I. Leadership
Leadership is an interpersonal process of motivating others in the accomplishment of a goal or change. It involves assisting others to develop a sense of control and purpose, developing a commitment to accomplish a desired outcome, and helping others meet the challenges that arise in the fast-paced, technologically advanced, constantly changing health-care environment.
A. Behavioral leadership styles
1. Behavioral leadership styles are associated with what a leader does.
2. A nurse should know various leadership styles because each style lends itself to different settings and different situations. For example, an emergency might require a nurse to decide and act quickly, whereas a complex problem might require reflective thinking about and thorough discussion of the alternatives with others before making a decision.
3. The most common behavioral leadership styles include the autocratic, democratic, and laissez-faire styles.
B. Transformational leadership theory
1. Leaders motivate followers by communicating the importance of their vision (goal), inspiring commitment, and exciting others to participate in the achievement of the vision. The vision is noble and for the good of humanity.
2. Transformational leaders often are characterized as being charismatic, energetic, optimistic, and courageous; having integrity; and being risk takers.
C. Situational leadership theories
1. Situational leadership theories propose that each circumstance may require a different leadership style because situations can be multifaceted, and the individuals involved have different strengths and weaknesses.
2. The ability to acclimate to a situation is the central premise of situational theories.
D. Quantum leadership theory
1. Quantum is a “unit of radiant energy.”
2. Quantum leadership theory is based on the concept that the fast growth of new information requires people to experience change, even as it is identified; this concept limits the thoughtful design and cautious implementation that other theories advocate.
3. It is based on the tenets of quantum physics.
- Leadership involves an interactive energy field between the leader and followers.
- Leadership cannot be estimated or structured.
- Leadership is not continuous.
- The impact depends on interaction (content and level) between the leader and followers.
II. Management
Management is the process of ensuring that tasks are accomplished to meet organizational goals. Managers are formally and authoritatively appointed to a position that inherently holds power and entitlement to implement and enforce decisions.
A. Management activities
1. Identifying problems and implementing new initiatives.
- Determining the significance of collected data and identifying trends that indicate a problem.
- Implementing projects based on results of evidence-based practice research, new technology, and new ideas.
2. Planning: Developing goals and determining strategies that are most likely to achieve organizational goals.
3. Organizing: Obtaining and managing human and economic resources to meet desired clinical and financial goals.
4. Directing: Motivating, guiding, and leading staff members in meeting organizational goals.
5. Controlling: Using outcome criteria to measure effectiveness in goal achievement, ensuring ongoing evaluation, and implementing corrective actions when necessary.
B. Management theories
1. Scientific management.
- Focuses on the task component of the management of subordinates.
- Based on the concept that when jobs are evaluated, tasks are planned so that they are more efficient, and workers are provided with adequate incentives so that productivity increases.
2. Human relations–oriented management.
- Focuses on the interrelationship component of management.
- Includes two types of management styles.
- Theory X: Managers believe that firm rules, continuous supervision, and fear of negative consequences produce effective, productive workers.
- Theory Y: Managers believe that assistance, support, guidance, and rewards produce satisfied, inspired workers; managers work at addressing conflict and supporting mutual respect and understanding to ensure a setting in which individuals can be most effective and productive.
III. Nursing Management
Nurse managers are formally and authoritatively appointed to the position. Inherent in the position is the power and entitlement to implement and enforce organizational decisions. Actual responsibilities and activities depend on the specific position within the hierarchy of the organization in which a nurse manager works. To function in this role effectively, a nurse manager should have strong leadership traits.
A. Principles of management applicable to nursing
1. Authority.
a. Authority is the power to direct the work of others. b. Authority is expressed through leadership and management activities and is related to accountability and responsibility.
2. Accountability.
- Accountability is the assumption of liability for the consequences of one’s own actions and the actions of subordinates.
- Accountability is reflected in one’s personal ethical integrity, support of the philosophy and objectives of the organization, standards of nursing practice, and elements of the state nurse practice act.
3. Responsibility.
- Responsibility is the assumption of the obligation to accomplish a task or perform an assigned role.
- Responsibility is assumed for the management and supervision of subordinates, utilization of financial resources, communication of information to and from subordinates, implementation of organizational policies and procedures, and achievement of organizational goals and objectives.
B. Levels of management in nursing
1. First-level managers.
- Are commonly responsible for managing daily activities associated with a specific group of people on a unit level, including delegating, supervising, and motivating staff to achieve organizational goals.
- Communicate staff and unit issues to unit-level managers and communicate information from higher-level managers back to staff on the unit.
- May have such titles as:
- Primary nurse
- Team leader
- Charge nurse
- Case manager
2. Unit-level managers.
- Are commonly responsible for 24-hour operation of a nursing unit, including staffing schedules, budget management, supervision of staff, and ongoing quality improvement.
- Communicate information to middle-level managers and to first-level managers.
- May have such titles as:
- Nurse manager
- Assistant nurse manager
3. Middle-level managers.
- Are commonly responsible for supervising several unit-level managers and the overall functioning of areas, units, or departments for which they are responsible.
