is administered on their units. Managers also should work closely with others
employed in human resources or personnel positions in the organization. These professionals
generally prove to be invaluable resources in dealings with union employees.
THE MARGINAL EMPLOYEE
Marginal employees are another type of problem employee; however, traditional discipline is
generally not constructive in modifying their behavior. This is because marginal employees
often make tremendous efforts to meet competencies yet usually manage to meet only
minimal standards at best. All organizations have at least a few such employees. Managing
these employees then is often a frustrating and tiring task.
Marginal employees usually do not warrant dismissal, but they contribute very little to overall
organizational efficiency.
Managers typically try multiple strategies to deal with marginal employees. One common
strategy is simply to transfer the employee to another department, section, or unit. Although

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 613
some marginal employees may be more successful on one unit than another, more commonly,
the problem is simply transferred from one unit to another, and the marginal employee
experiences yet another failure.
Other managers choose to dismiss marginal employees or attempt to talk them into early
retirement or resignation. Again, this does little to help the marginal employee succeed.
Other managers simply choose to ignore the problem and attempt to “work around” the
employee. This is not always possible, however, and the end result is frequently resentment
from coworkers who have to carry the burden of finishing work the marginal employee was
unable to accomplish.
The most time-intensive option in dealing with marginal employees is coaching. With
this strategy, the manager attempts to improve the marginal employee’s performance through
active coaching and counseling. While this strategy holds the greatest promise for personal
growth in the marginal employee, there is no guarantee that the employee’s performance will
improve or that the end results will justify the time and energy costs to the manager. The
strategy chosen for dealing with the marginal employee often varies with the level of the
manager. Ignoring the problem is a passive response and is more frequently used by low-
level managers. High-level managers tend to employ the more active measures of coaching,
transferring, and dismissal.
The nature of the organization also plays a role in determining what strategy is used to
deal with the marginal employee. Government-controlled organizations are more likely to use
passive measures, whereas managers in nongovernmental organizations are more likely to
use active measures. The size of the organization also influences how managers deal with the
marginally productive employee. In larger organizations, the trend has been toward passive
managerial coping strategies with marginal employees.
It is important for the manager to remember that each person and situation is different and
that the most appropriate strategy depends on many variables. Looking at past performance
will help determine if the employee is tired, needs educational or training opportunities, is
unmotivated, or just has very little energy and only marginal skills for the job. If the latter is
true, then the employee may never become more than a marginal employee, no matter what
management functions and leadership skills are brought into play.
Learning Exercise 25.5, which has been solved for the reader (see Appendix), depicts
alternatives that managers may consider in dealing with the marginal employee.
LEARNING EXERCISE 25.5
The Marginal Employee
You are the oncology supervisor in a 400-bed hospital. there are 35 beds on your unit that are
usually full. it is an extremely busy unit, and your nursing staff needs high-level assessment and
communication skills for providing patient care. Because the nursing care needs on this floor
are unique and because you use primary nursing, it has been very difficult in the past to float
staff from other units when additional staffing has been required. although you have been able
to keep the unit adequately staffed on a day-to-day basis, there are two open positions for RNs
on your unit that have been unfilled for almost 3 months.
Historically, your staff members have been excellent employees. they enjoy their work and are
highly productive. Unit morale has been exceptionally good. However, in the last 3 months, the
staff has begun complaining about Judy, a full-time employee who has been with the unit for
about 4 months. Judy has been an RN for approximately 15 years and has worked in oncology
(Continued )
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614 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
THE CHEMICALLY IMPAIRED EMPLOYEE
Substance misuse involves maladaptive patterns of psychoactive substance abuse, with the
substance user continuing use in the face of recurrent occupational, social, psychological
or physical problems, and/or dangerous situations. Effective management demands that the
organization takes an active role in ensuring patient safety by immediately removing these
employees from the work setting. However, managers also have a responsibility to help these
employees deal with their disease so that they can return to the workforce in the future as
productive employees.
Nursing administrators may face no management problem more costly or emotionally draining
than that of nurses whose practice is impaired by substance abuse or psychological dysfunction.
Modlin and Montes (1964) first documented chemical dependency in the health professions
in studies in the late 1940s, although Monroe (2009) suggests the public recognition of
chemical impairment in nursing profession did not even really begin until 1980, when the
National Nurses Society of Addictions established a task force on addiction. Despite this
relatively recent examination of the problem of substance abuse in nursing, there is little
doubt that chemical dependency has been around as long as alcohol and drugs.
The exact magnitude of chemical impairment in nursing is not known and estimates
vary widely, but a review of the literature suggests that somewhere between 8% and 16%
of all nurses are chemically impaired. In addition, the chemical impairment rate of health
professionals is generally acknowledged as being greater than that of the general public.
Scimeca (2008) suggests that a conservative estimate is that one in ten nurses will develop
a problem with drugs and/or alcohol within their lifetime and that the prevalence may be
double that. She notes that given the millions of nurses licensed in the United States alone,
even the lower assessment of 10% represents nearly 500,000 individuals. If one were to
calculate this number on an annual basis over a 70-year span, this would mean that more than
7,000 nurses cross an invisible line into what often becomes a very visible problem each year
in this country (Scimeca). Heacock (2013) adds that while the risk of addiction is not limited
to any one specialty, the specialties with the highest prevalence of substance abuse uses are
intensive care unit, emergency room, operating room, and anesthesia.
Talbert (2009) suggests that several factors have been identified as increasing the risk of
substance abuse in nurses, including a family history of emotional impairment, alcoholism,
units at other facilities. References from former employers identified Judy’s work as competent,
although little other information was given. at Judy’s 6-week and 3-month performance
appraisals, you coached her regarding her barely adequate work habits, assessment and
communication skills, and decision-making. Judy responded that she would attempt to work on
improving her performance in these areas because working with this unit was one of her highest
career goals.
although Judy has been receptive to your coaching and has verbalized to you her efforts to
improve her performance, there has been little observable difference in her behavior. You have
slowly concluded that Judy is probably currently working at the highest level of her capability
and that she is a marginal employee at best. the other nurses believe that Judy is not carrying
her share of the workload and have asked that you remove her from the unit.
Assignment: Use the traditional problem-solving process to help you resolve this issue.
compare your solution to the one in appendix.

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 615
drug use, or emotional abuse, resulting in low self-esteem, overwork, and overachievement.
This family history is significant since being in an environment with dependent family
members may lead to enabling behaviors, often described as “helping” behaviors. Research
by Dittman (2012) concurs, suggesting that having experienced physical or emotional abuse
during their formative years was a common finding in male nurses who developed substance
abuse problems. These nurses reported chaotic environments in childhood in the form of
maltreatment, neglect, denial, and enabling behavior that resulted in an unstable lifestyle.
Stress in the workplace is another reason cited for nurses abusing substances, since
overtime, floating, rotating shifts, and workplace bullying can contribute to stress, fatigue,
and feelings of alienation (Talbert). Substance use may be one way of coping. Again,
research by Dittman (2012) supports these assertions in that substance abusing male nurses
reported a need to cover up stress and sensation-seeking behaviors related to medication
diversion. Similarly, Heacock (2013) suggests that long hours and stress related to caring
for the sick and dying as well as easy access to medications increase the risk of addiction
in nursing.
One difference, however, between chemically impaired health professionals and other
addicts is that chemically impaired nurses and physicians tend to obtain their drugs of choice
through channels such as legitimate prescriptions that were written for them or diversionary
measures on the job rather than purchasing them illegally on the street. Since nurses have
greater access to undiverted medications (colleagues write prescriptions or prescriptions are
forged) and since they are highly experienced in administering medications to others, they
sometimes erroneously believe that they have the ability to control their own medication use
(Talbert, 2009).
Despite narcotic-dispensing machines, introduced to reduce the diversion of these
drugs, workplace theft has been identified as the most frequent source of illegally obtained
narcotics. Indeed, one nurse who surrendered her license after being investigated by the
Board of Nursing for an addiction to prescription drugs suggested that “In nursing school
they really should warn you that you’re going to have a buffet of narcotics at your hands
that’s part of your job” (Jorgensen, 2013, para 3). In fact, the majority of disciplinary actions
by licensing boards are related to misconduct resulting from chemical impairment including
the misappropriation of drugs for personal use and the sale of drugs and drug paraphernalia
to support an addiction (Lillibridge, 2014).
Although alcohol is the most frequently abused substance, meperidine (Demerol) is a
common drug of choice, while oxycodone (OxyContin) and clonazepam (Klonopin) are
increasing in popularity (National Institute on Drug Abuse, 2013). Other frequently abused
chemicals include benzodiazepines such as diazepam (Valium) and narcotic drugs such as
morphine and pentazocine (Talwin). Barbiturates may replace alcohol in the workplace so
that the employee may feel a similar effect without having alcohol detectable on their breath.
RECOGNIZING THE CHEMICALLY IMPAIRED EMPLOYEE
Although most nurses have finely tuned assessment skills for identifying patient problems,
they may be less sensitive to behaviors and actions that may signify chemical impairment in
their coworkers. Sensitivity to others and to the environment is a leadership skill. The profile
of the impaired nurse may vary greatly, although several behavior patterns and changes
are noted frequently. These behavior changes can be grouped into three primary areas:
personality/behavior changes, job performance changes, and time and attendance changes.
Display 25.5 shows characteristics of these categories.
As the employee progresses into chemical dependency, managers can more easily
recognize these behaviors. Typically, in the earliest stages of chemical dependency, the
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616 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
employee uses the addictive substance primarily for pleasure, and although the alcohol or
drug use is excessive, it is primarily recreational and social. Thus, substance use usually does
not occur during work hours, although some secondary effects of its use may be apparent.
As chemical dependency deepens, the employee develops tolerance to the chemical
and must use greater quantities more frequently to achieve the same effect. At this point,
the person has made a conscious lifestyle decision to use chemicals. There is a high use
of defense mechanisms, such as justifying, denying, and bargaining about the drug. Often,
the employee in this stage begins to use the chemical substance both at and away from
work. Work performance generally declines in the areas of attendance, judgment, quality,
and interpersonal relationships. An appreciable decline in unit morale, resulting from an
unreliable and unproductive worker, becomes apparent.
In the final stages of chemical dependency, the employee must continually use the
chemical substance, even though he or she no longer gains pleasure or gratification.
Physically and psychologically addicted, the employee generally harbors a total disregard for
self and others. Because the need for the substance is so great, the employee’s personal and
professional lives focus on the need for drugs, and the employee becomes unpredictable and
CHANGES IN PERSONALITY OR BEHAVIORS
l increased irritability with patients and colleagues, often followed by extreme calm
l social isolation; eats alone, avoids unit social functions
l extreme and rapid mood swings
l euphoric recall of events or elaborate excuses for behaviors
l Unusually strong interest in narcotics or the narcotic cabinet
l sudden dramatic change in personal grooming or any other area
l Forgetfulness ranging from simple short-term memory loss to blackouts
l change in physical appearance, which may include weight loss, flushed face, red or bleary eyes,
unsteady gait, slurred speech, tremors, restlessness, diaphoresis, bruises and cigarette burns,
jaundice, and ascites
l extreme defensiveness regarding medication errors
CHANGES IN JOB PERFORMANCE
l difficulty meeting schedules and deadlines
l illogical or sloppy charting
l High frequency of medication errors or errors in judgment affecting patient care
l Frequently volunteers to be medication nurse
l Has a high number of assigned patients who complain that their pain medication is ineffective in
relieving their pain
l consistently meeting work performance requirements at minimal levels or doing the minimum
amount of work necessary
l Judgment errors
l sleeping or dozing on duty
l complaints from other staff members about the quality and quantity of the employee’s work
CHANGES IN ATTENDANCE AND USE OF TIME
l increasingly absent from work without adequate explanation or notification; most frequent
absence on a Monday or Friday
l Long lunch hours
l excessive use of sick leave or requests for sick leave after days off
l Frequent calling in to request compensatory time
l arriving at work early or staying late for no apparent reason
l consistent lateness
l Frequent disappearances from the unit without explanation
DISPLAY 25.5 Characteristic Changes in Chemically Impaired Employees

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 617
undependable in the work area. Assignments are incomplete or not done at all, charting may
be sloppy or illegible, and frequent judgment errors occur. Because the employee in this stage
must use drugs frequently, signs of drug use during work hours may be seen. Narcotic vials
are missing. The employee may be absent from the unit for brief periods with no plausible
excuse. Mood swings are excessive, and the employee often looks physically ill.
Research by Dittman (2012, p. 37) concurs, noting that substance abusing male nurses
reported that access to medications at this point in their life became a driving force. “Their
guiding principles of lying, hiding, denying, diverting, and manipulating affected their
families, peers, patients, and profession. Their motivation to continue the competent nurse
appearance was based on the underlying concern of how this would affect their lives, not how
it would affect others.” In addition, addiction clouded their professional compasses since no
need was greater than the need for chemical substances (Dittman).
The bottom line is that chemically impaired employees should be removed from the work
setting long before they reach this stage. The reality, however, is that the identification of
chemical impairment is often very difficult. Nursing school courses generally focus on the
physiological effects of alcohol and other drugs, dealing little with the psychological process of
addiction and even less with chemical dependency in nurses. Because of this limited knowledge
about chemical impairment, many nurses are ill-prepared to deal with chemical impairment.
Confronting the Chemically Impaired Employee
Unlike most alcoholics or IV narcotic users, health-care professionals do not achieve tacit
peer acceptance of their addictive behavior. Thus, physicians and nurses are much less likely
to admit, even to colleagues, that they are using—much less that they are addicted to—a
controlled substance. Frequently, they deny their chemical impairment even to themselves.
Indeed, research by Dittman (2012) found that none of the impaired male nurses in the study
self-reported their addiction; all were caught in either a medication audit or urine drug screen.
This self-denial is perpetuated because nurses and managers traditionally have been slow
to recognize and reluctant to help these colleagues. This is changing. All but a few state
boards of nursing now have treatment programs for nurses (discussed later in this chapter),
and as managers gain more information about chemical impairment, how to recognize it, and
how to intervene, more employees are being confronted with their impairment.
The first step in dealing with the chemically impaired employee actually occurs before the
confrontation process. In the data- or evidence-gathering phase, the manager collects as much
hard evidence as possible to document suspicions of chemical impairment in the employee.
All behavior, work performance, and time and attendance changes presented in the displays
in this chapter should be noted objectively and recorded in writing. If possible, a second
person should be asked to validate the manager’s observations. In suspected drug addiction,
the manager also may examine unit narcotic records for inconsistencies and check to see that
the amount of narcotic the nurse signed out for each patient is the same as the amount ordered
for that patient.
Because few nurses drink alcohol while on duty, managers have to observe for more subtle
clues, such as the smell of alcohol on the employee’s breath. If the organization’s policy
allows for it, the manager may wish to require an employee suspected of chemical impairment
to undergo immediate drug or alcohol testing. If the employee refuses to cooperate, the
organization’s policy for documenting and reporting this incident should be followed.
Proving alcohol impairment is often more difficult than detecting drug impairment, as an
employee can generally hide alcoholism more easily than drug addiction.
If at any time the manager suspects that an employee is chemically influenced and thus
presents a potential hazard to patient safety, the employee must be immediately removed from
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618 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
the work environment. The manager should decisively and unemotionally tell the employee
that he or she will not be allowed to return to the work area because of the manager’s
perception that the employee is chemically impaired. The manager should arrange for the
employee to be taken home so that he or she does not drive while impaired. A formal meeting
to discuss this incident should be scheduled within the next 24 hours.
This type of direct confrontation between the manager and the employee is the second
phase in dealing with the employee suspected of chemical impairment. Although some
employees admit their problem when directly confronted, many use defense mechanisms
(including denial) because they may not have admitted the problem to themselves. Indeed,
research conducted on nurses with a history of substance abuse suggests that chemically
dependent individuals often report becoming masterminds at manipulating all connections to
human and professional resources, including family, friends, professional peers, professional
superiors, and the rehabilitation process (Dittman, 2012).
Denial and anger should be expected in the confrontation. If the employee denies having
a problem, documented evidence demonstrating a decline in work performance should be
shared. The manager must be careful to keep the confrontation focused on the employee’s
performance deficits and not allow the discussion to be directed to the cause of the underlying
problem or addiction. These are issues and concerns that the manager is unable to address.
The manager also must be careful not to preach, moralize, scold, or blame.
Confrontation always should occur before the problem escalates too far. However, in
some situations, the manager may have only limited direct evidence but still may believe
that the employee should be confronted because of rapidly declining employee performance
or unit morale. There is, however, a greater risk that confrontation at this point may be
unsuccessful in terms of helping the employee. If direct confrontation is unsuccessful, it
may have been too early; the employee may not have been desperate enough or may still
be in denial. In these situations, job performance will probably continue to be marginal or
unsatisfactory, and progressive discipline may be necessary. If the employee continues to
deny chemical impairment and work performance continues to be unsatisfactory despite
repeated constructive confrontation, dismissal may be necessary.
The last phase of the confrontation process is outlining the organization’s plan or
expectations for the employee in overcoming the chemical impairment. This plan is similar to
the disciplinary contract in that it is usually written down and clearly outlines the rehabilitative
measures that should be undertaken by the employee and consequences if remedial action is
not sought. Although the employee is generally referred informally by the manager to outside
sources to help deal with the impairment, the employee is responsible for correcting his or her
work deficiencies. Timelines are included in the plan, and the manager and employee must
agree on and sign a copy of the contract.
LEARNING EXERCISE 25.6
The Chemically Impaired Colleague
Write a two-page essay that speaks to the following: Has your personal or professional life
been affected by a chemically impaired person? in what ways have you been affected? Has it
colored the way that you view chemical abuse and chemical impairment? do you believe that
you can separate your personal feelings about chemical abuse from the actions that you must
take as a manager in working with chemically impaired employees? Have you ever suspected
a work colleague of chemical abuse? What, if anything, did you do about it? if you did suspect
a colleague, would you approach him or her with your suspicions before talking to the unit
manager? describe the risks involved in this situation.

