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Chapters 1-25

Chapter 1
Decision making, Problem Solving, and Critical Thinking
Successful decision makers are
self-aware, courageous, sensitive, energetic, and creative.
The rational approach to problem solving begins with
a fixed goal and ends with an evaluation process.
Naturalistic decision making blends intuition and analysis
but pattern recognition and experience guide decision makers when time is limited or systematic rational decision making is not possible.
Evidence-based nursing practice integrates
the best evidence available to achieve desired outcomes
The successful decision maker understands the significance that gender, personal and individual values, life experiences, preferences, willingness to take risk, brain hemisphere dominance, and predominant thinking style have on
alternative identification selection.
The critical thinker is aware of areas of vulnerability that hinder successful decision making and makes efforts to
avoid the pitfalls of faulty logic in his or her data gathering.
The act of making and evaluating decisions
increases the expertise of the decision maker.
There are many models for improving decision-making. Using a systematic decision making model or problem solving model reduces
heuristic trial-and-error, rule of thumb methods, and increases the probability that appropriate decisions will be made.
Left and right brain dominance as well as thinking styles influence
at least to some degree, how individuals think.
Two major considerations in organizational decision-making are
how power affects decision-making, needs to be only satisficing.
Management science has produced many tools to help decision makers make better and more objective decisions, but
all are subject to human error, and many do not adequately consider the human element.
Chapter 2
Classical Views of Leadership and Management
Management functions include
planning, organizing, staffing, directing, and controlling. Known as the management process.
Classical, or traditional, management science focused on production in the workplace and on delineating organizational barrier to productivity.
Workers were assumed to be motivated solely by economic rewards, and little attention was given to worker job satisfaction.
The human relations era of management science
emphasized concepts of participatory and humanistic management.
Three primary leadership styles have been identified:
authoritarian, democratic, and laissez- faire.
Research has shown that the leader-manager must assume a variety of leadership styles
depending on the needs of the workers, the task to be performed, and the situation or environment. This is known as situational or contingency leadership theory.
Leadership is a process of
persuading and influencing others towards a goal and is composed of a wide variety of roles.
Early leadership theories focused on
the traits and characteristics of leaders.
Interactional leadership theory focuses more on leadership as a process of
influencing others within an organizational, culture, and the interactive relationship of the leader and the follower.
The manager who is committed, has a vision, and is able to empower others with this vision is termed a transformational leader
whereas the traditional manager, concerned with the day-to-day operations is called a transactional leader.
Full-range leadership theory suggests that
context is an important mediator of transformational leadership.
Integrating leadership skills with the ability to carry out management functions
is necessary if an individual is to become an effective leader-manager.
Chapter 3
Twenty-First Century Thinking about Leadership and Management
Many new leadership and management theories have emerged in the 21st century to explain the
complexity of the leader- follower relationship and the environment in which work is accomplished and goals are achieved.
Strengths-based leadership focuses on the development or empowerment of workers’ strengths
as opposed to identifying problems, improving underperformance, and addressing weaknesses and obstacles.
Level 5 leadership is characterized by
knowledge, team building skills, ability to help groups achieve goals, humility, and empowerment of others through servant leadership.
Servant leadership is
a contemporary leadership model that puts serving others as the first priority.
Followers can and do influence leaders
in both positive and negative ways.
Principal agent theory suggests that followers may have an informational (expertise or knowledge) advantage over the leader, as well as their own preferences
which may deviate from those of the principal, This may lead to a misalignment of goals.
Human capital represents the capability of the individual
Social capital represents what a group can accomplish together.
Emotional intelligence refers to the ability to
use emotions effectively and is considered by many to be critical to leadership and management success.
Authentic leadership
suggest that in order to lead, leaders must be true to themselves and their values and act accordingly.
Thought leadership refers to any situation whereby one individual
convinces another to consider a new idea, product, or way of looking at things.
Thought leaders attract followers not by promise of representation, or empowerment, but by
their risk taking and vision in terms of being innovative.
Quantum leadership
suggest that the environment and context in which people work is complex and dynamic and that this has a direct impact on organizational productivity.
A transition has occurred in the 21st -century from industrial age leadership
to relationship age leadership.
Chapter 4
Ethical Issues
Ethics is the systematic study of what a person’s conduct and actions should be with regard to self, other human beings, and the environment;
it is the justification of what is right or good, and the study of what a person’s life and relationships should be – not necessarily what they are.
In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by nurse-managers involves some ethical component.
Multiple advocacy roles and accountability to the profession further increase the likelihood that managers will be faced with ethical dilemmas in their practice.
Many systematic approaches to ethical problem solving are appropriate. These include the use of
theoretical problem-solving and decision-making models, ethical frameworks, and ethical principles
Outcomes should never be used as the sole criterion for assessing the quality of ethical problem solving
because many variables affect outcomes that have no reflection on whether the problem solving was appropriate.
Quality, should be evaluated both by the outcome and the process used to make the decision.
If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, then regardless of the outcome, the manger should feel comfortable that the best possible decision was made at that time with the information and resources available.
Four of the most commonly used ethical frameworks for decision-making are
utilitarianism, duty-based reasoning, rights-based reasoning, and intuitionism.
Ethical frameworks for decision-making do not solve the ethical problem but assist individuals involved in the problem solving to
clarify their values and beliefs.
Principles of ethical reasoning explore and define what beliefs or values form the basis for our decision-making. These principles include
autonomy, beneficence, nonmaleficence, paternalism, utility, justice, fidelity, veracity, and confidentiality.
Professional codes of ethics and standards for practice are
guides to the highest standards of ethical practice for nurses.