- Spend less time on day-to-day management issues and more time on departmental planning and interdisciplinary problem-solving.
- Function as liaisons between upper-level and unit-level managers.
- May have such titles as:
- Nurse coordinator.
- Supervisor.
- Assistant director of nursing.
4. Upper-level (top-level) managers.
- Are commonly nurse executives who are responsible for determining organizational goals and developing strategic plans to achieve these goals.
- Are responsible for the overall management and practice of nursing within the organization.
- May have such titles as:
- Director of nursing.
- Vice president for nursing.
- Chief nurse.
- Associate administrator.
- Assistant administrator.
- Vice president for clinical care services (if also responsible for such areas as pharmacy and dietary).
C. Examples of activities of nurse managers
- Recruiting, hiring, and firing staff.
- Scheduling staff.
- Formulating and managing a budget.
- Establishing annual goals.
- Monitoring achievement of standards of practice.
- Supervising and counseling staff.
- Participating in and engaging staff in ongoing quality improvement activities.
- Providing for staff education.
- Providing a communication link among clients, upper management, and subordinates.
- Alerting administration to changing client and subordinate needs.
- Problem-solving issues proactively or reactively.
- Conducting regular staff meetings.
- Making rounds with primary health-care providers and nursing team members.
- Encouraging staff to participate in interdisciplinary facility-wide committees.
- Encouraging staff to participate in nursing research.
IV. Power and Empowerment
Power involves having the authority and ability to influence others to achieve a goal even in the presence of resistance. Power relates to actions. Empowerment involves a personal sense of competence, self-determination, and/or entitlement. Empowerment relates to feelings. Nurse managers must understand these concepts and integrate them into their practice.
A. Sources of power
1. Power of authority: A person in a position of authority can mandate compliance as a result of the power of the position.
- Power of reward: A manager can use incentives, such as pay increases or promotions, to influence others.
3. Power of coercion: A manager can use the threat of an undesirable performance evaluation or job termination to influence others; clients can return a less-than-satisfactory client satisfaction survey or complain about a staff member to a charge nurse.
4. Power of expertise: A nurse can gain power by obtaining an advanced degree in nursing, such as nurse practitioner, or extensive experience in a specialty area, such as in pediatric, oncology, or emergency nursing.
B. Empowerment
1. Empowerment is a feeling of competence, a feeling of capability to influence another person, or a feeling of privilege or entitlement.
2. Nurse managers must support and nourish positive feelings of growth, accomplishment, and independence in subordinates that facilitate feelings of empowerment.
V. Delegation
The American Nurses Association (2009) defines delegation as the process of “transferring responsibility for the performance of an activity or task while retaining accountability for the outcome.” Many changes in health-care delivery (e.g., reengineering of hospital organizations and downsizing the professional nursing workforce as a measure of cost containment) have resulted in the need for nurses to delegate tasks to unlicensed personnel, requiring nurses to spend more time in supervisory roles. The profession of nursing is working to ensure that unlicensed personnel are used only in supportive roles and not as substitutes for licensed nurses.
A. Five Rights of Delegation (must be met when a nurse delegates aspects of nursing care)
1. Right task: The task is appropriate for delegation.
2. Right circumstances: The nurse considers the appropriateness of the client setting, available resources, and other relevant factors.
3. Right person: The task is delegated to a person who is competent to perform the task within his or her legal scope of practice.
4. Right direction/communication: The nurse provides a clear, concise description of the task, including what should be accomplished and how it should be accomplished.
5. Right supervision: The delegator is responsible for monitoring and evaluating the performance of the
task and providing feedback to the person performing the task.
B. Policy considerations associated with delegation
1. A registered nurse (RN) is responsible for delegating and supervising care provided by unlicensed individuals in health-care environments.
2. Each state has its own definitions, regulations, and directives regarding delegation.
3. The following general policy matters are common to all states regarding delegation.
- State nurse practice acts delineate the legal boundaries of nursing practice.
- There is a need for capable and properly supervised nursing assistive personnel in the delivery of cost-effective, quality health care.
- An RN should assign or delegate tasks based on clients’ needs and statuses, the risk of harm, constancy of a client’s condition, intricacy of the task, likelihood of the outcomes, capabilities of the staff member to whom the task is delegated, and the circumstances of other client needs.
- All delegation decisions should be based on maintaining the safety and welfare of the public.
4. A nurse must understand the nurse practice act and the regulations and directives regarding delegation in the state in which the nurse works as well its application to the setting in which the nurse works.
5. Nurses are responsible for providing safe and effective nursing care over a range of care provided in various settings (e.g., hospital, nursing home, school, public health clinic, home-health agency).
6. In each setting, nurses are generally the coordinators of the health teams, which comprise a variety of licensed and unlicensed caregivers.
C. Principles of delegation related to nursing
- A nurse may delegate elements of care but retains responsibility to answer for personal actions associated with the nursing process.
- Pervasive functions of assessment, planning, evaluation, and nursing judgment cannot be delegated.