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 619
The Manager’s Role in Assisting the Chemically Impaired Employee
Clearly, the incidence of chemical impairment in health professionals is substantial. On a
personal level, a person suffers from an illness that may go undetected and untreated for
many years. On a professional level, the chemically impaired employee affects the entire
health-care system. Nurses with impaired skills and judgment jeopardize patient care. The
chemically impaired nurse also compromises teamwork and continuity as colleagues attempt
to pick up the slack for their impaired team member. The personal and professional cost of
chemical impairment demands that nursing leaders and managers recognize the chemically
impaired employee as early as possible and intervene.
Because of the general nature of nursing, many managers find themselves wanting to nurture
the impaired employee, much as they would any other person who is sick. However, this
nurturing can quickly become enabling. The employee who already has a greatly diminished
sense of self-esteem and a perceived loss of self-control may ask the manager to participate
actively in his or her recovery. This is one of the most difficult aspects of working with the
impaired employee. Others who have greater expertise and objectivity should assume this role.
The manager must be very careful not to assume the role of counselor or treatment provider for
the impaired nurse.
The manager also must be careful not to feel the need to diagnose the cause of the chemical
addiction or to justify its existence. Protecting patients must be the top priority, taking precedence
over any tendency to protect or excuse subordinates. The manager’s role is to clearly identify
performance expectations for the employee and to confront the employee when those expectations
are not met. This is not to say that the manager should not be humanistic in recognizing the
problem as a disease and not a disciplinary problem or that he or she should be unwilling to refer
the employee for needed help. Although the manager may suggest appropriate help or refer the
impaired employee to someone, a manager’s primary responsibility is to see that the employee
becomes functional again and can meet organizational expectations before returning to work.
The manager can play a vital role in creating an environment that decreases the chances
of chemical impairment in the work setting. This may be done by controlling or reducing
work-related stressors whenever possible and by providing mechanisms for employee
stress management. The manager also should control drug accessibility by implementing,
enforcing, and monitoring policies and procedures related to medication distribution. Finally,
the manager should provide opportunities for the staff to learn about substance abuse, its
detection, and available resources to help those who are impaired.
LEARNING EXERCISE 25.7
Working Under the Influence
there have been rumors for some time that Mrs. clark, one of the night nurses on the unit you
supervise, has been coming to work under the influence of alcohol. Fellow staff have reported
the odor of alcohol on her breath, and one staff member stated that her speech is often slurred.
the night supervisor states that she believes “this is not my problem,” and your night charge
nurse has never been on duty when Mrs. clark has shown this behavior. this morning, one of the
patients whispered to you that he thought Mrs. clark had been drinking when she came to work
last night. When you question the patient further, he states, “Mrs. clark seemed to perform her
nursing duties okay, but she made me nervous.” You have decided that you must talk with Mrs.
clark. You call her at her home and ask her to come to your office at 3 pm.
Assignment: determine how you are going to approach Mrs. clark. Outline your plan and
provide rationale for your choices. What flexibility have you built into your plan? How much of
your documentation will be shared with Mrs. clark?
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620 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
The Recovery Process
Although most authorities disagree on the name or number of steps in the recovery process,
they do agree that certain phases or progressive observable behaviors suggest that the person
is recovering from the chemical impairment. In the first phase, the impaired employee
continues to deny the significance or severity of the chemical impairment but does reduce
or suspend chemical use to appease family, peers, or managers. These employees hope to
reestablish their substance abuse in the future.
In the second phase, as denial subsides, the impaired employee begins to see that the
chemical addiction is having a negative impact on his or her life and begins to want to change.
Frequently, people in this phase are buoyant with hope and commitment but lack maturity
about the struggles they will face. This phase generally lasts for about 3 months.
During the third phase, the person examines his or her values and coping skills and works
to develop more effective coping skills. Frequently, this is done by aligning himself or herself
with support groups that reinforce a chemical-free lifestyle. In this stage, the person realizes
how sick he or she was in the active stage of the disease and is often fraught with feelings of
humiliation and shame.
In the last phase, people gain self-awareness regarding why they became chemically
addicted, and they develop coping skills that will help them deal more effectively with
stressors. As a result of this, self-awareness, self-esteem, and self-respect increase. When this
happens, the person can decide consciously whether he or she wishes to or should return to
the workplace.
State Board of Nursing Treatment Programs
Although chemical dependency can impair nurses’ physical, psychological, social, and
professional functioning, the problem was largely ignored until the late 1970s and early
1980s. Since that time, assistance occurs primarily in the form of diversion programs
(also called intervention or peer assistance programs). A diversion program is generally a
voluntary, confidential program for nurses whose practice may be impaired due to chemical
dependency or mental illness.
The goal of a diversion program is to protect the public by early identification of impaired
nurses and by providing these nurses access to appropriate intervention programs and
treatment services. Public safety is protected by immediate suspension of practice, when
needed, and by ongoing careful monitoring of the nurse. In addition to rehabilitating nurses
with chemical dependence, most diversion programs also serve nurses impaired by certain
mental illnesses such as anxiety, depression, bipolar disorder, and schizophrenia. Some
programs cover nurses with physical disabilities as well.
Several factors have led state boards to adopt diversion programs. First, a punitive system
creates barriers to reporting and keeps impaired nurses from getting help. Nurse colleagues or
practitioners who suspect a nurse is impaired may well hesitate to report something that could
cost a nurse his or her job and license. Monroe (2009) agrees, suggesting that coworkers
are more likely to intervene and report impairment when supportive alternative-to-dismissal
policies are in place. In addition, from an employer’s standpoint, the fear of litigation often
makes it easier to dismiss a nurse without charges of misconduct. But this practice leaves the
nurse, who is at risk for self-harm and for harming patients, free to seek work elsewhere. A
board investigation can take months to 2 years, during which time the nurse in question may
be able to continue working without restraint. Moving to another state will not, however,
allow the nurse to avoid disciplinary action and states typically consider this in granting
license reciprocity.
Diversion programs are voluntary and confidential. Besides helping the nurse with
recovery, the programs offer assistance to the employers and staff in coping with employee

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 621
substance abuse. Impaired nurses who refuse participation in diversion programs are
subject to disciplinary review by their state board of nursing and possible license
revocation. Nurse-leader-managers should advocate for those who are impaired so that
they receive appropriate assistance, treatment, and access to fair institutional and legal
processes.
The fear of being ostracized by their colleagues has kept many nurses from seeking help
even though they knew they were addicted to drugs. Indeed, negative and stigmatizing
attitudes continue to surround most individuals experiencing drug and alcohol dependency
and this is accentuated for the nursing professional, who is often held to an even higher
standard of behavior. Lillibridge (2014) suggests that while nursing is a profession known
for its caring nature toward others, we often fail to care for ourselves. She goes on to say
that employers must create positive work environments, know their employees so that
confrontation can occur early, increase awareness about substance abuse so that nurses are
not afraid to ask for help, ensure that an Impaired Practice Policy is in place, and provide a
process that facilitates reentry into practice following recovery.
LEARNING EXERCISE 25.8
Researching Your State Board of Nursing’s Recovery Program
determine if your state board of nursing offers some type of recovery program for chemically
impaired nurses and for mentally ill nurses. You may either call the board or use the internet.
Research the following questions:
● is the program voluntary and confidential?
● What is the rate of recidivism?
● What types of monitoring mechanisms are in place?
● What is the duration of the program?
● are nurses allowed to continue practicing while completing the treatment program?
● are there practice restrictions?
Assignment: Write a one-page report of your findings.
The Chemically Impaired Employee’s Reentry to the Workplace
Because chemically impaired nurses recover at varying rates, predicting how long this process
will take is difficult. Many experts believe that impaired employees must devote at least 1 year
to their recovery without the stresses of drug availability, overtime, and shift rotation. Success
in reentering the workforce depends on factors such as the extent of the recovery process
and individual circumstances. Again, although managers must show a genuine personal
interest in their employee’s rehabilitation, their primary role is to be sure that the employee
understands the organization’s right to insist on unimpaired performance in the workplace.
The following are generally accepted reentry guidelines for the recovering nurse:
• No psychoactive drug use will be tolerated.
• The employee should be assigned to day shift for the first year.
• The employee should be paired with a successfully recovering nurse whenever
possible.
• The employee should be willing to consent to random urine screening with toxicology
or alcohol screens.
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622 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
• The employee must give evidence of continuing involvement with support groups such
as Alcoholics Anonymous and Narcotics Anonymous. Employees should be encouraged
to attend meetings several times each week.
• The employee should be encouraged to participate in a structured aftercare program.
• The employee should be encouraged to seek individual counseling or therapy as
needed.
These guidelines should be a part of the employee’s return to work contract. Mandatory
drug testing, however, invokes questions about privacy rights and generally should not be
implemented without advice from human resources personnel or legal counsel. Humanistic
leaders recognize the intrinsic self-worth of each individual employee and strive to
understand the unique needs these workers have. If the leader genuinely cares about and
shows interest in each employee, employees learn to trust and the helping relationship has
a chance to begin.
Managers have the responsibility to be proactive in identifying and confronting chemically
impaired employees. Prompt and appropriate intervention by managers is essential for
positive outcomes. Organizations have an ethical responsibility to actively assist these
employees to return as productive members of the workforce.
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS
WHEN DEALING WITH PROBLEM EMPLOYEES
The leader recognizes that all employees have intrinsic worth and assists them in reaching
their maximal potential. Because individual abilities, achievement drives, and situations
vary, the leader recognizes each employee as an individual with unique needs and intervenes
according to those specific needs. In some situations, such as frequent rule-breaking,
discipline may be the most effective tool for ensuring that employees succeed. In the case of
the chemically or psychologically impaired employee, there is a need to balance the concern
for patient safety with concern for the health of the employee (Lillibridge, 2014). Assisting
the employee to get the treatment needed is a primary management responsibility.
Constructive discipline then requires leadership and management skills. In administering
discipline, the leader actively shapes group norms and promotes self-discipline. The leader
also is a supporter, motivator, enabler, and coach. The humanistic attributes of the leadership
role make employees want to follow the rules of the leader and thus the organization.
In dealing with the employee with special needs (the marginal employee, those who are
psychologically or chemically impaired), the leader serves more as a coach and resource
person than as a counselor, disciplinarian, or authority figure.
The manager, however, must enforce established rules, policies, and procedures, and
although good managerial practice greatly reduces the need for discipline, some employees
still need external direction and discipline to accomplish organizational goals. Discipline
allows employees to understand clearly the expectations of the organization and the penalty
for failing to meet those expectations. The manager’s primary obligation is to see that patient
safety is assured and that productivity is adequate to meet unit goals. The manager uses
the authority inherent in his or her position to provide positive and negative sanctions for
employee behavior in an effort to meet these goals.
The effective leader-manager blends these unit productivity needs and human resource
needs; however, selecting and implementing appropriate strategies to meet both goals is
difficult. The leader-manager believes that each employee has the potential to be a successful
and valuable member of the unit and intervenes accordingly to meet each employee’s special
needs.

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 623
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
KEY CONCEPTS
l it is essential that managers are able to distinguish between employees who need progressive discipline
and those who are chemically impaired, psychologically impaired, or marginal employees so that the
employee can be managed in the most appropriate manner.
l discipline is a necessary and positive tool in promoting subordinate growth.
l the optimal goal in constructive discipline is assisting employees to behave in a manner that allows
them to be self-directed in meeting organizational goals.
l to ensure fairness, rules should include McGregor’s “hot stove” components of forewarning, immediate
application, consistency, and impartiality.
l if a rule or regulation is worth having, it should be enforced. When rule-breaking is allowed to go
unpunished, groups generally adjust to and replicate the low-level performance of the rule-breaker.
l as few rules and regulations as possible should exist in the organization, all rules, regulations, and
policies should be regularly reviewed to see if they should be deleted or modified in some way.
l except for the most serious infractions, discipline should be administered in progressive steps, which
include verbal admonishment, written admonishment, suspension, and dismissal.
l in performance deficiency coaching, the manager actively brings areas of unacceptable behavior or
performance to the attention of the employee and works with him or her to establish a short-term plan to
correct deficiencies.
l the grievance procedure is essentially a statement of wrongdoing or a procedure to follow when one
believes that a wrong has been committed. all employees should have the right to file grievances about
disciplinary action that they believe has been arbitrary or unfair in some way.
l the presence of a union generally entails more procedural, legalistic safeguards for administering discipline
and a well-defined grievance process for employees who believe that they have been disciplined unfairly.
l Because chemical and psychological impairment are diseases, traditional progressive discipline is
inappropriate because it cannot result in employee growth.
l the profile of the impaired nurse may vary greatly, although typically behavior changes are seen in three
areas: personality/behavior changes, job performance changes, and time and attendance changes.
l Nurses and managers traditionally have been slow to recognize and respond to chemically impaired
colleagues.
l confronting an employee who is suspected of chemical impairment should always occur before the
problem escalates and before patient safety is jeopardized.
l the manager should not assume the role of counselor or treatment provider or feel the need to diagnose
the cause of the chemical addiction. the manager’s role is to clearly identify performance expectations
for the employee and to confront the employee when those expectations are not met.
l strategies for dealing with marginal employees vary with management level, the nature of the health-care
organization, and the current prevailing attitude toward passive or active intervention.
LEARNING EXERCISE 25.9
Determining an Appropriate Action When Proof Is Unavailable
You are the supervisor of a pediatric acute-care unit. One of your patients, Joey, is a 5-year-old
boy who sustained 30% third-degree burns, which have been grafted and are now healing. He
has been a patient in the unit for approximately 2 months. His mother stays with him nearly all
the waking hours and generally is supportive of both him and the staff.
(Continued )
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624 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
in the last few weeks, Joey has begun expressing increasing frustration with basic nursing tasks,
has frequently been uncooperative, and in your staff’s opinion has become very manipulative. His
mother is frustrated with Joey’s behavior but believes that it is understandable given the trauma
he has experienced. she has begun working with the staff on a mutually acceptable behavior
modification program.
although you have attempted to assign the same nurses to care for Joey as often as possible, it
is not possible today. this lack of continuity is especially frustrating because the night shift has
reported frequent tantrums and uncooperative behavior. the nurse whom you have assigned
to Joey is Monica. she is a good nurse but has lacked patience in the past with uncooperative
patients. during the morning, you are aware that Joey is continuing to act out. although Monica
begins to look more and more harried, she states that she is handling the situation appropriately.
When you return from lunch, Joey’s mother is waiting at your office. she furiously reports that
Joey told her that Monica hit him and told him he was “a very bad boy” after his mother had
gone to lunch. His mother believes that physical punishment was totally inappropriate, and she
wants this nurse to be fired. she also states that she has contacted Joey’s physician and that
he is on his way over.
You call Monica to your office where she emphatically denies all the allegations. Monica states
that during the lunch hour, Joey refused to allow her to check his dressings and that she followed
the behavior modification plan and discontinued his television privileges. she believes that his
accusations further reflect his manipulative behavior. You then approach Joey, who tearfully and
emphatically repeats the story that he told to his mother. He is consistent about the details and
swears to his mother that he is telling the truth. None of your staff was within hearing range of
Joey’s room at the time of the alleged incident. When Joey’s doctor arrives, he demands that
Monica be fired.
Assignment: determine your action. You do not have proof to substantiate either Monica or
Joey’s story. You believe that Monica is capable of the charges but are reluctant to implement
any type of discipline without proof. What factors contribute the most to your decision?
LEARNING EXERCISE 25.10
What Type of Discipline Is Appropriate?
susie has been an RN on your medical–surgical unit for 18 months. during that time, she has
been competent in terms of her assessment and organizational skills and her skills mastery. Her
work habits, however, need improvement. she frequently arrives 5 to 10 minutes late for work
and disrupts report when she arrives. she also frequently extends her lunch break 10 minutes
beyond the allotted 30 minutes. Her absence rate is twice that of most of your other employees.
You have informally counseled susie about her work habits on numerous past occasions. Last
month, you issued a written reprimand about these work deficiencies and placed it in susie’s
personnel file. susie acknowledged at that time that she needed to work on these areas but that
her responsibilities as a single parent were overwhelming at times and that she felt demotivated
at work. every day this week, susie has arrived 15 minutes late. the staff are complaining about
susie’s poor attitude and have asked that you take action.
You contemplate what additional action you might take. the next step in progressive discipline
would be a suspension without pay. You believe that this action could be supported given the
previous attempts to counsel the employee without improvement. You also realize that many of
your staff are closely watching your actions to see how you will handle this situation. You also
recognize that suspending susie would leave her with no other means of financial support and

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Chapter 25 Rule Breakers, Marginal Employees, and the Chemically Impaired Nurse 625
that this penalty is somewhat uncommon for the offenses described. in addition, you are unsure
if this penalty will make any difference in modifying susie’s behavior.
Assignment: decide what type of discipline, if any, is appropriate for susie. support your
decision with appropriate rationale. discuss your actions in terms of the effects on you, susie,
and the department.
LEARNING EXERCISE 25.11
Discipline and Insubordination
You are the coordinator of a small, specialized respiratory rehabilitation unit. two other nurses
work with you. Because all of the staff are professionals, you have used a very democratic
approach to management and leadership. this approach has worked well, and productivity has
always been high. the nurses work out schedules so that there are always two nurses on duty
during the week, and they take turns covering the weekends, at which time there is only one RN
on duty. With this arrangement, it is possible for three nurses to be on duty 1 day during the
week, if there is no holiday or other time off scheduled by either of the other two RNs.
several months ago, you told the other RNs that the state licensing board was arriving on
Wednesday, October 16, to review the unit. it would, therefore, be necessary for both of them
to be on duty because you would be staying with the inspectors all day. You have reminded
them several times since that time.
today is Monday, October 14, and you are staying late preparing files for the impending
inspection. suddenly, you notice that only one of the RNs is scheduled to work on Wednesday.
alarmed, you phone Mike, the RN who is scheduled to be off. You remind him about the
inspection and state that it will be necessary for him to come to work. He says that he is sorry
that he forgot about the inspection but that he has scheduled a 3-day cruise and has paid a
large, nonrefundable deposit. after a long talk, it becomes obvious to you that Mike is unwilling
to change his plans. You say to him, “Mike, i feel this borders on insubordination. i really need
you on the 16th, and i am requesting that you come in. if you do not come to work, i will need
to take appropriate action.” Mike replies, “i’m sorry to let you down. do what you have to do.
i need to take this trip, and i will not cancel my plans.”
Assignment: What action could you take? What action should you take? Outline some
alternatives. assume that it is not possible to float in additional staff because of the specialty
expertise required to work in this department. decide what you should do. Give rationale for your
decision. did ego play a part in your decision?
REFERENCES
Dittman, P. (2012). Mountains to climb: Male nurses
and their perspective on professional impairment.
International Journal For Human Caring, 16(1),
34–41.
Heacock, S. (2013, January 6). Nurses and substance abuse.
Nursetogether. Retrieved June 29, 2013, from http://
www.nursetogether.com/nurses-and-substance-abuse
Jorgensen, D. (2013, April 25). Prescription drug abuse
among nurses. Keloland TV. Retrieved June 29,
2013, from http://www.keloland.com/
newsdetail.cfm/prescription-drug-abuse
-among-nurses/?id=147176
Levoy, B. (2012). How to deal with problem employees.
Podiatry Management, 31(5), 47–48.
Lillibridge, J. (2014). Impaired nursing practice. What are
we doing about it? In C. Huston (Ed.), Professional
issues in nursing (3rd ed.). Philadelphia, PA:
Lippincott Williams & Wilkins 266–277.
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http://www.nursetogether.com/nurses-and-substance-abuse

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626 UNIT VII ROLES AND FUNCTIONS IN CONTROLLING
Luse, K. A. (2013). Managerial strategies for creating an
effective work environment. Radiologic Technology,
84(4), 383–397.
McGregor, D. (1967). The professional manager. New York,
NY: McGraw-Hill.
Modlin, H. C., & Montes, A. (1964). Narcotics addiction
in physicians. American Journal of Psychiatry, 121,
358–363.
Monroe, T. (2009, May). Educational innovations. Addressing
substance abuse among nursing students: Development
of a prototype alternative-to-dismissal policy. Journal
of Nursing Education, 48(5), 272–278.
National Institute on Drug Abuse (NIDA). (2013, May).
Drug Facts: Prescription and over-the-counter
medications. Retrieved August 22, 2013, from
http://www.drugabuse.gov/publications/drugfacts/
prescription-over-counter-medications
O’donnell, D. M., Livingston, P. M., & Bartram, T. (2012).
Human resource management activities on the front
line: A nursing perspective. Contemporary Nurse: A
Journal for the Australian Nursing Profession, 41(2),
198–205.
Scimeca, P. D. (2008) Unbecoming a nurse. Bypassing the
hidden chemical dependency trap. Staten Island, NY:
Sea Meca, Inc.
Talbert, J. (2009, February). Substance abuse among
nurses. Clinical Journal of Oncology Nursing,
13(1), 17–19.

