Problem solving
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.
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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
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Library of Congress Cataloging-in-Publication Data
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.
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continue to shape the nursing workforce and
patient populations.
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demics require all healthcare organizations to
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be better educated to participate as full partners
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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
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Introducing Nursing Management 11
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12 Chapter 1
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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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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
Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake,
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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
mailto:aone@aha.org
mailto:aone@aha.org
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?
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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.
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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,
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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.
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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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
• 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:
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Berrett-Koehler Publishers.
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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.
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Sheer, V. C., & Chen, L. (2004). Improving media
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Sullivan, E. J. (2013). Becoming influential: A guide
for nurses (2nd ed.). Upper Saddle River, NJ:
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E., & Deutschlander, S. (2009). Role understanding
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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
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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
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Castner, J., Foltz-Ramos, K., Schwartz, D. G., &
Ceravolo, D. J. (2012). A leadership challenge:
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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,
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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:
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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?
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24, 2015, from http://www.biomedcentral.
com/1472-6920/11/15
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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
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.
Medicare.gov. (2016). Linking quality to payment.
Retrieved January 14, 2016, from http://www.
medicare.gov/hospitalcompare/linking-quality-
to-payment.html
Welton, J. M., & Harper, E. M. (2015). Nursing care
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 metropo