- A nurse must consider the education and skills of the person to whom the nurse delegates components of care.
- The decision to delegate should be based on the nurse’s judgment regarding the condition of the client, the abilities of nursing team members, and the amount of supervision that is necessary for the task delegated.
- A nurse must follow the Five Rights of Delegation and use professional judgment when delegating a task to another nursing team member.
- A nurse must communicate effectively and ensure that communication is a two-way process between the delegator and the subordinate.
- Nursing administrators are responsible for ensuring that assessment of policies and procedures and the evaluation of competence requirements associated with delegation are regularly conducted.
D. Delegation of activities to unlicensed assistive personnel
- A nurse should delegate only those tasks permitted by the state nurse practice act and facility policies and procedures.
- A nurse must know which care can be performed by unlicensed assistive personnel.
VI. Managing Change and Conflict
Change is the process of transforming, modifying, or making something different; it also can be defined as learning, growth, or progress. With the explosion of advances in technology and vast increases in knowledge, nurses must be able to incorporate new information into nursing practice to meet clients’ needs. However, points of view and opinions about how something should be
accomplished can cause conflict. Nurses must be willing to negotiate and compromise with other members of the health team to effect change.
A. Change theory (Lewin)
1. Proposes a process to plan and implement change in organizations.
2. Purports that effective change entails three steps.
- Unfreezing: The need for change is identified, various supportive and resistive solutions are explored, and group members are motivated to change.
- Moving: Group members agree that the status is unacceptable. Change is implemented after careful planning and with input from group members.
- Refreezing: Change is integrated, stabilized, and incorporated into practice.
B. Planned change
1. A purposeful, intended, systematic effort by a person, group, or organization to alter its present state.
2. A nurse must identify factors relative to the change.
- What is the complexity of the change?
- What is the magnitude of the change (how many people/departments are involved)?
- Is there readiness for the change?
- What is the pace of the change (is it urgent or can it be implemented slowly)?
- What is the current stress level of participants?
- Are there forces of resistance within the organization?
3. A nurse should follow a process, such as the nursing process.
- Recognize the need for change.
- Identify the problem.
- Analyze possible solutions.
- Choose a solution.
- Plan for making the change (e.g., objectives, implementation steps, timetables, selection of individuals to implement the change, preparation to address resistance, and ways to stabilize the change).
- Put the plan into effect.
- Evaluate the outcomes of the change.
- Stabilize the change (may be permanent).
C. Resistance to change
1. Effective change requires the cooperation of all participants.
2. Individuals might resist change for four major reasons:
- Technical concerns, such as lack of experience using a computer system.
- Psychosocial concerns, such as fear, anxiety, low tolerance to change, and impact on income.
- Threats to power, such as position or influence.
- Lack of knowledge or misunderstanding.
3. Nurse managers should identify and address issues that can contribute to resistance as early as possible.
4. Nurse managers need to identify and address resistive behaviors because they can undermine the effort to change.
- Obvious resistive behaviors include refusing to be involved in the process, writing negative memos, and organizing resistance.
- Passive-aggressive resistive behaviors include missing meetings and agreeing with the change but avoiding activities to implement the change.
5. Nurse managers should implement strategies for lowering resistance to change.
- Be prepared for resistance before change is introduced.
- Increase communication and information to overcome lack of knowledge and to correct misconceptions, which are often significant threats to change.
- Involve a resistive participant in developing and implementing the change, incorporating as many suggestions as feasible to ensure a vested interest in the success of the project.
- Reduce the anxiety and fears of participants by recognizing their competence, providing staff education programs that support new learning and personal growth, allowing time for learning and practice, providing a nonjudgmental climate where participants can express feelings, and expressing appreciation for each participant’s contributions.
- Assure participants, when possible, that no one will lose a job or position because of the change.
- Make the organization’s commitment to the project clear.
- Identify the positive consequences of the change, including ways in which the change will benefit participants.
D. Conflict
1. Conflict is an antagonistic state between individuals that results from different points of view or opinions. It can occur in the workplace when there are differences about if or how something should be accomplished.
Strategies for managing conflict:
- Recognize that health-care workers have differences (e.g., different ages, nationalities, cultures, income levels, genders, educational backgrounds, and lifestyles).
- Recognize that each person has personal values, beliefs, habits, and experiences.
- Understand that the clinical setting can be stressful, which can generate problems.
- Identify occurrences of conflict, which can occur between two individuals (e.g., two nurses, nurse and family member), workers of different shifts (workers on the day shift versus the night shift), or different departments (nursing and physical therapy, nursing and dietary).
- Address conflict in a constructive manner that leads to professional growth rather than rejection and anger.
- Handle conflict in a way that enables each party to gain insight into the other person’s point of view; it can stimulate individuals to work together in more constructive ways, leading to increased productivity and improved relationships.
- Use a win-win approach to conflict resolution. For example, when possible, integrate a combination of suggestions from those offered from both sides of a conflict so that both sides gain some benefit.
- Engage in informal or formal negotiation if conflict cannot be managed through problem-solving.