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627
Appendix
Solutions to Selected Learning Exercises
The following are possible solutions for challenging situations presented in various Learning
Exercises throughout the book.
LEARNING EXERCISE 9.6
A Busy Day at the Public Health Agency
Here is how one nurse handled interruptions and still had time for lunch.
Time Task Rationale
8:00 am Assign lunch breaks:
11:30–12:30—receptionist
12:30–1:30—clerical worker
12:00–1:00—you
Because you have a lunch engagement
at noon, make sure other employees
know when their lunch times must be.
Finish reports Because reports are due tonight, this
would be the immediate task to be
accomplished.
Plan to finish these by 9 am.
8:30 am Supervisor’s request Ask her when she needs the information.
Tell her an estimate using primary
diagnoses is now available but that an
accurate figure that includes secondary
diagnoses must wait until you have
time to go through your 150 family
case files, which will be next week.
9:00 am Client with pregnant daughter The pregnancy takes priority over
the chest clinic drop-ins. Ask the
receptionist to start the paperwork
on drop-ins while you spend 30 min
with the mother.
9:30 am Phone call Delegate this to the receptionist.
9:30 am Dental clinic referral Delegate this duty to the clerical worker.
10:00 am Client call Because this person is confused and you
do not have available information, ask
that he come in at 10 am tomorrow
with his bills.
(Continued)
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628 APPenDix
Time Task Rationale
10:45 am Families with food vouchers Ask receptionist to finish paperwork and
interviews on the families. Then quickly
review information and sign vouchers.
These families should not have had
such a long wait. Make a note to find
out what happened, and later counsel
office staff about the delay.
11:45 am Drug call Talk with client. Make a referral to a local
drug clinic, and make an appointment
for a part-time psychiatrist at the clinic.
Do not get too involved on the phone
with the client because it is better to
make the appropriate referrals.
LEARNING EXERCISE 12.3
Cultures and Hierarchies
Below is an analysis of how one might approach a problem involving a nonnursing department
but affecting the nurses’ work and the nursing staff.
Analysis: Data Assessment
1. A copy of the organization chart was given to you when you were hired. The formal structure
is a line-and-staff organization. The housekeeping department head is below the nursing
director and the nursing section supervisor but at the same level as the immediate clinic
supervisor. The housekeeping department head reports directly to the maintenance and
engineering department head.
2. The county administrator has stated that she has an open-door policy. You do not know if
this means that bypassing department heads is acceptable or merely that the administrator
is interested in the employees. An important reason for not skipping intermediate supervisors
when communicating is that they must know what is going on in their departments.
A manager’s position, value, and status are strengthened if he or she serves as a vital and
essential link in the vertical chain of command.
3. You have twice attempted to talk with your immediate supervisor; however, whether you
followed up regarding your supervisor’s action on the complaint is unclear.
4. You are a new employee and therefore probably do not know how the formal or informal
structure works. This newness might render the complaints less credible.
5. Possible risks include creating trouble for the housekeeping staff or their immediate
supervisor, being labeled a troublemaker by others in the organization, and alienating your
immediate supervisor.
6. Before proceeding, you need to assess your own values and determine what is motivating
you to pursue this issue.
Alternatives for Action
There are many choices available to you.

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Appendix 629
1. You can do nothing. This is often a wise choice and should always be an alternative for any
problem-solving. Some problems solve themselves if left alone. Sometimes, the time is not
right to solve the problem.
2. You can talk with the county health administrator. Although this involves some risk, the
possibility exists that the administrator will be able to take action. At the very least, you will
have unburdened your problem on someone.
3. You can talk directly with the individual housekeepers by using “I” messages, such as, “I
get angry when the housekeeping staff take naps, and the bathrooms are dirty.” Perhaps, if
feelings and frustrations were shared, you would learn more about the problem. Maybe there
is a reason for their behavior; maybe they only socialize during their breaks. This alternative
involves some risk: The housekeepers might look on you as a troublemaker.
4. Have all the evening staff sign a petition and give it to the immediate supervisor. Forming
a coalition often produces results. However, the supervisor could view this action as
overreacting or meddlesome and might feel threatened.
5. Go to the housekeeping staff’s department head and report them. In this way, you are saving
some time and going right to the person who is in charge. However, this might be unfair to
the housekeepers and certainly will create some enemies for you.
6. Follow up with the immediate supervisor. You could request permission to take action
yourself and ask how best to proceed. This would involve your immediate supervisor and
keep her informed. However, it also shows that you are willing to take risks and devote some
personal time and energy to solving the problem.
Selecting an Alternative
This problem has no right answer. Under certain conditions, various solutions could be used.
Under most circumstances, it is more fair to others and efficient for you to select the third
alternative listed. However, because you are new and have little knowledge of the formal and
informal organizational structure, your wisest choice would be alternative 6. New employees
need to seek guidance from their immediate supervisors.
For this follow-up session with the supervisor to be successful, you need to do the following:
1. Talk with the supervisor during a quiet time.
2. Admit to personally “owning” the problem without involving colleagues.
3. Acknowledge that legitimate reasons for the housekeepers’ actions may exist.
4. Request permission to talk directly with the housekeepers. Role-play an appropriate
approach with the supervisor.
You must accept the consequences of your actions. However, your attempt to correct the
problem may motivate your supervisor to pursue the problem directly with the housekeeping
staff’s supervisor. If this is the action your supervisor takes, you should ask to speak with
the housekeeping staff directly first. If, after talking with the housekeeping staff, you decide
a problem still exists and you elect to address that problem, then you should return to your
immediate supervisor before proceeding.
Analysis of the Problem-Solving
Would you have solved this problem differently? What are some other alternatives that could
have been generated? Have you ever gone outside the chain of command and had a positive
experience as a result?
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630 APPenDix
LEARNING EXERCISE 13.6
Turning Lemons into Lemonade
This is the strategy that Sally Jones used to solve the conflict between her and Bob Black. In
analyzing this case, one must forego feelings of resentment regarding Bob’s obvious play for
control and power. In reality, what real danger does his empire building pose for the director of
nursing? Is not Sally really just ridding herself and her staff of clerical duties and interruptions?
A certain amount of power is inherent in the ability to hire. Employees develop a loyalty for the
person who actually hires them. Because Sally Jones or her designee will still actually make the
final selection, Bob’s proposal should result in little loss of loyalty or power.
Let us look at what the real Sally Jones did to solve this conflict. When she was able to see
that Bob was not stripping her of any power, Sally was capable of using some very proactive
strategies. Here was a chance for her to appear compromising, thereby increasing her esteem
in the CEO’s eyes and gaining political clout in the organization.
When she met with Jane Smith and Bob, Sally began by complimenting Bob on his ideas. Then
she suggested that because nurses were in the habit of coming to the nursing department to
apply for positions and because human resources offices were rather cold and formal places,
stationing the new personnel clerk in the nursing office would be more convenient and inviting.
Sally knew that the human resources department lacked adequate space and that the nursing
office had some extra room. She went on to say that because some of her unit clerks were very
knowledgeable about the hospital organization, Bob might want to interview several of them for
the new position. Although an experienced unit clerk would be difficult to replace, Sally said she
was willing to make this sacrifice for the new plan to succeed.
The CEO, very impressed with Sally’s generous offer, turned to Bob and said, “I think Sally has an
excellent idea. Why don’t you hire one of her clerks and station her in the nursing office?” Jane then
said to Sally, “Now, do we understand that the clerk will be Bob’s employee and will work under him?”
Sally agreed with this because she felt she had just pulled off a great power play. Let us examine
what Sally won in this political maneuver.
1. She gained by not competing with Bob, therefore not making him her enemy.
2. She gained by impressing the CEO with her flexibility and initiative.
3. She gained a new employee.
Although the new employee would be working for Bob with the salary charged to his cost
center, the clerk would be Sally’s former employee. Because the clerk would be working in the
nursing office, she would have some allegiance to Sally. In addition, the clerk would be doing all
the work that Sally and her assistants had been doing and at no cost to the nursing department.
When Sally first received Bob’s memo, she was angry; her initial reaction was to talk to the CEO
privately and complain about Bob. Fortunately, she did not do this. It is nearly always a political mistake
for one manager to talk about another behind his or her back and without his or her knowledge. This
generally reflects unfavorably on the employee, with a loss of respect from the supervisor.
Another option Sally had was to compete with Bob and be uncooperative. Although this might
have delayed centralizing the personnel department, in the end Bob undoubtedly would have
accomplished his goal, and Sally would not have been able to reap such a great political victory.
The later effects of this political maneuver were even more rewarding. The personnel clerk
remained loyal to Sally. Bob became less adversarial and more cooperative with Sally on other
issues. The CEO gave her a sly grin later in the week and said, “Great move with Bob Black.”
This case might be concluded by saying that this is an example of someone being given a lemon
and then making lemonade.

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Appendix 631
LEARNING EXERCISE 21.3
Conflicting Personal, Professional, and Organizational Obligations
The following is conflict resolution strategy used by you when the nursing office supervisor
(Carol), who considers you to be competent and responsible, asked you to help cover the
workload in the delivery room. Although this supervisor believes you can do the job, you think
that you do not know enough about labor and delivery nursing to be effective. Here are some
strategies you can use to resolve the conflict.
Analysis: You need to examine your goal, the supervisor’s goal, and a goal on which you can
both agree. Your goal might be protection of your license and doing nothing that would bring
harm to a patient. Carol’s goal might be to provide assistance to an understaffed unit. A possible
supraordinate goal would be for neither you nor Carol to do anything that would bring risk or
harm to the organization.
The following conflict resolution strategies were among your choices:
Accommodating. Accommodating is the most obvious wrong choice. If you really believe you are
unqualified to work in the delivery room, this strategy could be harmful to patients and your
career. Such a decision would not meet with your goal or the supraordinate goal.
Smoothing or avoiding. Because you have little power and no one is available to intervene
on your behalf, you are unable to choose either of these solutions. The problem cannot be
avoided, nor will you be able to smooth the conflict away.
Compromising. In similar situations, you might be able to negotiate a compromise. For instance,
you might say, “I cannot go to the delivery room, but I will float to another medical–surgical
area if there is someone on another medical–surgical unit who has OB experience.”
Alternatively, you could compromise by stating, “I feel comfortable working postpartum and
will work in that area if you have a qualified nurse from postpartum that can be sent to the
delivery room.” It is possible that either solution could end the conflict, depending on the
availability of other personnel and how comfortable you would feel in the postpartum area.
Often, someone attempting to solve problem, such as the supervisor in this case, becomes
so overburdened and stressed that other alternatives are not apparent.
Collaborating. If time allows and the other party is willing to adopt a common goal, this is the
preferred method of dealing with conflict. However, the power holder must view the other
as having something important to contribute if this method of conflict management is to be
successful. Perhaps, you could convince Carol that the hospital and she could be at risk if
an unqualified registered nurse (RN) was assigned to an area requiring special skills. Once
the supraordinate goal is adopted, you and Carol would be able to find alternative solutions
to the problem. There are always many more ways to solve a problem than any one person
can generate.
Competing. Normally, competing is not an attractive alternative for resolving conflict, but
sometimes it is the only recourse. Before using competition as a method to manage this
conflict, you need to examine your motives. Are you truly unqualified for work in the delivery
room, or are you using your lack of experience as an excuse not to float to an unfamiliar area
that would cause you anxiety? If you are truly convinced that you are unqualified, then you
possess information that the supervisor does not have (a criterion necessary for the use of
competing as a method of conflict resolution). Therefore, if other methods for solving the
conflict are not effective, you must use competition to solve the conflict. You must win at
the expense of the supervisor’s losing. You risk much when using this type of resolution. The
supervisor might fire you for insubordination or, at best, she may view you as uncooperative.
(Continued)
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632 APPenDix
The most appropriate method for using competition in this situation is an assertive approach.
An example would be repeating firmly but nonaggressively, “I cannot go to the delivery room
to work because I would be putting patients at risk. I am unqualified to work in that area.”
This approach is usually effective. You must not work in an area where patient safety would
be at risk. It would be morally, ethically, and legally wrong for you to do so. (Note: The legal
implications of this case are discussed in Chapter 5.)
LEARNING EXERCISE 21.4
An exercise in negotiation Analysis
Analysis: A head nurse’s goal is to be sure that all patients receive safe and adequate care.
However, some hidden agendas may exist. One might be that the head nurse does not want
to relinquish any authority or does not want to devote energy to the change that has been
proposed. The staff nurses have goals of job satisfaction and providing more continuity of care;
however, their hidden agenda is probably the need for more autonomy and control of the work
setting.
If the conflict is allowed to escalate, the staff nurses could begin to disrupt the unit because
of their dissatisfaction, and the head nurse could transfer some of the “ringleaders” or punish
them in some other way. The head nurse is wise in reconsidering these nurses’ request. By
demonstrating a willingness to talk and negotiate the conflict, the staff will view the head nurse
as cooperative and interested in their job satisfaction.
The staff nurses must realize that they are not going to obtain everything they want in this
conflict resolution nor should they expect that result. To demonstrate their interest, they should
develop some sort of workable policy and procedure for patient care assignments, recognizing
that the head nurse will want to modify their procedure. Once the plan is developed, the nurses
need to plan their strategy for the coming meeting. The following may be their outline:
1. Select as a spokesperson a member of the group who has the best assertive skills but whose
approach is not abrasive or aggressive. This keeps the group from appearing overpowering
to the head nurse. The other group members will be at the meeting lending their support but
will speak only when called on by the group leader. Preferably, the spokesperson should be
someone who the head nurse knows well and whose opinion is respected.
2. The designated leader of the group should begin by thanking the head nurse for agreeing to
the meeting. In this way, the group acknowledges the authority of the head nurse.
3. There should be a sincere effort by the group to listen to the head nurse and to follow
modifications to their plan. They must be willing to give up something as well, perhaps some
modification in the staffing pattern.
4. As the meeting progresses, the leader of the group should continue to express the goal of
the group−to provide greater continuity of patient care−rather than focus on how unhappy
the group is with the present system.
5. At some point, the nurses should show their willingness to compromise and offer to evaluate
the new plan periodically.
Ideally, the outcome of the meeting would be some sort of negotiated compromise in patient
care assignment, which would result in more autonomy and job satisfaction for the nurses,
enough authority for the head nurse to satisfy ongoing responsibilities, and increased continuity
of patient care assignment.

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Appendix 633
LEARNING EXERCISE 23.1
Designing an Audit Tool
When writing audit criteria, first define the patient population as clearly as possible so that information
can be retrieved quickly. In this case, eliminate patients who had complicated births, births of
abnormal newborns, cesarean section births, and home births because these patients will need
more assessment and teaching. The performance expectations should be set at 100% compliance
with an allowance made for reasonable exceptions. One hundred percent is recommended because
if any of these criteria are not recorded in the patient’s record, remedial actions should be taken.
Select the patient’s record as the most objective source of information. It should be assumed
that if criteria were not charted, they were not met. Audit 30 charts to give the agency enough
data to make some assumptions but not too many as to make it economically burdensome to
review records. An audit form that could be developed follows:
nURSinG AUDiT FORM FOR ViSiTinG nURSeS
nursing Diagnosis: Initial home visit within 72 hours after uncomplicated vaginal delivery, with
normal newborn, occurring in a birth center or obstetrical facility
Source of information: Patient’s record
expected Compliance: 100%, unless specific exceptions are noted
number of Records to Be Audited: 30
After the audit committee reviews the records, a summary should be made of the findings.
A summary could look like this:
SUMMARY OF AUDiT FinDinGS
nursing Diagnosis: Initial home visit, within 72 hours after uncomplicated delivery, with normal
newborn, occurring in a birth center or obstetrical facility
number of Records Audited: 30
Date of Audit: 7/6/2014
Summary of Findings: 100% compliance in all areas except recording of mother’s temperature
(50% compliance) and of newborn’s temperature (70% compliance)
Suggestions for improving Compliance: Remind nurses to record temperature of mother and
infant in record, even if normal. Time might be a factor in initial home visit because temperatures
for both were generally recorded on subsequent visits. Committee agrees that temperatures on
mother and baby should be taken during first home visit and suggests an in-service and staff
meeting regarding this area of noncompliance.
Signed, Chair of the Committee ___________________________________________________
The summaries should be forwarded to the individual responsible for quality improvement, in this
case the director of the agency. At no time should individual public health nurses be identified as not
having met the criteria. Quality improvement must always be separated from performance appraisal.
LEARNING EXERCISE 24.3
Using Management by Objective as a Part of Performance Appraisal
Analysis: This case could have several different approaches, depending on whether motivation
or change theory or another rationale was being implemented to support the decisions. In reality,
a manager may employ several different theories to increase productivity. However, this case
(Continued)
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634 APPenDix
will be solved by using only performance appraisal techniques to demonstrate that they can also
serve as an effective method to control productivity.
There are several aspects that seem to stand out in the information presented in this case. First,
it appears that Ms. Irwin is a person who needs to be reminded. She functions well in Objective
3 because she received monthly reminders of the meetings, and since she worked with a group
of people, she was able to make a real contribution to this committee. The similarities among the
other four objectives are that (a) they all required Ms. Irwin to work alone to accomplish them
and (b) there were no built-in reminders.
Rather than viewing this performance appraisal critically, the charge nurse should expend her
energy in developing a plan to help Ms. Irwin succeed in the coming months. Nothing is as
depressing or demotivating to an employee as failure. The following plan concentrates only on
the management by objective (MBO) portion of Ms. Irwin’s performance appraisal and does not
center on the rating scale of job performance.
Prior to the interview Rationale
1. Ask Ms. Irwin to review her objectives from
last year and to come prepared to discuss
them.
1. Gives the employee opportunity for
individual problem-solving and personal
introspection.
2. Set a convenient time for you and Ms. Irwin
and allow adequate time and privacy.
2. Shows interest in and respect for the
employee.
At the interview Rationale
1. Begin by complimenting Ms. Irwin on
meeting Objective 3. Ask her about her
work on the committee, what procedures
she is working on, and so forth.
1. Shows interest in and support of the
employee.
2. Review each of the other four objectives
and ask for Ms. Irwin’s input. Withhold any
evidence or criticism at this point.
2. Allows the employee to make her own
judgments about her performance.
3. Ask Ms. Irwin if she sees a pattern. 3. Guide the employee into problem-
solving on her own.
4. Tell Ms. Irwin that MBO often works better
if objectives are reviewed on a more timely
basis, and ask how she feels about this.
4. This is an offer to assist the employee
in achieving improved performance and
is not a punitive measure. It allows the
employee to have input.
5. Suggest that she keeps her unmet four
objectives, and add one new one.
5. Employees should be encouraged to
meet objectives unless they were stated
poorly or were unrealistic.
6. Work with Ms. Irwin in developing a
reminder or check point system that will
assist her in meeting her objectives.
6. Again, this helps the employee to
succeed. Do not simply tell employees
that they should do better; help them to
identify how to do better.
7. Do not sympathize or excuse her for not
meeting objectives.
7. The focus should remain on growth and
not on the status quo.
8. End on a note of encouragement and
support: “I know that you are capable of
meeting these objectives.”
8. Employees often live up to their
manager’s expectations of them, and if
those expectations are for growth, then
the chances are greater that it will occur.

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Appendix 635
LEARNING EXERCISE 25.5
The Marginal employee
As the nursing supervisor of a 35-bed oncology unit in a 400-bed hospital, this is how you may
solve the problems posed by a marginal employee (Judy) on your staff.
1. Identify the problem: The marginal performance of one employee is affecting unit morale.
2. Gather data to analyze the causes and consequences of the problem. The following
information should be gathered and considered:
● Judy has been an RN for 15 years and probably has always been a marginal employee.
● Judy states she is highly motivated to be an oncology nurse.
● Judy has been coached on several occasions regarding how she might improve her
performance and no improvement is evident.
● It is difficult to recruit and retain staff nurses for this unit.
● The unit is already short of two full-time RN positions.
● Judy’s performance is not unsatisfactory; it is only marginal.
● The other nurses on the floor considered Judy’s performance to be disruptive enough to
ask you to remove her from the floor.
3. Identify alternative solutions.
Alternative 1—Terminate Judy’s employment.
Alternative 2—Transfer Judy to another floor.
Alternative 3— Continue coaching Judy, and help her identify specific and realistic goals about
her performance.
Alternative 4—Do nothing and hope the problem resolves itself.
Alternative 5— Work with the other staff nurses to create a work environment that will make
Judy want to be transferred from the unit.
4. Evaluate the alternatives.
Alternative 1— Although this would provide a rapid solution to the problem, there are many
negative aspects to this alternative. Judy, although performing at a marginal
level, has not done anything that warrants discipline or termination. Although
some staff members have requested her removal from the unit, this action
could be viewed as arbitrary and grossly unfair by a silent minority. Thus,
employees’ sense of security and unit morale could decrease even more. In
addition, it would be difficult to fill Judy’s position.
Alternative 2— This alternative would immediately remove the problem from the supervisor and
would probably please the staff. This alternative merely transfers the problem
to a different unit, which is counterproductive to organizational goals. This
might be an appropriate alternative if the supervisor could show that Judy could
be expected to perform at a higher level on another unit. It is difficult to predict
how Judy would feel about this alternative. Judy is probably aware of the other
staff’s frustration with her, and a transfer would provide at least temporary
shelter from her colleagues’ hostility. In addition, although Judy would be
pleased that she was not dismissed, she would appropriately view the transfer
as her failure. This recognition is demoralizing, and the opportunity for her to
fulfill a long-term career goal would be denied.
(Continued)
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636 APPenDix
Alternative 3— This alternative requires a long-term and time-consuming commitment on the
part of the manager. There is inadequate information in the case to determine
whether the supervisor can make this type of commitment. In addition, there is
no guarantee that setting short-term, specific, and realistic goals will improve
Judy’s work performance. It should, however, increase Judy’s self-esteem
and reinforce her supervisor’s interest in her as a person. It also retains an
RN who is difficult to replace. This alternative does not address the staff’s
dissatisfaction.
Alternative 4— There are few positive aspects to this alternative other than that the supervisor
would not have to expend energy at this point. The problem, however, will
probably snowball, and unit morale will get worse.
Alternative 5— Although most would agree that this alternative is morally corrupt, there are
some advantages. Judy would voluntarily leave the unit, and the supervisor and
staff would not have to deal with the problem. The disadvantages are similar to
those cited in Alternative 1.
5. Select the appropriate solution. As in most decisions with an ethical component, there is
no one right answer, and all the alternatives have desirable facets. Alternative 3 probably
presents the least number of undesirable attributes. The cost to the supervisor is in
time and effort. There is really little to lose in attempting this plan to increase employee
productivity, because there are no replacements to fill the position anyway. Losing Judy by
dismissal or transfer merely increases the workload on the other employees due to short
staffing. It also cannot help the employee.
6. Implement the solution. In implementing Alternative 3, the supervisor should be very clear
with Judy about her motives. She also must be sure that the goals they set are specific
and realistic. Although the staff may continue to verbalize their unhappiness with Judy’s
performance, the supervisor should be careful not to discuss confidential information about
Judy’s coaching plan with them. The manager should, however, reassure the staff that she
is aware of their concerns and that she will follow the situation closely.
7. Evaluate the results. The supervisor elected to review her problem solving 6 months after
the plan was implemented. She found that although Judy was satisfied with her performance
and appreciative of her supervisor’s efforts, her performance had not improved appreciably.
Judy continued to be a marginal employee but was meeting minimal competency levels.
The supervisor did find, however, that the staff seemed more accepting of Judy’s level of
ability and rarely verbalized their dissatisfaction with her anymore. In general, unit morale
increased again.

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637
Index
A
Accommodating transfers, 609
Accommodation, 527
Accomplishment, rewarding, 470–471
Accountable Care Organizations (ACOs),
209d, 227
Accountability, 270
fiscal and ethical, for staffing, 405–406
organizational, 556–559
outcomes, 545
Accounting. See also Fiscal planning
responsibility, 208
Achievement-oriented people, 420
Active management-by-exception, 47
Acuity index, 209d
Acute care case management, 321
Ad hoc design, 271
Administrative agencies, 96, 96t
Administrative cases, 97
Administrative decision making, 19–20
Administrative man, 19–20, 20t
Administrative Simplification plan, HIPAA, 110
Adult learning theory, 368–369, 369d
Advance directives (ADs), 109
Advanced practice nurses (APNs), 99
Adverse drug events (ADEs), 562
Advocacy, 117–136
definitions in, 118
leadership roles and management functions in,
118d–119d, 131–2
learning of, 118–119
media and, 130
nursing values central to, 119, 119d
patient, 120–121
professional, 127–130
subordinate, 124–125
whistle-blowing as, 125–127
workplace, 124–125
Advocacy, nursing
in legislation and public policy, 128–129
values central to, 119, 119d
Advocate, 118
nurses as, 118
Affective conflict, 493
Affiliation-oriented people, 420
Affirmative action, 531
Affirming consequences, 15
Affordable Care Act, 209d, 226–228
Age Discrimination and Employment Act
(ADEA), 532
Aged organizations, 174
Agency for Health Care Research and Quality
(AHRQ), 550
Agency nurses, 395
Agenda for Change, 558
Agents, 58
Aggressive communication, 446
Alcohol impairment, 617
Alternative dispute resolution (ADR), 506
Alternatives, generating many, 14
Ambiguous questioning, 504
American Academy of Nursing (AAN), 278
American Association of Colleges of Nursing
(AACN), 326
American Federation of Government
Employees, 519
American Federation of Labor–Congress of Industrial
Organizations
(AFL-CIO), 519
American Federation of State, County, and Municipal
Employees, 519
American Hospital Association (AHA), 518
American Nurses Association (ANA), 113, 278, 472,
518, 548
and collective bargaining, 519
in developing professional standards, 548–550
scope and standards of practice, 549d
Note: Page numbers followed by d indicate displays, those followed by f indicate figures, and those followed
by t indicate tables.
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638 Index
American Nurses Association Code of Ethics for
Nurses, 79–80, 79d
American Nurses Credentialing Center (ANCC),
246, 278, 349
American Recovery and Reinvestment Act of 2009
(ARRA), 111, 122
Americans with Disabilities Act, 535
America, unionization in, 536
ANA Certification Program, 246
Analogy, arguing from, 15
Analysis tools, 15
Anticipatory socialization, 374
Applied ethics, 71
Appraisal interview, 587
difficulties, overcoming, 587–589
Arbitration, 509, 610
Arguing from analogy, 15
Argyris, Chris, 38
Aristotle, 48t. See also Great man theory
Assault, 104
Assertive behavior, 438
Assets, 209d
Associate nurses, 319
“At the will,” 612
At-will doctrine, 612
Audit, 551
concurrent, 551
definition of, 551
outcome, 551–552
process, 552
prospective, 551
retrospective, 551
structure, 552
Authentic leadership, 60–62, 66d
Authoritarian leadership, 40
Authority, 269, 288
interdependency of response to, 293f
Authority–power gap, 292–296
Autonomy, 75d, 76
Avoiding, 496
Avolio, B. J., 44, 45
B
Background screening, 350
Balanced Budget Act (BBA), 220
Balanced processing, 61
Balanced Scorecard, 145
Balancing technology and human element, 454
Bandura, A., 369
Barbiturates, 615
Bar coding, usage of, 564
Baseline data, 209d
Bass, B.M., 44
Battery, 104–105
Behavioral expectation scales, 580
Behaviorally anchored rating scale (BARS), 580–581
Behavioral theories of leadership, 39–41
Behavior change, 499
Behavior modification, 418
Benchmarking, 547. See also Quality control
Beneficence, 75d, 76
Benefit time, 214
Best practice, 547
Biases, confirmation, 24
“Big stick” approach, 599
Biometrics, 142
Body language, 444
Boom generation, 403
Brain hemisphere dominance, thinking styles and, 17
Brainstorming, 14
Brandt, M.A., 43
Breach of duty, 100
Break-even point, 209d
Budgetary process, 211–212
Budget busters, 215, 215d
Budgeting methods, 216–218
Budgets
basics of, 208, 209d–211d
budget busters in, 216d
capital, 215
fixed, 209d
flexible, 217
incremental, 216
operating, 214–215
performance, 217
perpetual, 211
personnel, 212–214 (See also Personnel budgets)
zero-based, 216–217
Budget, workforce, 212
Bundled payment, 209d, 226
Burden of proof, 96, 612
Bureaucracy, Weber concept of, 263
Bureaucratic organizational designs, 36, 271
Burns, F., 43
Burns, J.M., 44
Butterfly effect, 174
C
California Nurses Association (CNA), 518
California, patient rights in, 123d
Capital budgets, 215
Capitation, 209d, 221
Care-centered organizations, 271
Career coaching, 240–243
long-term, 242–243, 242d
short-term, 242
Career development, 235–256
career coaching in, 240–243, 243d
competency assessment in, 245–246
definition of, 236
individual responsibility for, 238–239, 240d
justifications for, 238, 238d
leadership roles and management functions in,
236d, 253

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Index 639
management development in, 243–245
organization’s responsibility for, 239–240, 240d
professional portfolio in, 248
professional specialty certification in, 246–248
reflective practice in, 248
résumé preparation in, 251–252, 252f
Career ladders, 239
Career planning, 239
Career-planning guide, for professional nurse, 256
Career planning, new graduate nurse and, 249
Career stages, 237
harvest, 237
momentum, 237
promise, 237
reentry, 237
Care MAP, 321
Care pairs, 318
Case management, 321–322
Case Management Society of America (CMSA), 321
Case method of assignment, 313. See also Total
patient care nursing
Case mix, 209d
Case studies, simulation, and problem-based
learning (PBL), 4–5
Case study learning, 4–5
Cash flow, 209d
Centers for Medicare and Medicaid Services
(CMMS), 220, 456, 559–562
Centralized decision making, 273
Centralized staffing, 390–391
Central tendency, 578
Certification programs, 113
Change agent, 163
responsibilities during stages of change, 165d
Change theory, by Kurt Lewin, 164–165
movement in, 164–165, 165d–166d
refreezing in, 165, 166d
unfreezing in, 164, 165d
Chaos theory, 172, 173–174
Chapman, B. T., 458, 458d
Charismatic power, 291
Checklist appraisal tools, 581
Chemical impairment, 598
Chemically impaired employee, 614–
characteristic changes in, 616d
confrontation of, 617–618
diversion programs for, 620
drugs used by, 616–617
history of, 614–615
manager’s role in assisting of, 619
recognition of, 615–622
recovery process for, 620
reentry to workplace of, 621–622
State Board of Nursing treatment programs for,
620–621
Chunking, 371
Cinical pathways. See Critical pathways
Clinical nurse-leader, 326–327
clinical reasoning, 4
Civil cases, 97
Civil law, 528
Civil Rights Act of 1964, 531
Classic change strategies, 167–168
normative–reeducative approach, 168
power–coercive approach, 168
rational–empirical approach, 168
Clear and convincing standard, 97
Clinical coaching, 590
Clinical nurse–leader (CNL), 326–327
Clinical practice guidelines, 545
Clonazepam, 615
Closed shop, 521
Closed-unit staffing, 405
Closure, of group communication, 457
Coaching, 591, 613
clinical, 591
ongoing, 605
in performance appraisal, 590
performance deficiency, 605, 605d–606d
problem-centered, 605
Code of ethics, 79
Coercive power, 291
Collaborating, 497–498
Collaborative practice matrix, 43
Collective bargaining, 516
ANA and, 519
leadership roles and management functions
and, 514d, 536
terminology, 516d
Collins, Jim, 56
Committee
opportunities and responsibilities, 280–281
structure, 280, 280d
Communication, 436–464
aggressive, 446
assertive, 447
channels of, 442–443
confidentiality in, 454–455
culture and, 445
definitions of, 438
diagonal, 442
downward, 442
effective, 445
eye contact in, 445
face-to-face, 444
on financial performance, 456
gender in, 440
grapevine, 442
group, 456–457
group dynamics in, 457–459
horizontal, 442
internal and external climate in, 439
leadership roles and management
functions in, 437d–438d
listening skills in, 449
modes of, 443–444
nonverbal, 444
passive, 446
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640 Index
Communication (Continued )
posture in, 445
process of, 438–440, 439f
telecommunication and e-mail in, 453–454
telephone, 444
upward, 442
verbal skills for, 446–447
written, 443, 450–451
Communication, organizational
strategies of, 441–443
technology on, 452–454
variables in, 440
written, 450–451
Competence, 371
Competence assessment, 579
Competing, 495–496
Complementary and alternative medicine, 141
Complex adaptive systems (CAS) change theory,
172–173, 173d
Compromising, 495
Computerized physician–provider order
entry (CPOE), 563, 563d
Concurrent audits, 551
Confidentiality, 75d, 78, 454
Confirmation biases, 24
Conflict
affective, 493
categories of, 490–493
definition and nature of, 488
felt, 493
intergroup, 490–491
interpersonal, 491–492
intrapersonal, 491
latent, 493
manifest, 494
overt, 494
perceived, 493
process, 493–494, 494f
qualitative, 489
quantitative, 489
Conflict aftermath, 494
Conflict management, 495–513
alternative dispute resolution in, 505
avoiding in, 496–497
collaborating in, 497–498
competing in, 495–496
compromising in, 495
conflict resolution in, 495d
consensus in, 506
cooperating/accommodating in, 496
gender in, 494
goal of, 491
history of, 489–490
leadership roles and management functions in,
488d, 506
negotiation in, 500–504
smoothing in, 496
strategies for, 495d
in units, 498–500
Conflict process, 493–494, 494f
Conflict resolution, 488
Confrontation, 499
Congruent leadership, 60
Consensus, 506
Consequences, affirming, 15
Consequence tables, 21–22, 22t
Consistency, 601
Constitution, 95–96, 96t
Constructive discipline, 599
Consumer Bill of Rights and Responsibilities.
See Patient’s Bill of Rights
Contingent reward, 47
Continuous quality improvement (CQI), 554
Control criteria, establishing, 546
Controllable costs, 209d
Controllable expenses, 208–209
Controlling, in management process, 37
Cooperating, 496
Cost–benefit ratio, 209d
Cost center, 209d
Cost containment, 207
Cost-effective, 207
Court decisions, 96, 96t
Criminal cases, 97
Criminal law, 528
Critical event analysis (CEA), 547
Critical incident, 577
Critical pathways, 218, 321–322
Critical thinker, 4d
Critical thinking
components of, 4
definition of, 3–4
experiential learning, 6
Marquis-Huston critical thinking teaching model
for, 5–7, 6f
CRM Learning, 499
Crossing the Quality Chasm: A New Health System
for the 21st Century, 565
Cross-training, 404
Cultural diversity
staff education and, 382
workforce, legal considerations in, 111–112
D
Data gathering, careful, 12, 12d
Decentralized decision making, 273
Decentralized staffing, 390–391
Decertification, 526
Decision grid, 20–21
Decision making, 3–25
critical elements in, 11–15, 11d
choose and act decisively, 15
define objectives clearly, 11–12
gather data carefully, 12, 12d

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Index 641
generate many alternatives, 14
take the time necessary, 12–13
think logically, 14–15
use evidence-based approach, 12–13, 13d
definition of, 3
ethical frameworks for, 74–73, 74t
individual variations in, 15–17
brain hemisphere dominance, 17
gender, 16
life experience, 16
preference, 16
thinking styles, 16–17
values, 16
individual vulnerability in, overcoming, 18–19
individual preference, 18
individual ways of thinking, 18–19
life experience, 18
values, 18
intuitive models of, 10–11
managerial models of, 8
naturalistic, 11
in organizational hierarchy, 272–273
in organizations, 19–20
effect of organizational power, 19
rational and administrative decision
making, 19–20
participative, 35
rational and administrative, 19–20
theoretical approaches to, 7–11
heuristics, 6–7
integrated ethical problem-solving model,
9–10, 10d
intuitive model, 10–11
managerial models, 8, 8d
nursing process, 8–9, 8d
structured approach, 7
traditional problem-solving process, 7–8, 7d
tools in, 20–23
consequence tables, 21–22, 22t
decision grid, 20–21
decision trees, 21
logic models, 23
payoff tables, 21
pitfalls in using of, 23
program evaluation and review technique, 23
Decision package, 216, 216d
Decision trees, 21, 22f
Decisive choices and actions, 15
Defamation, 105
Defendant, 99
Delegation, 467–481
common errors in, 471–472, 471d
communicating goal clearly in, 469
cultural phenomena, 480d
definitions of, 467
difficulty in, 471
effective, 468–471
empowerment in, 470
as function of professional nursing, 473–479
leadership roles and management functions in,
integrating, 480–481
preparation for role of, 473
steps in, 477
subordinate resistance to, 478
task-based guide to, 477–478
to transcultural work team, 479–480
to unlicensed assistive personnel, 474–478
immediate, 482
improper, 472
leadership roles and management functions in, 468d
necessary skills and levels in, identifying, 469
overdelegating in, 472
performance evaluation in, 470
planning ahead in, 469
resistance to, 478
rewarding accomplishment in, 470–471
rights of, 473d
role modeling and guidance in, 470
selecting capable personnel in, 469
setting deadlines and monitoring progress in, 470
strategies for successful, 468d
to UAP, 474–478
underdelegating in, 471–472
Deming, W. Edward, 554–555
Democratic leadership, 40
Deontological ethical theory, 74t, 75
Diagnosis-related groups (DRGs), 209d, 220, 557
Diagonal communication, 442
Digital natives, 404
Direct costs, 209d
Directing, in management process, 37
Director of nursing, 266
Disability, 535
Disciplinary conference, 606–608
agreement and acceptance of action plan, 607–608
clarification of expectations for change, 607
employee’s response to action, 607
rationale for, 607
reason for, 606–607
Disciplinary strategies, 604–609
agreement and acceptance of action plan, 607
clarification of expectations for change, 607
disciplinary conference, 605–608
employee’s response to action, 607
overview of, 604–605
performance deficiency coaching, 605
rationale for disciplinary action, 607
reasons for disciplinary action, 607
termination conference, 608
transferring the problem employee, 609–610
Discipline, 599
for chemically impaired employee, 614–615
constructive vs. destructive, 599
definition and origin of, 599
enforcement of, 600
fair and effective rules for, 600–601
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642 Index
Discipline (Continued )
grievance procedures in, 610–611
group norms and, 600
lack of, 600
leadership roles and management functions for, 622
marginal employees and, 597–598
reprimand form for, 602d
self, 600
with unionized employee, 611–612
Discipline, progressive, 601–603
formal reprimand or written admonishment in, 602
guide to, 603t
informal reprimand or verbal admonishment in, 602
involuntary termination or dismissal in, 603
suspension from work in, 602
Discover Nursing campaign, 62
Disease management (DM), 323–324, 324d
Dismissal, 603
Distinguished Hospitals for Patient Safety, 565
Diversion programs, 620
Diversity, 111. See also Cultural diversity workforce,
legal considerations in, 109–110
Division of labor, 263
Doctrine of charitable immunity, 103
Downward communication, 442
Downward transfer, 609
Driving forces, 166, 166f
Due process hearings, 505
Durable power of attorney, 109
Duty-based reasoning, 74t, 75
E
Economic man, 19, 20t
Education, 366
Effective communication, 445
Effectiveness
leadership, Hollander on, 42
Electronic health records (EHR), 141, 456
Emotional intelligence (EI), 59–60, 59d
Emotional literacy, 59
Employee indoctrination, 354–358, 355d. See also
Indoctrination, employee; Staffing
Employee motivation, performance appraisal in,
520–524
Employee placement, 353. See also Staffing
Employee recruitment, 338–339. See also Staffing
Employee selection, 349–352, 352f. See also
Selection, employee; Staffing
Employment and Labor Laws, 528t
Employment legislation, 528–535
Age Discrimination and Employment Act
(ADEA), 532
Americans with Disabilities Act, 535
Civil Rights Act of 1964, 531–532
equal employment opportunity laws, 530–531
labor relations laws, 530
labor standards, 529
leadership roles and management functions and,
515d, 536
minimum wages and maximum hours, 529
Occupational Safety and Health Act, 535
sexual harassment, 532–534
state health facilities licensing boards, 535–536
time clocks and, 530
Veterans Readjustment Assistance Act, 535
Empowerment, 295–296
End-of-shift overtime, 58
Environmental control, culture and, 480
Equal employment, 528
Equal employment opportunity laws, 530–531
Equal Pay Act of 1963, 529
Essay appraisal method, 581
Ethical frameworks, for decision making, 74–75, 74t
Ethical issues, 71–92
ANA code of ethics and professional standards in,
79–80, 79d, 80d
definitions in, 71
ethical frameworks for decision making in, 74–75
ethical problem solving and decision
making in, 80–82
MORAL decision-making model in, 84
nursing process in, 82
outcome in, 80
structured problem solving in, 80–81
traditional problem-solving process in, 81
individual values, beliefs, and philosophy in, 74
in leadership and management, 88–89, 86d
collaborating through ethics committees in, 87
ethical behavior as norm in, 86
fostering ethical work environments in, 87
separating legal and ethical issues in, 86–87
using institutional review boards
appropriately in, 87
leadership roles and management functions with,
72d, 89
principles of ethical reasoning in, 75–78
types of, 72–74
Ethical principles, 75–78, 75d
autonomy (self-determination), 76
beneficence (doing good), 76
confidentiality (respecting privileged
information), 78
fidelity (keeping promises), 78
justice (treating people fairly), 76
paternalism, 76
utility, 76
veracity (truth telling), 77
Ethical relativism, 75
Ethical universalism, 75
Ethical work environment, creation of, 87
Ethics, 71, 94
ANA code of, 79–80, 79d
applied, 71
aspirational
consequential, 74

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Index 643
definition of, 71
deontological, 75
teleological theory of, 74–75
Ethics committees, 87
Evaluation, definition of, 575
Evidence-based hospital referral (EHR), 563
Evidence-based practice (EBP), 13–14,
13d, 245
Exchanges, 227
Exclusive provider organization (EPO) plans, 222
Executive Order 10988, 517
Executive Order 11246, 531
Executive Order 11375, 531
Expectancy model, 420
Expenses, in budget, 208
Expert networks, 18, 141
Expert patient, 142
Expert power, 291
Express consent, 106
External climate, in communication, 439
Extrinsic motivation, 416–417
Eye contact, in communication, 445
F
Face-to-face communication, 444
Facial expression, in communication, 445. See also
Communication
Fair and effective rules, for discipline, 600–601
Fair Labor Standards Act (FLSA), 529
False imprisonment, 105
Fayol, Henri, 36
Federal Mediation and Conciliation Service
(FMCS), 522
Fee-for-service (FFS) system, 209d, 218
Felt conflict, 493
Fidelity, 75d, 78
Fiedler, F., 41
First-level managers, 266–267, 267t
Fiscal accountability for staffing, 405–406
Fiscal planning, 204–233
balancing costs and quality in, 207–208
budgetary process in, 211–212
budgeting methods in, 216–218
budget types in, 212–215
critical pathways in, 218
forecasting in, 208
health care milestones in, 224d–226d
health care reimbursement in, 218–219
leadership roles and management functions in,
206d–207d, 228, 228
managed care in, 220–221
future of, 224
proponents and critics of, 223
Medicare and Medicaid in, 219–220
overview of, 205–206
prospective payment system in, 220–221
responsibility accounting in, 208
terminology in, 209d–211d
Fiscal-year budget, 211
Fixed budget, 209d
Fixed costs, 209d
Fixed expenses, 208
Flat organizational designs, 272, 273f
Flat-percentage increase method, 216
Flattening the organization, 266
Flattery, 504
Flexible budgets, 217
Flextime, 396
Float pools, 395
Follett, Mary Parker, 37–38, 41
Followers, 58
Forced checklist, 581
Forecasting, 143, 208
Foreseeability of harm, 100
Forewarning, 601
Formal communication networks, 441
Formal reprimand, 602
Formal structure, 261
Forming, 456, 457t
For-profit organization, 210d
Free-form review, 581
Frontline Service Alliance, 519
Full costs, 210d
Full-range leadership theory, 45–47, 46d, 55
Full-time equivalent (FTE), 210d
Functional foremen, 36
Functional method, 314–316, 315f
G
Gardner, J.W., 47, 48t
Gatekeepers, 221
Gellerman, Saul, 421
Gender
in communication, 440
on decision making, 16
and power, 289–290
Generational diversity, 335, 403–404
Generation Y, 404
Glass ceiling, 290
Goals, of organization, 153–154, 154d
Goleman, D., 59–60
Good Samaritan laws, 110
Governmental immunity, 103
Government-controlled organizations, 613
Grapevine, 262
Grapevine communication, 442
Grapevine, definition of, 442
Great Man theory, 39
Greenleaf, R. K., 56
Greeting, Respectful Listening, Review, Recommend
or Request More Information, and Reward
(GRRRR), 449, 449d
Grievance procedures, 610–611
arbitration, 610–611
formal process, 610
rights and responsibilities in, 611
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644 Index
Group building, 458
Group communication, 456–457
integrating leadership and management in, 459–460
Group dynamics, 457–459, 458d
group building and maintenance roles, 458
group task roles, 457–458
individual roles, of group members, 458–459
Group HMO, 221
Group maintenance, 458
Group norms, 600
Groupthink, 281
Guidance, in delegation, 470
Gulick, Luther, 36
H
Halo effect, 578
Hawthorne effect, 38, 38t
Healthcare in the Crossroads, recommendations
from, 101, 102d
Healthcare quality, 545–546. See also Quality
health care
Health-care reform and patient protection, 226–228
accountable care organizations, 227
bundled payments, 226
health insurance marketplaces, 227–228
hospital value-based purchasing, 227
medical home, 227
Health Insurance Portability and Accountability Act of
1996 (HIPAA), 110–111, 122, 454–455
Health Maintenance Organization Act of 1973, 221
Health maintenance organization (HMO), 210d, 221
plans in, 222
types of, 221–222
Health Plan Employer Data and Information
Set (HEDIS), 561
Herrmann, Ned, 17
Hersey, P., 42
Herzberg, Frederick, 419, 419d
Heuristics, 7
Hidden agendas, 502
Hierarchy of authority, 263
High-performance teams, 43
Hollander, E. P., 42–43
Horizontal communication, 442
Horns effect, 578
Hospital information system (HIS), 452
Hospital Quality Initiative (HQI), 559
Hospital Quality Measures, 558
Hospital value-based purchasing, 227
“Hot stove” rules, 600, 600d
Hours per patient-day (HPPD), 210d
Human and social capital theory, 58–59
Human capital, 58
Human capital theory, 59
Human relations era, 37–38
Human relations management, 37–38
Hygiene factor, 419, 419d
I
ICU physician staffing (IPS), 563
Idealized influence
attributed, 46
behavior, 46
Immediacy, 601
Impaired employees, 598
Impaired Practice Policy, 621
Impartiality, 601
Impersonality of interpersonal relationships, 263
Improper delegation, 472. See also Delegation
Inactivism, 142
Inappropriate questioning, 504
Inappropriate transfer, 609–610
Incident reports, 104
Incremental budgeting, 216
Independent practice association (IPA), 221
Indirect costs, 210d
Individualized consideration, 47
Indoctrination, employee, 354–358. See also Staffing
content of, 355d
definition of, 354
induction in, 355–356
orientation in, 356–358
Induction, 355–356
Industrial age leadership, 63–64
and relationship age leadership, 63t
Informal communication networks, 441
Informal reprimand, 602
Informal structure, 261
Informational power, 291
Informed consent, 105–106, 106d
for clinical research, 106–107
Inspirational motivation, 46
Institute for Health Improvement (IHI), 556
Institute of Medicine (IOM), 101, 545
Institutional licensure, 112–113
Institutional review boards (IRBs), 87
Integrated ethical problem-solving model, 9–10, 10d
Integrated leader–managers, 47
Integrated model of leadership, 64f
Intellectual stimulation, 46
Intentional torts, 104–105
Interactional leadership theories, 42–47
Intergroup conflict, 490–491
Internal climate, in communication, 439
Internalized moral perspective, 61
International Brotherhood of Teamsters, 519
International Classification for Nursing Practice
(ICNP), 554
International Classification of Disease
(ICD) codes, 210d
International Council of Nurses (ICN), 554
Internet, 452
Interpersonal communication, 491–492
integrating leadership and management in, 459–460
Interpersonal conflict, 491–492

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Index 645
Interprofessional primary health-care teams, 321
Interviewing, 339–347
acceptable and unacceptable inquiries in, 347t
definition of, 339
evaluation of, 346
interviewee tips for, 347–349, 348d
legal aspects of, 346–347
limitations of, 340–344
planning, conducting, and controlling, 344–346
sample questions for, 344d
structured, 340, 342d–343d
unstructured, 340
Intranets, 452
Intrapersonal conflict, 491
Intrinsic motivation, 416
Introduction, Situation, Background, Assessment,
Recommendation (ISBAR), 448
Intuitionist framework, 74t, 75
Intuitive decision-making model, 10–11
Intuitive thinking, 17
Involuntary termination, 603
IPA HMOs, 221
J
Job dimension scales, 580
for industrial nurse, 580d
Job interview, conducting. See Interviewing
Joint Commission, 557–558
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), 557–558, 561
Joint Commission’s Annual Report on Quality
and Safety, 448
Joint liability, 102
Joint practice committees, 277
Joint Statement on Delegation, 467
Just cause, 612
Justice, 76, 75d
Just-in-time ordering, 215
K
Kanter, R.M, 43–44
Kassebaum–Kennedy Act, 110
Kentucky Board of Registered Nursing, 475, 477
Klein, Gary, 11
Knowles, M., 368
L
Labor intensive, 335
Labor legislation, 518t
Labor–management relations, 526–527. See also
Union organizing/unionization
Labor relations, 528
Labor relations laws, 530
Labor standards, 529
Laissez-faire leadership, 41
Latent conflict, 493
Lateral transfer, 609
Laws and courts, types of, 96–97, 97t
Leaders, 34–35
characteristics of, 34
definition of, 34
followers and, 57–58
Leadership
authentic, 60–62, 61d
authoritarian, 40
behavioral theories of, 39–41
characteristics associated with, 40d
competencies, 47
contingency theories of, 41–42
definition of, 34
democratic, 40
fatal flaws, 35d
integration with management of, 48
interactional, 42–44
laissez-faire, 40–41
nondirected, 41
quantum, 63
roles, 34d
servant, 56–57, 57d
situational theories of, 41–42
thought, 62
transactional, 44–45, 44t
transformational, 44–45, 44t
Leadership and management, classical
views, 33–50
historical development of leadership theory in,
39–42 (See also Leadership theory,
historical development of)
historical development of management theory
in, 35–38 (See also Management theory,
historical development of)
integrating leadership and management
in, 47–48
interactional leadership theories (1970 to
present), 42–47
leaders in, 34–35
managers in, 33
Leadership and management, 21st century, 54–67
industrial age to relationship age
transition in, 63–64
new thinking about, 54–63
authentic leadership, 60–62, 61d
emotional intelligence, 59–60, 59d
human and social capital theory, 58–59
leaders and followers, 57–58
Level 5 Leadership, 56, 56d
positive psychology movement, 55
principal agent theory, 58
quantum leadership, 63
servant leadership, 57–56, 57d
strengths-based leadership, 55, 55d
thought leadership, 62
for nursing’s future, 65
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646 Index
Leadership styles, 40
Leadership theory, historical development of, 39–47
behavioral theories, 39–41
full-range theory, 45–47
Great Man theory and trait theories, 39
interactional theories, 42–47
competencies, 47
situational and contingency theories, 41–42
theorists, 48t
transactional and transformational
leadership, 44–45
Leapfrog Group, 563–564, 563d
Learning organization (LO), 365–366
Learning theories
adult, 368–369
chunking, 371
knowledge of results, 371
motivation to learn, 369
overview, 367
readiness to learn, 369
reinforcement, 370
social, 369
span of memory, 371
task learning, 370
transfer of learning, 370
Left-brain thinkers, 17
Legal and legislative issues, 94–115
avoiding malpractice claims in, 101, 102d
extending liability in, 102–104
Good Samaritan laws in, 110
Health Insurance Portability and Accountability
Act of 1996 in, 110–111
incident reports in, 104
informed consent, 105–107, 106d
intentional torts in, 104–105
laws and courts in, 96–97
leadership roles and, 95d
leadership roles and management functions in,
integrating, 113
legal doctrines in, 97–98
legal responsibility of managers, 105–111
licensure in, 112–113
malpractice cases, 99–100
management functions and, 95d
in managing diverse workforce, 111–112
medical records in, 107–108
Patient Self-Determination Act in, 109
product liability in, 105
professional negligence in, 98–100, 99t
quality control in, 105
reporting improper/substandard care in, 105
sources of law in, 95–96, 96t
Legal doctrines, 97–98
Legal-rational authority, 263
Legitimate power, 291
Level 5 Leadership, 56, 56d
Lewin, Kurt, 40
Lewin’s model of change, 164–166
contemporary adaptation of, 167
driving and restraining forces in, 166
Libel, 105
License, 112
revocation of, causes of, 112d
Life experience, on decision making, 18
Lillibridge, J., 621, 622
Line structures, 271
Lippitt, R., 40
List, as planning tool, 188–189
Listening skills, 449
Logical thinking, 14–15
Logic models, 23
M
Magnet designation, 278–279, 279d
Maintenance factor, 419
Malpractice, 99. See also Professional negligence
definition of, 99
elements of, 99–100
Managed care, 210d, 221–223, 222d
characteristics, 222d
definition of, 221
future of, 224, 226, 224d–226d
by Medicare and Medicaid, 222–223
organizations, 221–222
proponents and critics of, 223
Managed care backlash, 224
Managed care organizations (MCO), 221–222
Management
classical views of, 32–50 (See also Leadership and
management, classical views)
control in, 33
definition of, 33
participative, 37
scientific, 35–36
seven activities of, 36
in 21st century (See Leadership and management,
21st century)
Management-by-exception passive, 47
Management by objectives (MBO), 578, 582–583
usage of, 583
Management development, 244–245
Management process, 37, 37f
Management theory, historical development of, 35–38
human relations management, 37–38
management functions identified, 36–37
management process, 37, 37f
scientific management, 35–36
up to 1970, 38t
Manager, disciplinary strategies for, 604–608
agreement and acceptance of action plan, 607
clarification of expectations for change, 607
disciplinary conference, 606–608
employee’s response to action, 607
performance deficiency coaching, 605
rationale for disciplinary action, 607

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Index 647
reasons for disciplinary action, 606–607
termination conference, 609
Managerial decision-making models, 8
Managers, 33
liability for negligence for, 103
Managers’ role
in chemically impaired employee, 619
in union-organizing, 525–526, 525d
Mandatory overtime, 405
Manifest conflict, 494
Manthey, M., 590
Marginal employees, 596–597, 612–613
Marquis-Huston critical thinking teaching
model, 5–7, 6f
Maryland Hospital Association Quality Indicator
Project (QI Project), 561
Maslow’s hierarchy of needs, 418, 418f
Matrix organization structure, 271, 272f
Matthew effect, 578
Maximum wages, 529
Mayo, Elton, 38
McClelland, David, 420–421
McGregor, Douglas, 38, 421–422, 421d
McGregor’s hot stove, 600d
Media and nursing, 130, 131d
Mediation, 505
Medicaid, 210d, 219
Medical errors, 562–565
future of, 565
Leapfrog Group on, 563–564, 563d–564d
overview of, 562
reforming medical liability system and, 564–565
reporting and analyzing, 562–563
Six Sigma approach to, 564
Medical home, 227
Medical liability system, 564–565
Medical records, 107–108
Medical savings accounts (MSAs), 223
Medicare, 210d, 219–220
Medicare Quality Initiative (MQI), 559
Medicare Shared Savings Program, 227
Medication reconciliation, 552
Memo, 450
Merit rating, 575
Metrics, 145
Middle-level managers, 266, 267t
Minimum staffing ratios, 402
Minimum wages, 529
Mission statement, 147–148, 148d
Modular nursing, 318
MORAL decision-making model, 84
Moral distress, 72
Moral hazard, 223
Moral uncertainty, 72
Motivating climate, 414–434
creating, 422–425, 425d
employee and supervisor, relationship between, 424
generational differences and motivation, 423–424
incentives and rewards, 422–423
individual vs. collective motivators in, 416–417
joy at work in, 426
leadership roles and management functions in,
415d, 429
positive reinforcement in, 425
theory, 417–422, 418f, 419d, 420f, 421d
Motivation
definition of, 415
individual and collective motivators in, 416–417
intrinsic vs. extrinsic, 416–417, 415d
to learn, 431–432
Motivational theory
Gellerman on, 421
Herzberg on, 419, 419d
Maslow on, 418, 418f
McClelland on, 420–421
McGregor on, 421–422, 421d
overview of, 415–416
Skinner on, 418
Vroom on, 420, 420f
Motivation–hygiene theory, 419
Motivator factors, 419
Motivators, individual vs. collective, 417
Mouton, J.S., 41–42, 48t
Multidisciplinary action plans (MAPs), 321
Multidisciplinary team leader role, 317–318
Multistate Nursing Home Case Mix and Quality
demonstration, 561
N
National Committee for Quality Assurance
(NCQA), 561
National Council of State Boards of Nursing
(NCBSN), 467
National drug code (NDC), 564
National Guideline Clearinghouse (NGC), 550, 550d
National Labor Relations Act (NLRA), 523–524
National Labor Relations Board (NLRB),
517, 523–524
National Nurses Organizing Committee (NNOC), 518
National Nurses Society of Addictions, 614
National Nurses United (NNU), 518
National Patient Safety Goals (NPSGs), 559
National Survey of Registered Nurses, 518
Naturalistic decision making, 11
Negligence, 98–100
Negotiation, 500–504, 503d. See also Conflict
management
before the, 500–502
during the, 502
closure and follow-up to, 504
destructive negotiation tactics, 503–504
Network groups, 129
Network HMOs, 222
Noncontrollable costs, 210d
Noncontrollable expenses, 208
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648 Index
Non leadership, 46
Nonmaleficence, concept of, 76
Nonproductive time, 214
Nonverbal communication, 444
elements of, 444–446
Normative–reeducative strategy, 168
Norming, 456, 457t
North American Nursing Diagnosis
Association taxonomy, 554
Not-for-profit organization, 210d
Nursebots, 141
Nurse Practice Act, 94, 96, 98, 469
Nurse practitioners, 99
Nurse recruiter, 338
Nursing assistive personnel (NAP), 315
Nursing care hours (NCH) per patient-day
(PPD), 212, 213f
Nursing Interventions Classification (NIC), 553–554
Nursing Minimum Data Set (NMDS), 553–554
Nursing process, 8–9
decision-making process and, comparison of, 9t
as ethical decision-making tool, 82
feedback mechanism of, 9f
Nursing profession
action plan for, 297, 297d
mobilizing power of, 296–299, 296d
renewal of, 178
Nurse navigator, 326
Nursing roles, newer health-care delivery
models and, 326
Nursing service philosophy, 148, 149d
O
Objectives, 153–155
Observational learning, 369
Occupational Safety and Health Act (OSHA), 535
Ombudspersons, 505
Omnibus Budget Reconciliation Act of 1987, 475
Ongoing coaching, 605
Open shops, 521
Operant conditioning, 418, 420
Operating budget, 214–215
Operating expenses, 210d
Operational and strategic planning, 138–160
forecasting in, 143
for future, 140–142
goals in, 153–155
individual philosophies and values in, 151–153
leadership roles and management functions in,
139d–140d, 158
long-term planning in, 139 (See also
Strategic planning)
mission statements in, 147–148, 148d
objectives in, 153–155
overcoming barriers to, 157–158
philosophy statement in, 148–150, 149d, 150f
(See also Philosophy statement)
planning hierarchy in, 146, 147f
policies in, 155–157 (See also Policies)
proactive planning in, 142–143
procedures in, 155–157
rules in, 157
societal philosophies and values in, 151
strategic planning in, 144–146 (See also
Strategic planning)
vision statements in, 147, 148d
Oral language, 440. See also Communication
Organizational aging, 174–175
Organizational change with nonlinear dynamics,
172–174
chaos theory in, 173–174
complex adaptive systems theory in, 173–174, 173d
complexity science in, 172
overview of, 172
Organizational communication, 437. See also
Communication
integrating leadership and management in, 459–460
overview of, 437
social media, 453–454
strategies of, 441–443
technology on, 452–454
variables in, 440
Organizational conflict, sources of, 498d
Organizational culture, 274–276, 276d
Organizational effectiveness, 281–282
Organizational standards, 549
Organizational structure, 260–286. See also
Organization chart
bureaucracy in, 263
committee responsibilities and opportunities in,
280–281
committee structure in, 279
components of, 264–269
centrality, 267–269
managerial levels, 266–267, 267t
organizational chart, 264, 264f
relationships and chain of command, 264–265
span of control, 265–266
decision making within organizational hierarchy in,
272–273
definition and scope of, 261
formal and informal structure in, 261–262
leadership roles and management functions in,
262d, 282
magnet status and, 278–279
organizational culture in, 274–276, 276d
organizational effectiveness in, 281–282
organizational theory in, 263
organization charts in, limitations of, 269–270
shared governance in, 277–278
stakeholders in, 273–274, 274d
types of, 270–273
ad hoc design, 271
flat designs, 272, 273f
line structures, 271

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Index 649
matrix structure, 271, 272f
service line, 271
Organizational theory and bureaucracy, 263
Organization chart, 263, 264f
advantages of, 270d
centrality in, 267–269
limitations of, 269–270, 270d
managerial levels in, 266–267, 267t
relationships and chain of command in, 264–265
span of control in, 265–266
Organizing, 261
Organizing, in management process, 37
Orientation program, 357–358
purpose of, 356
responsibilities for, 357d
sample 2-week orientation schedule, 356d
ORYX, 558
ORYX Plus, 558
Ouchi, W.G., 43
Outcome audit, 551–552
Outcomes accountability, 545. See also Quality control
Outlier, 220
Overdelegating, 472. See also Delegation
Overgeneralizing, 15
Overt conflict, 494
P
Participative decision making, 37
Participatory management, 277
Passive–aggressive communication, 446
Passive communication, 446
Paternalism, 76, 76d
Pathway to Excellence program, 279
Patient advocacy, 120–121
Patient- and family-centered care, 327–328, 327d
Patient care, organizing, 311–330
clinical nurse–leader in, 326–327
disease management in, 323–324, 324d
future of patient delivery models and, 329
leadership roles and management functions in,
312d, 329–320
optimum mode for, selecting, 324–325
clinical nurse-leader, 326–327
newer health-care delivery models and nursing
roles, 326
nurse navigator, 326
patient- and family-centered care,
327–328, 327d
traditional modes of, 313–323
case management, 321–322
functional method, 314–315
interprofessional primary health-care
teams, 321
modular nursing, 318
multidisciplinary team leader role, 317–318
overview, 313, 313d
primary nursing, 319–320, 319f
team nursing, 316–317
total patient care nursing/case method
nursing, 313–314
Patient-centered medical home (PCMH), 227
Patient classification system, 397d
Patient injury, 100
Patient rights, 121
in California, 122d
Patient Safety and Quality Improvement Act, 563
Patient safety officer, 556
Patient’s Bill of Rights, 121
Patient Self-Determination Act (PSDA), 95
Pay for Performance (P4P), 210d
Pay for value programs, 210d
Payoff tables, 21
Peer review, 583–584
Perceived conflict, 493
Performance appraisal, 573–592
accuracy and fairness in, 576–577, 577d
coaching in, 605
documentation of interview in, 559, 559d
for employee motivation, 589–590
factors influencing effective, 576d
interview in
overcoming difficulties in, 587–589
planning, 586
leadership roles and management functions in,
574d, 576
performance management vs., 590
tools in, 549–556
Performance appraisal tools, 585–587
behaviorally anchored rating scales, 580–581
checklists, 581
360-degree evaluation, 585
essays, 581
job dimension scales, 580, 580d
management by objectives, 582–583
peer review, 583–584
self-appraisals, 581
summary, 555d, 556
trait rating scales, 550, 550d
Performance budgeting, 218
Performance deficiency coaching, 605–606, 605d
Performance evaluation, 575, 579
Performance management, 590
Performing, 457, 457t
Perpetual budget, 211
Personal liability, 103
Personal power base, building, 299–301, 301d
Personal time management, 191–193
Personnel budgets, 212–214
nursing care hours per patient-day in, 212, 213f
staffing mix in, 212
worked/productive time and nonproductive/benefit
time in, 213
Peter Principle, 427
Philosophical congruence, in planning hierarchy,
150, 150f
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650 Index
Philosophy statement, 148–150
nursing service philosophy in, 148, 149d
organizational philosophy in, 148
philosophical congruence in planning hierarchy in,
148, 149f
sample, 149d
unit philosophy in, 149
working, 150
Physician Group Practice Demonstration, 559
Physician Quality Reporting Initiative (PQRI), 559
Placement, employee. See Staffing
Plaintiff, 99
Planned change, 162–176
classic change strategies in, 167–169
as collaborative process, 171
definition of, 163
leader-manager as role model in, 171
leadership roles and management functions in,
164d, 175–176
Lewin’s driving and restraining forces in,
166–166
Lewin’s model (change theory) in, 167
in nursing profession, 176
organizational aging and, 174
organizational change with nonlinear dynamics in,
172–174
(See also Organizational change with
nonlinear dynamics)
renewal from, 174–175
resistance in, 169–170
Planning, 139
effective, 139
long-term, 139
overcoming barriers to, 157–158
proactive, 142–143
reactive, 142
Planning hierarchy
in organizations, 146, 147f
philosophical congruence in, 148, 150f
Planning, in management process, 36
Point-of-service (POS) plans, 222
Policies
expressed, 156
implementation of, 156
implied, 156
value of, 157
Politics of power, 302–304
Population-based healthcare, 323
POSDCORB, 37
Positive organizational scholarship, 55
Positive psychology movement, 55
Positive reinforcement, as motivator, 425
Posture, in communication, 445. See also
Communication
Power, 287–306
authority–power gap in, 292–299
building personal power base in, 299–302
charismatic, 291
coercive, 291
definition of, 287
expert, 291
feminist, 289
gender and, 289
informational, 291
leadership roles and management functions
in, 262d, 305–306
legitimate, 291
manager, 292
of nursing, mobilizing, 296–299
politics of, 302–305
and powerlessness, 290
referent, 290–291
reward, 290
types and sources of, 291–292, 291t
Power–coercive strategy, 168
Power differentials, 588
Powerlessness, 290
Power-oriented people, 420
Preactive planners, 143
Preemployment testing, 350
Preferred provider organization (PPO), 209d, 211
Pregnancy Discrimination Act, 531
Preponderance of the evidence, 97
Primary nursing, 319–320
Principal, 53
Principal agent theory, 55
Priority common goal, 497
Priority setting, 187–188, 187d
Privacy Rule, HIPAA, 110–111
Private fee-for service (PFFS) plans, 222
Proactive leader, 303
Proactive planning, 142–143
Problem-centered coaching, 605
Problem employees, 596–625
chemically impaired employee, 614–615
(See also Chemically impaired employee)
disciplinary strategies for, 604–609
disciplining of
constructive vs. destructive, 599
with unionized employee, 611–612
fair and effective rules and, 600–601
grievance procedures for, 610–611
group norms and, 600
leadership roles and management functions for,
598d, 622–623
marginal employee, 597–598
progressive discipline in, 602–603
reprimand form, 603d
self-discipline of, 600
Problem solving
critical elements of, 11–15
definition of, 3
theoretical approaches to, 7–11
heuristics, 7
integrated ethical problem-solving model,
9–10, 10d

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Index 651
intuitive model, 10
managerial models, 8
nursing process, 8–9
structured approach, 7
traditional problem-solving process, 7
Problem-solving process, traditional, 7
Procedures, 155
Process audit, 552
Process objectives, 154
Procrastination, 187
Production hours, 211d
Productive time, 214
Product liability, 105
Professional advocacy, 127–131
Professional boundaries, 588
Professional mediator, 610
Professional negligence, 99–100, 99t
Professional nursing, delegation of, 437–479
leadership roles and management functions in,
integrating, 480–481
preparation for role of, 473
steps in, 475
subordinate resistance to, 478
task-based guide to, 449
to transcultural work team, 459
to unlicensed assistive personnel, 455–456
Professional nursing license. See License
Professional portfolio, reflective practice and, 248
Professional specialty certification, 246–248, 247d
personal benefits of, 247
patient outcomes and, 247–248
Professional Standards Review Board
legislation, 557
Professional standards review organizations
(PSROs), 557
Program evaluation and review technique
(PERT), 23, 23f
Progressive discipline, 601–604
formal reprimand or written admonishment in, 602
guide to, 603t
informal reprimand or verbal admonishment
in, 602
involuntary termination or dismissal in, 603
suspension from work in, 602
Promotions, 426–427
Prospective audits, 551
Prospective payment system (PPS), 209d, 220, 557
Provider-sponsored organizations (PSOs), 223
Proxemics, definition of, 444
Psychological impairment, 598
Punishment, 597, 599
Purpose statement, 147–148, 147d
Q
Qualitative conflict, 489
Quality assurance (QA), 561
Quality-based purchasing, 559
Quality control, 542–567
audits in, 551–552
Centers for Medicare and Medicaid Services on,
559–562
core measures, 558–559
definition of, 542
effective, 547d
external impacts on, 556
Hospital Consumer Assessment of Healthcare
Providers and Systems Surveys, 560–561
Joint Commission on, 557–558
leadership roles and management functions in,
515d, 565–567
Maryland Hospital Association Quality Indicator
Project for, 561
medical errors in, 562–565
Multistate Nursing Home Case Mix and Quality
Demonstration on, 561
National Committee for Quality Assurance on, 561
National Patient Safety Goals, 559
as organizational mandate, 556–559
ORYX, 558
outcomes in, 542, 544
participants in, 561
pay for performance, 559–560
as process, 544–547, 546f
professional standards review organizations in, 557
prospective payment system in, 557
quality-based purchasing, 559–560
quality health care definition in, 545–546
quality improvement models in, 554–555
report cards in, 565
standardized nursing languages, 553–554, 553d
standards development in, 548–551
Quality gap, 547
Quality health care
definitions of, 545–546
maintaining (see Quality control)
Quality improvement (QI), 563
Quality measurement, 545, 556–559. See also
Quality control
Quantitative conflict, 487
Quantum leadership, 63
R
Rational decision making, 5
Rational–empirical strategy, 8
Reactive leader, 43
Reactive planning, 142
Recency effect, 577
Recognition-Primed Decision (RPD) model, 11
Recruitment, 334–359
definition of, 334
nurse recruiter in, 338
and retention, 339
Reference checks, 350
Referent power, 291–292
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652 Index
Reflective practice, 590
Registered nurse (RN), 267
Rehabilitation Act of 1973, 535
Reimbursement, 218
Relational transparency, 61
Relationship age leadership, 63
Relationship-based nursing. See Primary nursing
Renewal, of nursing profession, 174
Report cards, 562
Resistance, to change, 169–171
Res judicata, 98
Resocialization, 373
Respondeat superior, 102–103
Responsibility, 238
Responsibility accounting, 208
Responsibility charting, 499
Responsive leader, 43
Restraining forces, 166–167, 166f
Result-focused objectives, 154
Résumé, 251
preparation, 251–252, 252f
Retention, recruitment and, 339
Retrospective audits, 551
Revenue, 211d
Revocation, of nursing license, 112, 112d
Reward power, 291
Rewards accomplishment, in delegation, 470
Ridicule, 503
Right-brain thinkers, 17
Rights
patient (See Advocacy)
patient bill of, 226
Rights-based reasoning, 75t, 75
Robert Wood Johnson Foundation (RWJF), 317, 327
Roe v. Wade, 98
Role models, in delegation, 470
Role strain, 376
Root cause analysis (RCA), 544
Rules, 157
S
Scabs, 522
Scalar chain, 272
Schedule completion stage, 396
Scheduling
agency nurses and travel nurses in, 395
developing policies on, 406–407
flextime in, 396
float pools in, 395
leadership roles and management functions in,
389d, 407–408
self-scheduling in, 396
shift bidding in, 396
Scheduling and staffing policies, 406–407, 389d
Schein, E.H, 42
Scientific management, 35–36
Scientific management theory, 599
Scope and Standards of Practice for Nurse
Administration, 120
Selection, employee, 349–352. See also Staffing
background screening, 350
educational and credential requirements in, 349–350
finalizing selection in, 351–352
internal applicants in, 351
making the selection in, 351
physical examination in, 351
preemployment testing in, 350–351
process overview in, 352f
reference checks in, 350
Selective contracting, 221
Self-appraisal, 581
Self-awareness
in authentic leadership, 60
in ethical decision making, 74
Self-care, 428–429
Self-discipline, 600
Self-scheduling, 396
Semistructured interview, 340
Senge, P., 365
Sentinel events, 448, 558
Servant leadership, 56–57, 57d
Service Employees International Union (SEIU), 518
Service line organization, 271
Sexual harassment, 532–534
Shared governance, 277, 277f, 277–278
Shift-based staffing, 406
Shift bidding, 396
Silence, 444. See also Nonverbal communication
Silent generation, 403
Simple assault, 104
Simple checklist, 581
Situation, Background, Assessment, Recommendation
(SBAR), 448–448, 448d
Six Sigma approach, 564
Skinner, B. F., 418
SMART approach to studying, 184d
Smart pumps, for intravenous (IV) therapy, 564
Smoothing, 496
Socialization. See also Team building
anticipatory, 374
clarifying role expectations in, 378–380
coaching as teaching strategy in, 381–382
definition of, 374
experienced nurse in new position, 376
international nurses and, 377–378
mentors in, 379–380
negative sanctions in, 380
and new nurse, 374–375
and orientation of new managers, 376–377
overcoming motivational deficiencies in, 380
positive sanctions in, 380
preceptors in, 378
role models in, 378

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Index 653
Social learning theory, 369, 370f
Social organization, importance of, 479. See also
Delegation
Soothing one party, 500
Sources of law, 95–96, 96t
administrative agencies, 97
constitution, 96
court decisions, 97
statutes, 96
Space, definition of, 479
Span of control, 265
Staff development, 366–367
assessing needs for, 369–370
education and training in, 367
evaluation of activities for, 370–371
responsibility for, 367–368
Staff HMOs, 221
Staffing, 334–361
aging workforce and, 337
centralized, 390–391
closed-unit, 405
decentralized, 390–391
demand factors in, 337
indoctrination in, 354–358, 355d (See also
Indoctrination, employee)
interviewee tips in, 346, 348–349, 349d
interviewing as selection tool in, 339–347, 348t
(See also Interviewing)
leadership roles and management functions in,
335d, 358
nursing education enrollments and, 337
nursing shortage and, 337–338
overview of, 335
placement in, 353–354
predicting needs for, 336–337
recruitment for, 338–339
requirements for, 397
selection in, 349–352 (See also Selection,
employee)
sequential steps in, 336d
supply factors in, 338
Staffing, in management process, 37
Staffing mix, 209d, 211
Staffing needs, 388–408. See also Scheduling
centralized vs. decentralized staffing in, 390–391
complying with mandates on, 391–393
developing policies for, 406–407
diverse staff management in, 402
fiscal and ethical accountability for, 405–406
generations and, 403–404
leadership roles and management functions in,
408d, 407–408
nursing care hours, staffing mix, and quality of care
relationship in, 401–402
nursing shortage on, 405
scheduling options and, 393–395 (See also
Scheduling)
unit manager’s responsibilities for, 390
workload measurement tools in, 397–401 (See also
Workload measurement tools)
Staffing ratios, 380–382
Staff organizations, 271
Stages of Change Model (SCM), 167, 167d
contemplation in, 167
maintenance in, 167
precontemplation in, 167
preparation in, 167
Stakeholder analysis, 274
Stakeholders, 273–274
external, 273–274, 274t
internal, 273, 274t
Standardized clinical guidelines, 550
Standardized nursing language, 553
Standards, establishing, 547
Standards of care, 99
Standards of Care and Standards of Professional
Performance, 548, 549d
Standards of Clinical Nursing Practice, 120
Standards of Practice, 120
Standards of Practice for Nurse Administrators, 80d
Standards of Professional Performance, 548
Stare decisis, 97
State Board of Nursing treatment programs,
620–621
State health facilities licensing boards, 535
Statutes, 96, 96t
Storming, 456, 457t
Strategic planning
balanced scorecard in, 145–146
as management process, 146
participants in, 147–147
SWOT analysis in, 145, 145d, 144d
Strengths-based leadership, 55, 55d
Strike, 522
Structure audit, 552
Structure change, 499
Structured approach, decision making, 7
Structured interview, 339
Subordinate advocacy, 124–125
Subordinate resistance, to delegation, 478. See also
Delegation
Substance misuse, 614
Substantive conflict. See Perceived conflict
Succession planning. See Management development
Sullivan v. Edward Hospital, 98
Supraordinate common goal, 497
SWOT analysis, 144, 144d, 145d
System, 42
Systematic soldiering, 35
T
Taft-Hartley Amendment (1947), 530
Taylor, Frederick W., 35
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654 Index
Team building
culturally diverse staff educational needs in, 382
evidence-based practice implementation in, shared
responsibility for, 373
leadership roles and management functions
in, 364d
learning organization in, 365
learning theories in, 367–371 (See also
Learning theories)
socialization and resocialization in, 373–380
(See also Resocialization; Socialization)
staff development in, 367
assessing needs for, 371
evaluation of activities for, 372–373
Team nursing, 316–317, 317f
Technology, in organizational communication, 452–454
Telecommunication, 453–454
Teleological theory of ethics, 74
Telephone communication, 444
Termination conference, 609
Termination, of group communication, 456
Theory X, 38, 421–422, 421d
Theory Y, 38, 421–422, 421d
Theory Z, 43
Thinking logically, 14–15
Thinking styles, on decision making, 17
Third-party consultation, 499
Third-party payment system, 211d
Thought leadership, 62–63
Time clocks and employment legislation, 530
Time inventory, 193
Time management, 181–195
definition of, 182
leadership roles and management functions in,
182d, 195–196
three basic steps to, 183–190
overview, 182–183, 183f
planning lists, 189–190
priority setting, 187–188
procrastination, 187–188
reprioritizing, 189–190
taking time to plan and establishing
priorities, 183–185
time-efficient work environment, 185–186
at work
daily planning actions, 186–187
interruptions, 189
personal, 191–193
time inventory, 193
time wasters, 190–191
Time wasters, 190–191
To Err Is Human, 543
Top-level managers, 266, 267t
Torts, 104
Total patient care nursing, 313–316, 314f
Total quality management (TQM), 554, 555
principles, 555d
TOWS analysis. See SWOT analysis
Toyota Production System (TPS), 554, 556–557
Trade-offs, 501
Training, 366
Trait rating scale, 579, 580d
Trait theories, 39
Transactional leadership, 45–47
Transfer, 609–611
accommodating, 609
definition of, 609
downward, 609
inappropriate, 609
lateral, 609
Transformational leadership, 44–46
Transforming Care at the Bedside (TCAB), 556
transition-to-practice programs/residencies
for new graduate nurses, 249–250
Travel nurses, 395
True value, characteristics of, 152
Turnover ratio, 211d
Two Factor theory, 419
U
Underdelegating, 471. See also Delegation
Unintentional tort, 104
Union, 516
Union membership, 520d
Union organizing/unionization
ANA and, 518
disciplining with, 597–598
effective labor–management relations and,
526–527
employee motivation for joining, 520–523
employee motivation for rejecting, 520–523
averting union, 522
nurse as supervisor, 523–524
historical perspective on, 517–518
leadership roles and management functions and,
515d, 536–537
managers’ role during, 525–526, 525d
membership, 520d
steps to establish, 526
strategies in, 524–525, 525d
Union representation of nurses, 518–519
Union shop, 517
United Auto Workers, 519
United Steelworkers of America (USWA), 519
Unity of command, 265
Unlicensed assistive personnel (UAP), 315, 476f
delegation to, 474–475
Unstructured interview, 340
Upward communication, 442
U.S. Food and Drug Administration (FDA), 564
U.S. government’s Equal Employment Opportunity
Commission (USEEOC), 531
Utilitarianism, 74–75, 74t
Utility, 76, 75d
Utilization review, 221

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Index 655
V
Value-based purchasing, 211d
Value indicator, 152
Values, 151
individual philosophies and, 151–152
societal philosophies and, 151
Variable costs, 211d
Variable expenses, 208
Variance, 322
Veracity, 75d, 77
Verbal admonishment. See Informal reprimand
Verbal communication, 444–446. See also
Communication
Veteran generation, 403
Veterans Readjustment Assistance Act, 535
Vicarious learning, 4–5
Vicarious liability, 102
Violence, workplace, 492
Vision statements, 147–148, 147d
Vocal expression, in communication, 445. See also
Communication
Vroom, Victor, 420, 420f
W
Wagner Act (1935), 517, 518, 530
Walkout, 522
Weber, Max, 36, 263–265
Weighted scale, 581
Whistle-blowing, 126–127
external, 126
internal, 126
White, R.K., 40
Wireless, local area networking (WLAN), 452–453
Worked time, 214
Workforce budget, 212–214
Workforce, diverse, 111–112
Work Force Engagement Online survey, 453
Workload measurement systems, 398–400
Workload measurement tools, 397–400
internal and external forces on, 397
nursing care hours per patient-day in, 397, 397f
patient classification systems in, 397–398,
399t–400t
workload measurement systems and, 398–399
Workload units, 407d
Workplace advocacy, 124
Workplace violence, 493
Written admonishment. See Formal reprimand
Written communication, 443, 450–451
Z
Zero-based budgeting, 216–217
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Leadership Roles and Management Functions in Nursing Theory and Application
Title Page
Copyright
Dedication
Reviewers
Preface
TEXT ORGANIZATION
LEARNING TOOLS
NEW AND EXPANDED CONTENT
THE CROSSWALK
Contents
UNIT I:The Critical Triad: Decision Making, Management, and Leadership
CHAPTER 1: Decision Making, Problem Solving, Critical Thinking, and Clinical Reasoning: Requisites for Successful Leadership and Management
DECISION MAKING, PROBLEM SOLVING, CRITICAL THINKING, AND CLINICAL REASONING
VICARIOUS LEARNING TO INCREASE PROBLEM-SOLVING AND DECISION-MAKING SKILLS
THEORETICAL APPROACHES TO PROBLEM SOLVING AND DECISION MAKING
CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING
INDIVIDUAL VARIATIONS IN DECISION MAKING
OVERCOMING INDIVIDUAL VULNERABILITY IN DECISION MAKING
DECISION MAKING IN ORGANIZATIONS
DECISION-MAKING TOOLS
PITFALLS IN USING DECISION-MAKING TOOLS
SUMMARY
ADDITIONAL LEARNING EXERCISE AND APPLICATIONS
REFERENCES
CHAPTER 2:
Classical Views of Leadership and Management
MANAGERS
LEADERS
HISTORICAL DEVELOPMENT OF MANAGEMENT THEORY
HISTORICAL DEVELOPMENT OF LEADERSHIP THEORY (1900 TO PRESENT)
INTERACTIONAL LEADERSHIP THEORIES (1970 TO PRESENT)
INTEGRATING LEADERSHIP AND MANAGEMENT
ADDITIONAL LEARNING EXERCISES
REFERENCES
CHAPTER 3:
Twenty-First-Century Thinking about Leadership and Management
NEW THINKING ABOUT LEADERSHIP AND MANAGEMENT
TRANSITION FROM INDUSTRIAL AGE LEADERSHIP TO RELATIONSHIP AGE LEADERSHIP
LEADERSHIP AND MANAGEMENT FOR NURSING’S FUTURE
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES

UNIT II:Foundation for Effective Leadership and Management Ethics, Law, and Advocacy
CHAPTER 4:
Ethical Issues
TYPES OF ETHICAL ISSUES
ETHICAL FRAMEWORKS FOR DECISION MAKING
PRINCIPLES OF ETHICAL REASONING
AMERICAN NURSES ASSOCIATION CODE OF ETHICS AND PROFESSIONAL STANDARDS
ETHICAL PROBLEM SOLVING AND DECISION MAKING
THE MORAL DECISION-MAKING MODEL
WORKING TOWARD ETHICAL BEHAVIOR AS THE NORM
ETHICAL DIMENSIONS IN LEADERSHIP AND MANAGEMENT
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN ETHICS
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 5: Legal and Legislative Issues
SOURCES OF LAW
TYPES OF LAWS AND COURTS
LEGAL DOCTRINES AND THE PRACTICE OF NURSING
PROFESSIONAL NEGLIGENCE
AVOIDING MALPRACTICE CLAIMS
EXTENDING THE LIABILITY
INCIDENT REPORTS
INTENTIONAL TORTS
OTHER LEGAL RESPONSIBILITIES OF THE MANAGER
LEGAL CONSIDERATIONS OF MANAGING A DIVERSE WORKFORCE
PROFESSIONAL VERSUS INSTITUTIONAL LICENSURE
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN LEGAL AND LEGISLATIVE ISSUES
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 6:
Patient, Subordinate, and Professional Advocacy
BECOMING AN ADVOCATE
PATIENT ADVOCACY
PATIENT RIGHTS
SUBORDINATE AND WORKPLACE ADVOCACY
WHISTLEBLOWING AS ADVOCACY
PROFESSIONAL ADVOCACY
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN ADVOCACY
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES

UNIT III:Roles and Functions in Planning
CHAPTER 7:
Strategic and Operational Planning
LOOKING TO THE FUTURE
PROACTIVE PLANNING
STRATEGIC PLANNING
ORGANIZATIONAL PLANNING: THE PLANNING HIERARCHY
VISION AND MISSION STATEMENTS
THE ORGANIZATION’S PHILOSOPHY STATEMENT
SOCIETAL PHILOSOPHIES AND VALUES
INDIVIDUAL PHILOSOPHIES AND VALUES
GOALS AND OBJECTIVES
POLICIES AND PROCEDURES
RULES
OVERCOMING BARRIERS TO PLANNING
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN PLANNING
ADDITIONAL LEARNING EXERCISE AND APPLICATIONS
REFERENCES
CHAPTER 8:
Planned Change
THE DEVELOPMENT OF CHANGE THEORY: KURT LEWIN
LEWIN’S DRIVING AND RESTRAINING FORCES
A CONTEMPORARY ADAPTATION OF LEWIN’S MODEL
CLASSIC CHANGE STRATEGIES
RESISTANCE: THE EXPECTED RESPONSE TO CHANGE
PLANNED CHANGE AS A COLLABORATIVE PROCESS
THE LEADER-MANAGER AS A ROLE MODEL DURING PLANNED CHANGE
ORGANIZATIONAL CHANGE ASSOCIATED WITH NONLINEAR DYNAMICS
ORGANIZATIONAL AGING: CHANGE AS A MEANS OF RENEWAL
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN PLANNED CHANGE
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 9:
Time Management
THREE BASIC STEPS TO TIME MANAGEMENT
PERSONAL TIME MANAGEMENT
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN TIME MANAGEMENT
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 10:
Fiscal Planning
BALANCING COST AND QUALITY
RESPONSIBILITY ACCOUNTING AND FORECASTING
BASICS OF BUDGETS
STEPS IN THE BUDGETARY PROCESS
TYPES OF BUDGETS
BUDGETING METHODS
CRITICAL PATHWAYS
HEALTH-CARE REIMBURSEMENT
MEDICARE AND MEDICAID
THE PROSPECTIVE PAYMENT SYSTEM
THE MANAGED CARE MOVEMENT
PROPONENTS AND CRITICS OF MANAGED CARE SPEAK UP
THE FUTURE OF MANAGED CARE
HEALTH-CARE REFORM AND THE PATIENT PROTECTION AND AFFORDABLE CARE ACT
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN FISCAL PLANNING
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 11: Career Development: From New Graduate to Retirement
CAREER STAGES
JUSTIFICATIONS FOR CAREER DEVELOPMENT
INDIVIDUAL RESPONSIBILITY FOR CAREER DEVELOPMENT
THE ORGANIZATION’S RESPONSIBILITY FOR CAREER DEVELOPMENT
CAREER COACHING
MANAGEMENT DEVELOPMENT
COMPETENCY ASSESSMENT AS PART OF CAREER DEVELOPMENT
PROFESSIONAL SPECIALTY CERTIFICATION
REFLECTIVE PRACTICE AND THE PROFESSIONAL PORTFOLIO
CAREER PLANNING AND THE NEW GRADUATE NURSE
TRANSITION-TO-PRACTICE PROGRAMS/RESIDENCIES FOR NEW GRADUATE NURSES
RESUMÉ PREPARATION
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN CAREER DEVELOPMENT
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES

UNIT IV:Roles and Functions in Organizing
CHAPTER 12: Organizational Structure
FORMAL AND INFORMAL ORGANIZATIONAL STRUCTURE
ORGANIZATIONAL THEORY AND BUREAUCRACY
COMPONENTS OF ORGANIZATIONAL STRUCTURE
LIMITATIONS OF ORGANIZATION CHARTS
TYPES OF ORGANIZATIONAL STRUCTURES
DECISION MAKING WITHIN THE ORGANIZATIONAL HIERARCHY
STAKEHOLDERS
ORGANIZATIONAL CULTURE
SHARED GOVERNANCE: ORGANIZATIONAL DESIGN FOR THE 21ST CENTURY?
MAGNET DESIGNATION AND PATHWAY TO EXCELLENCE
COMMITTEE STRUCTURE IN AN ORGANIZATION
RESPONSIBILITIES AND OPPORTUNITIES OF COMMITTEE WORK
ORGANIZATIONAL EFFECTIVENESS
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH ORGANIZATIONAL STRUCTURE
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 13: Organizational, Political, and Personal Power
UNDERSTANDING POWER
THE AUTHORITY–POWER GAP
MOBILIZING THE POWER OF NURSING
STRATEGIES FOR BUILDING A PERSONAL POWER BASE
THE POLITICS OF POWER
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS WHEN USING AUTHORITY AND POWER IN ORGANIZATIONS
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 14: Organizing Patient Care
TRADITIONAL MODES OF ORGANIZING PATIENT CARE
DISEASE MANAGEMENT
SELECTING THE OPTIMUM MODE OF ORGANIZING PATIENT CARE
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN ORGANIZING PATIENT CARE
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES

UNIT V:Roles and Functions in Staffing
CHAPTER 15: Employee Recruitment, Selection, Placement, and Indoctrination
PREDICTING STAFFING NEEDS
IS THERE A CURRENT NURSING SHORTAGE?
RECRUITMENT
INTERVIEWING AS A SELECTION TOOL
TIPS FOR THE INTERVIEWEE
SELECTION
PLACEMENT
INDOCTRINATION
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN EMPLOYEE RECRUITMENT, SELECTION, PLACEMENT, AND INDOCTRINATION
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 16: Socializing and Educating Staff for Team Building in a Learning Organization
THE LEARNING ORGANIZATION
STAFF DEVELOPMENT
LEARNING THEORIES
ASSESSING STAFF DEVELOPMENT NEEDS
EVALUATION OF STAFF DEVELOPMENT ACTIVITIES
SHARED RESPONSIBILITY FOR IMPLEMENTING EVIDENCE-BASED PRACTICE
SOCIALIZATION AND RESOCIALIZATION
OVERCOMING MOTIVATIONAL DEFICIENCIES
COACHING AS A TEACHING STRATEGY
MEETING THE EDUCATIONAL NEEDS OF A CULTURALLY DIVERSE STAFF
INTEGRATING LEADERSHIP AND MANAGEMENT IN TEAM BUILDING THROUGH SOCIALIZING AND EDUCATING STAFF IN A LEARNING ORGANIZATION
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 17: Staffing Needs and Scheduling Policies
UNIT MANAGER’S RESPONSIBILITIES IN MEETING STAFFING NEEDS
CENTRALIZED AND DECENTRALIZED STAFFING
COMPLYING WITH STAFFING MANDATES
STAFFING AND SCHEDULING OPTIONS
WORKLOAD MEASUREMENT TOOLS
THE RELATIONSHIP BETWEEN NURSING CARE HOURS, STAFFING MIX, AND QUALITY OF CARE
MANAGING A DIVERSE STAFF
GENERATIONAL CONSIDERATIONS FOR STAFFING
THE IMPACT OF NURSING STAFF SHORTAGES UPON STAFFING
FISCAL AND ETHICAL ACCOUNTABILITY FOR STAFFING
DEVELOPING STAFFING AND SCHEDULING POLICIES
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN STAFFING AND SCHEDULING
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES

UNIT VI:Roles and Functions in Directing
CHAPTER 18: Creating a Motivating Climate
INTRINSIC VERSUS EXTRINSIC MOTIVATION
MOTIVATIONAL THEORY
CREATING A MOTIVATING CLIMATE
STRATEGIES FOR CREATING A MOTIVATING CLIMATE
PROMOTION: A MOTIVATIONAL TOOL
PROMOTING SELF-CARE
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN CREATING A MOTIVATING CLIMATE AT WORK
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 19: Organizational, Interpersonal, and Group Communication
THE COMMUNICATION PROCESS
VARIABLES AFFECTING ORGANIZATIONAL COMMUNICATION
ORGANIZATIONAL COMMUNICATION STRATEGIES
COMMUNICATION MODES
ELEMENTS OF NONVERBAL COMMUNICATION
VERBAL COMMUNICATION SKILLS
LISTENING SKILLS
WRITTEN COMMUNICATION WITHIN THE ORGANIZATION
THE IMPACT OF TECHNOLOGY ON CONTEMPORARY ORGANIZATIONAL COMMUNICATION
COMMUNICATION, CONFIDENTIALITY, AND HEALTH INSURANCE PORTABILITY AND ACCOUNTABLITY ACT
GROUP DYNAMICS
INTEGRATING LEADERSHIP AND MANAGEMENT IN ORGANIZATIONAL, INTERPERSONAL, AND GROUP COMMUNICATION
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 20: Delegation
DELEGATING EFFECTIVELY
COMMON DELEGATION ERRORS
DELEGATION AS A FUNCTION OF PROFESSIONAL NURSING
DELEGATING TO A TRANSCULTURAL WORK TEAM
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN DELEGATION
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 21: Effective Conflict Resolution and Negotiation
THE HISTORY OF CONFLICT MANAGEMENT
CATEGORIES OF CONFLICT: INTERGROUP, INTRAPERSONAL, AND INTERPERSONAL
THE CONFLICT PROCESS
CONFLICT MANAGEMENT
MANAGING UNIT CONFLICT
NEGOTIATION
ALTERNATIVE DISPUTE RESOLUTION
SEEKING CONSENSUS
INTEGRATING LEADERSHIP SKILLS AND MANAGEMENT FUNCTIONS IN MANAGING CONFLICT
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 22: Collective Bargaining, Unionization, and Employment Laws
UNIONS AND COLLECTIVE BARGAINING
HISTORICAL PERSPECTIVE OF UNIONIZATION IN AMERICA
UNION REPRESENTATION OF NURSES
AMERICAN NURSES ASSOCIATION AND COLLECTIVE BARGAINING
EMPLOYEE MOTIVATION TO JOIN OR REJECT UNIONS
AVERTING THE UNION
THE NURSE AS SUPERVISOR: ELIGIBLITY FOR PROTECTION UNDER THE NATIONAL LABOR RELATIONS ACT
UNION-ORGANIZING STRATEGIES
MANAGERS’ ROLE DURING UNION-ORGANIZING
STEPS TO ESTABLISH A UNION
EFFECTIVE LABOR–MANAGEMENT RELATIONS
EMPLOYMENT LEGISLATION
STATE HEALTH FACILITIES LICENSING BOARDS
INTEGRATING LEADERSHIP SKILLS AND MANAGEMENT FUNCTIONS WHEN WORKING WITH COLLECTIVE BARGAINING, UNIONIZATION AND EMPLOYMENT LAWS
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES

UNIT VII:Roles and Functions in Controlling
CHAPTER 23: Quality Control
DEFINING QUALITY HEALTH CARE
QUALITY CONTROL AS A PROCESS
THE DEVELOPMENT OF STANDARDS
AUDITS AS A QUALITY CONTROL TOOL
STANDARDIZED NURSING LANGUAGES
QUALITY IMPROVEMENT MODELS
WHO SHOULD BE INVOLVED IN QUALITY CONTROL?
QUALITY MEASUREMENT AS AN ORGANIZATIONAL MANDATE
CENTERS FOR MEDICARE AND MEDICAID SERVICES
MEDICAL ERRORS: AN ONGOING THREAT TO QUALITY OF CARE
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS WITH QUALITY CONTROL
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 24: Performance Appraisal
USING THE PERFORMANCE APPRAISAL TO MOTIVATE EMPLOYEES
STRATEGIES TO ENSURE ACCURACY AND FAIRNESS IN THE PERFORMANCE APPRAISAL
PERFORMANCE APPRAISAL TOOLS
PLANNING THE APPRAISAL INTERVIEW
OVERCOMING APPRAISAL INTERVIEW DIFFICULTIES
PERFORMANCE MANAGEMENT
COACHING: A MECHANISM FOR INFORMAL PERFORMANCE APPRAISAL
BECOMING AN EFFECTIVE COACH
USING LEADERSHIP SKILLS AND MANAGEMENT FUNCTIONS IN CONDUCTING PERFORMANCE APPRAISALS
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES
CHAPTER 25: Problem Employees: Rule Breakers, Marginal Employees, and the Chemically or Psychologically Impaired
CONSTRUCTIVE VERSUS DESTRUCTIVE DISCIPLINE
SELF-DISCIPLINE AND GROUP NORMS
FAIR AND EFFECTIVE RULES
DISCIPLINE AS A PROGRESSIVE PROCESS
DISCIPLINARY STRATEGIES FOR THE NURSE-MANAGER
TRANSFERRING THE PROBLEM EMPLOYEE
GRIEVANCE PROCEDURES
DISCIPLINING THE UNIONIZED EMPLOYEE
THE MARGINAL EMPLOYEE
THE CHEMICALLY IMPAIRED EMPLOYEE
RECOGNIZING THE CHEMICALLY IMPAIRED EMPLOYEE
INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS WHEN DEALING WITH PROBLEM EMPLOYEES
ADDITIONAL LEARNING EXERCISES AND APPLICATIONS
REFERENCES

Appendix : Solutions to Selected Learning Exercises
Index

Outline:

· Definition of problem and problem solving.​

· Problem Solving Methods.​

· Problem Solving Models.​

· Vicarious Learning To Increase Problem-Solving And Decision-Making Skills.​

· Advantage and disadvantage of Group Problem Solving.​

· Stumbling Blocks.

References

· Sullivan E.J. & Decker P.J. (2018). Effective Leadership & Management in Nursing.9th ed. Pearson Prentice Hall.​

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

· Deniz Kocoglu, R. N., et al. “Problem solving training for first line nurse managers.” International Journal of Caring Sciences 9.3 (2016): 955.‏​

· https://graduateway.com/problem-solving-methods-nursing/​

PROBLEM SOLVING RUBRIC

Capstone
4

Milestones
3 2

Benchmark
1

Define Problem Demonstrates the ability to
construct a clear and insightful

problem statement with
evidence of all relevant

contextual factors.

Demonstrates the ability to
construct a problem statement
with evidence of most relevant
contextual factors, and problem
statement is adequately detailed.

Begins to demonstrate the
ability to construct a problem
statement with evidence of
most relevant contextual

factors, but problem statement
is superficial.

Demonstrates a limited ability
in identifying a problem
statement or related contextual
factors.

Identify Strategies Identifies multiple approaches
for solving the problem that
apply within a specific context.

Identifies multiple approaches
for solving the problem, only
some of which apply within a
specific context.

Identifies only a single
approach for solving the
problem that does apply within
a specific context.

Identifies one or more
approaches for solving the
problem that do not apply
within a specific context.

Propose
Solutions/Hypotheses

Proposes one or more
solutions/hypotheses that
indicates a deep comprehension
of the problem.
Solution/hypotheses are
sensitive to contextual factors
as well as all of the following:
ethical, logical, and cultural
dimensions of the problem.

Proposes one or more
solutions/hypotheses that
indicates comprehension of the
problem. Solutions/hypotheses
are sensitive to contextual
factors as well as the one of the
following: ethical, logical, or
cultural dimensions of the
problem.

Proposes one
solution/hypothesis that is “off
the shelf” rather than
individually designed to address
the specific contextual factors
of the problem.

Proposes a solution/hypothesis
that is difficult to evaluate
because it is vague or only
indirectly addresses the
problem statement.

Evaluate Potential
Solutions

Evaluation of solutions is deep
and elegant (for example,
contains thorough and
insightful explanation) and
includes, deeply and
thoroughly, all of the following:
considers history of problem,
reviews logic/reasoning,
examines feasibility of solution,
and weighs impacts of solution.

Evaluation of solutions is
adequate (for example, contains
thorough explanation) and
includes the following:
considers history of problem,
reviews logic/reasoning,
examines feasibility of solution,
and weighs impacts of solution.

Evaluation of solutions is brief
(for example, explanation lacks
depth) and includes the
following: considers history of
problem, reviews
logic/reasoning, examines
feasibility of solution, and
weighs impacts of solution.

Evaluation of solutions is
superficial (for example,
contains cursory, surface level
explanation) and includes the
following: considers history of
problem, reviews
logic/reasoning, examines
feasibility of solution, and
weighs impacts of solution.

Implement Solution Implements the solution in a
manner that addresses
thoroughly and deeply multiple
contextual factors of the
problem.

Implements the solution in a
manner that addresses multiple
contextual factors of the
problem in a surface manner.

Implements the solution in a
manner that addresses the
problem statement but ignores
relevant contextual factors.

Implements the solution in a
manner that does not directly
address the problem statement.

Evaluate Outcomes Reviews results relative to the
problem defined with
thorough, specific
considerations of need for
further work.

Reviews results relative to the
problem defined with some
consideration of need for
further work.

Reviews results in terms of the
problem defined with little, if
any, consideration of need for
further work.

Reviews results superficially in
terms of the problem defined
with no consideration of need
for further work

Problem Solving

Prepared by:

Fadiah Abdullah Kariri

Zahrah Mohammed Dallak

Huda Alonazi

Outline:

Definition of problem and problem solving.
Problem Solving Methods.
Problem Solving Models.
Vicarious Learning To Increase Problem-Solving And Decision-Making Skills.
Advantage and disadvantage of Group Problem Solving.
Stumbling Blocks.

Definition
Problem
“a deficiency or undesired situation”( Le Storti et al.,1999)
Problem solving
Problem solving is the process of designing, evaluating and implementing a strategy to answer an open-ended question or achieve a desired goal.
Focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be”

Problem-Solving is a skill that can be learnt; many times by role modeling and mentoring.
Decision-making relies on scientific problem-solving process.

Problem-solving Methods
1.Trial-and-error method
People with little management experience tend to use the trial-and-error method, applying one solution after another until the problem is solved or appears to be improving. These managers often cite lack of experience, time, and resources to search for alternative solutions.

Heuristics (which are defined as shortcut mental strategies that help simplify information) use trial-and-error methods or a rule-of-thumb approach to problem solving, rather than set rules.

2. Experimentation
Involves testing a theory (hypothesis) or hunch to enhance knowledge, understanding, or prediction. Data are collected and analysed and the results interpreted to determine whether the solution tried has been effective.

3. Past experience and intuition
Everyone has various and countless experiences. Individuals build a repertoire of these experiences and base future actions on what they have considered successful solutions in the past.
Intuition relies heavily on past experience and trial and error. The extent to which past experience is related to intuition is difficult to determine, but nurses’ wisdom, sensitivity, and intuition are known to be valuable in solving problems.

Some problems are self-solving

YES NO

Question
Although the postoperative assessment of a client reveals no abnormalities, the nurse believes the client’s condition is deteriorating and orders frequent vital signs. This intervention was made on the basis of which type of problem solving?
Select all that apply.
1. Experimentation
2. Intuition
3. Satisficing
4. Past experience
5. Trial-and-error method

Answer 2,4
Intuition , Past experience

Problem Solving Models
Problem solving models are used to address the many challenges that arise in the workplace. While many people regularly solve problems, there are a range of different approaches that can be used to find a solution.
1. The Six Step Problem Solving Model
2. Managerial Decision-Making Model
3. Nursing Process
4. Integrated Ethical Problem-Solving Model

1. The Six Step Problem Solving Model

To solve a problem you need to follow this six-step process;

Complex challenges for teams and working groups are usually solved more quickly by using a shared, collaborative, and systematic approach to problem solving.

Step One: Define the Problem
The definition of a problem should be a descriptive statement of the state of affairs, not a judgment or conclusion.

At this stage groups will use techniques such as:
• Brainstorming
• Interviewing
• Questionnaires
As this step continues, the PS group will constantly revise the definition of the problem. As more symptoms are found, it clarifies what the real problem is.

Step Two: Determine the Root Cause(s) of the Problem
Once all the symptoms are found and the problem diagnosed and an initial definition agreed, the PS group begins to explore what has caused the problem.
In this step the problem solving team will use tools such as:
• Fishbone diagrams
This technique help collate the information in a structured way, and focus in on the underlying causes of the problem. This is called the root cause.

Step Three: Develop Alternative Solutions
At this stage it is not about finding one solution, but eliminating the options that will prove less effective at dealing with both the symptoms and the root cause.

Step Four: Select a Solution
In the fourth step, groups evaluate all the selected, potential solutions, and narrow it down to one.
This step applies two key questions.
1. Which solution is most feasible?
2. Which solution is favoured by those who will implement and use it?

Step Five: Implement the Solution
Once the solution has been chosen, initial project planning begins and establishes:
• The project manager.
• Who else needs to be involved to implement the solution.
• When the project will start.
• What actions need to be taken before implementing the solution.
• What actions need to be taken during the implementing the solution.
• Why are these actions necessary?

Step Six: Evaluate the Outcome

TIPS TO HELP WITH PROBLEM-SOLVING
Think before acting. Use a problem-solving process.
Think clearly – stay open-minded. Separate facts from opinions.
Consider the evidence (information) – do not jump to conclusions. Don’t try to make the facts fit the solution you want to use.
Ask as many questions as you can. Make sure you are asking the right questions to find out what the problem really is.
Be selective. You cannot solve every problem. Make sure the problem is yours to solve.
If a problem seems to be overwhelming, break it into parts.
Don’t wait for a problem to occur. If you can take action before a situation turns into a problem, do so.

Question
The nursing group has been charged with the task of solving a patient care problem on the unit. Which step should this group take first in this process?
1. Investigate what has already been tried to solve the issue.
2. Brainstorm about potential solutions.
3. Gather information to define the problem.
4. Categorize information in order of reliability.

Answer
3. Gather information to define the problem.

At the beginning of a brainstorming session, the manager lists the rules to be followed. Which rule should be included and enforced?

1. Do not suggest any solution that is prohibitively expensive.
2. Suggest only ideas that the group has not already tried.
3. Do not critique any ideas presented.
4. Limit the session to the first 15 ideas.

Answer
3. Do not critique any ideas presented.

A group of nurses has been convened to solve a problem. As the first step in this process, the group leader asks for a definition of the problem to be solved. Which statement reflects the best problem statement?
1. Emergency department nurses do not make professional client handoff reports.
2. Long-term care facility nurses lack the education to make complete assessments prior to client transfers.
3. Housekeepers are getting sloppy about cleaning rooms.
4. Unit clerks have made 10 transcription errors in the last 6 months.

Answer
4. Unit clerks have made 10 transcription errors in the last 6 months.

Problem Solving Models
2. Managerial Decision-Making Models
To address the weaknesses of the traditional problem-solving process, many contemporary models for management decision making have added an objective-setting step.
These models are known as managerial decision-making models or rational decision-making models.

Managerial Decision Making Model
1. Determine the decision and the desired outcome (set objectives).
2. Research and identify options.
3. Compare and contrast these options and their consequences.
4. Make a decision.
5. Implement an action plan.
6. Evaluate results.

3.The Nursing Process
The nursing process, developed by Ida Jean Orlando in the late 1950s, provides another theoretical system for solving problems and making decisions.
include at least five steps:
1. Assess
2. Diagnose
3. Plan
4. Implement
5. Evaluate

A serious disagreement has arisen between two staff nurses. The unit manager elects not to make a decision regarding the disagreement until more evidence is collected. Which part of the nursing process does this manager’s critical thinking reflect?
1. Assessment
2. Diagnosis
3. Planning
4. Evaluation

Answer
2. Diagnosis

4.Integrated Ethical Problem-Solving Model
1. State the problem.
2. Collect additional information and analyse the problem.
3. Develop alternatives and analyse and compare them.
4. Select the best alternative and justify your decision.
5. Develop strategies to successfully implement a chosen alternative and take action.
6. Evaluate the outcomes and prevent a similar occurrence.

Vicarious Learning To Increase Problem-Solving And Decision-Making Skills
Case studies, simulation, and problem-based learning (PBL) are some of the strategies that have been developed to vicariously improve problem solving and decision making.

Case studies
may be thought of as stories that impart learning.
They may be fictional or include real persons and events, be relatively short and self-contained for use in a limited amount of time, or be longer with significant detail and complexity for use over extended periods of time.

Simulation
provides learners opportunities for problem solving that have little or no risk to patients or to organizational performance.
For example, some organizations are now using computer simulation (known as discrete event simulation) to imitate the operation of a real-life system such as a hospital.

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

Problem-based learning (PBL):
learners meet in small groups to discuss and analyse real-life problems. Thus, they learn by problem solving.
The learning itself is collaborative as the teacher guides the students to be self-directed in their learning, and many experts suggest that this type of active learning helps to develop critical thinking skills.

Group Problem Solving
Traditionally, managers solved most problems in isolation. This practice, however, is outdated Both the complexity of problems and the staff’s desire for meaningful involvement create the impetus for using group approaches to problem solving.
Today consensus-based problem solving, inherent in shared governance, is the norm.

Advantages of Group Problem Solving
Groups collectively possess greater knowledge and information than any single member and may access more strategies to solve a problem. Under the right circumstances and with appropriate leadership.
Groups can deal with more complex problems than a single individual, , especially if there is no one right or wrong solution to the problem.

Individuals tend to rely on a small number of familiar strategies; a group is more likely to try several approaches.
Group members may have a greater variety of training and experiences and approach problems from more diverse points of view.
Together, a group may generate more complete, accurate, and less biased information than one person.

Groups may deal more effectively with problems. That cross organizational boundaries or involve change that requires support from other units or departments.
Participative problem solving has additional advantages: it increases the likelihood of acceptance and understanding of the decision, and it enhances cooperation in implementation.

Disadvantages of Group Problem Solving
Also managers may resist using groups to make decisions. They may fear that they may not agree with the decision the group makes.
Group problem solving also can be affected by groupthink. Groupthink is a negative phenomenon that occurs in highly cohesive groups that become isolated.

Group problem solving also has disadvantages: it takes time and resources and may involve conflict.
Members who are less informed or less confident may allow stronger members to control group discussion and problem solving.

Also groups tend to make riskier decisions than individuals. Groups are more likely to support unusual or unpopular positions (e.g., public demonstrations).
Individuals who lack information about alternatives may make a safe choice, but after group discussion they acquire additional information and become more comfortable with a less secure alternative.

Stumbling Blocks
The leader’s personality traits, inexperience, lack of adaptability, and preconceived ideas may be obstacles to decision making and problem solving.
Personality
The leader’s personality can and often does affect how and why certain decisions are made.
Managers are often selected because of their expert clinical, not managerial, skills. Inexperienced in management, they may resort to various unproductive actions.
On the one hand, a nurse manager who is insecure may base decisions primarily on approval seeking.

2. Rigidity
an inflexible management style, is another obstacle to problem solving.
It may result from ineffective trial-and-error solutions, fear of risk taking, or inherent personality traits.

The person who uses a rigid style in problem solving easily develops tunnel vision—the tendency to look at new things in old ways and from established frames of reference.

In today’s rapidly changing health care setting, rigidity can be a barrier to effective problem solving.

A nurse manager’s supervisor reports that many staff members have complained about the manager’s rigidity. What situations reflect this rigidity? 
Note: Select all that apply. 

1. The manager has historically used trial and error as a decision-making strategy. 
2. The manager takes unnecessary risks when staffing the unit. 
3. The manager is not concerned when staff members arrive late to work. 
4. The manager uses old ways of thinking to solve the day-to-day issues of the unit. 
5. The manager does not consider the advice of the assistant manager when making a decision. 

Answer:  1, 4

3. Preconceived Ideas
Effective leaders do not start out with the preconceived idea that one proposed course of action is right and all others wrong. Nor do they assume that only one opinion can be voiced and others will be silent.
They start out with a commitment to find out why others disagree. If the staff, other professionals, or patients see a different reality or even a different problem, leaders need to integrate this information into developing additional problem-solving alternatives.

Sullivan E.J. & Decker P.J. (2018). Effective Leadership & Management in Nursing.9th ed. Pearson Prentice Hall.
Leadership roles and management functions in nursing: theory and application/Bessie L. Marquis, Carol J. Huston.—8th edition.
Deniz Kocoglu, R. N., et al. “Problem solving training for first line nurse managers.” International Journal of Caring Sciences 9.3 (2016): 955.‏
https://graduateway.com/problem-solving-methods-nursing/