Sometimes it is very difficult to separate legal and ethical issues, although they are not the same. Legal controls are generally clear and philosophically impartial.
Ethical controls are much more unclear and individualized.
Chapter 5
Legal and Legislative Issues
Sources of law include
constitutions, statutes, administrative agencies, and court decisions.
The burden of proof is required to be found guilty and the punishment for the crime varies significantly between
criminal, civil, and administrative courts.
Nurse Practice Acts
define and limits the practice of nursing in each state.
Professional organizations generally hold standards of care that are
higher than those required by law. These voluntary controls often are forerunners of legal controls.
Legal doctrines such as stare decisis and res judicata
frequently guide courts in their decision-making.
Currently, licensing for nurses is a responsibility of State Boards of Nursing or State Boards of Nurse Examiners.
These state boards also provide discipline as necessary.
Some professionals have advocated shifting the burden of licensure, and thus accountability, from individual practitioners to an institution or agency.
Many professional nursing organizations oppose this move.
Malpractice or professional negligence is the failure of a person with professional training to act in a reasonable and prudent manner.
Five components must be present for an individual to be found guilty of malpractice.
Employers of nurses can now be held liable for an employee’s acts under the concept of
vicarious liability.
Each person, however, is liable for
his or her own tortuous conduct.
Managers are not automatically held liable for all acts of negligence on the part of those they supervise, but they may be held liable if
they were negligent in supervising those employees at the time that they committed the negligent acts.
While professional negligence is considered to be an unintentional tort
assault, battery, false imprisonment, invasion of privacy, defamation, and slander are intentional torts.
Consent can be informed, implied, or expressed.
Nurses need to understand the differences between these types of consents and use the appropriate one.
Although the patient owns the information in a medical record, the actual record belongs to the
facility that originally made it and is storing it.
It has been shown that despite good technical competence, nurses who have difficulty establishing positive interpersonal relationships with clients and their families are
at a greater risk of getting sued.
Each nurse should be aware of how laws such as Good Samaritan immunity or legal access to incident reports
are implemented in the state in which they live.
New legislation pertaining to confidentiality (HIPAA) and patient rights (PSDA)
continues to shape nurse-client interactions in the health-care system.
Chapter 6
Strategic and Operational Planning
The planning phase of the management process
is critical and precedes all other functions.
Planning is a
proactive function required of all nurses.
A plan is a
guide for action in reaching a goal and must be flexible.
Plans should be
specific, simple, and realistic.
All planning must include an
evaluation step, and requires periodic reevaluation, and prioritization.
All people and organizational units affected by a plan
should be included in the planning. Stakeholders
Plans have a time for evaluation built into them so that there can be
a midcourse correction if necessary.
New paradigms and trends emerge continuously, requiring leader-managers to
be observant and proactive in organizational strategic planning
Because of the rapid changing technology, increasing government regulatory involvement in healthcare, changing population demographics, and reduced provider autonomy,
healthcare organizations are finding it increasingly difficult to appropriately identify long-term needs and plan accordingly.
Organizations and planners tend to use one of the four planning modes:
reactive, inactivism, preactivism, or proactive. A proactive planning style is always the goal.
Strategic planning tools such as SWOT and balanced scorecard
help planners to identify those issues most likely to impact a particular organization or situation in the future and then to develop an appropriate plan for action.
All planning in the organizational hierarchy must
flow from and be congruent with planning down at higher levels in the hierarchy.
Planning in the organizational hierarchy typically includes the development of
organizational vision and mission statements, philosophies, goals, objectives, policies, procedures, and rules. Top-down…
An organizational philosophy that is not or cannot be implemented is
To avoid ongoing intrapersonal values conflicts,
employees should have a philosophy compatible with that of their employer.
Policies and procedures
should be evidence based.
Rules are fairly inflexible, so the fewer rules, the better. Existing rules, however,
should be enforced to keep morale from breaking down and to allow organizational structure.
Chapter 8
Planned Change
Change should not be viewed as a threat but as a
challenge and a chance to do something new and innovative.
Change should be implemented
only for good reason.
Because change disrupts the homeostasis or balance of the group
resistance should be expected as a natural part of the change process.
The level of resistance to change generally depends on the type of change proposed.
Technological changes encounter less resistance than changes that are perceived as social or that are contrary to established customs or norms.
Perhaps the greatest factor contributing to the resistance encountered with change is
a lack of trust between the employee and the manger of the employee and the organization.
It is much easier to change a person’s behavior
than it is to change an entire group’s behavior. It is also easier to change knowledge levels than attitudes.
Change should be planned and thus implemented
gradually, not sporadically or sudden.
Those who may be affected by a change should be
involved in planning for it. Likewise, workers should thoroughly understand the change and its effect on them.
The feeling of control
is critical to thriving in a changing environment.
Friends, family, and colleagues
should be used as a network of support during change.
The successful change agent has the leadership skills of
problem solving and decision-making and has good interpersonal skills.
In contrast to planned change, change by drift is
unplanned or accidental.
Historically, many of the changes that have occurred in nursing or have affected the profession are
the results of change by drift.
People maintain status quo or equilibrium when both driving and restraining forces operating within any field simultaneously occur.
For change to happen, this balance of driving and restraining forces must be altered.
Emerging theories such as complexity science suggest that change is
unpredictable, occurs at random, and is dependent upon rapidly changing relationships between agents and factors in the system and that even small changes can affect an entire organization.
Organizations are preserved by change and constant renewal.
Without change, the organization may stagnate and die.
Chapter 9
Time Management
Because time is a finite and valuable resource
learning to use it wisely is essential for effective management.
Time management can be reduced to three cyclic steps:
(a) allow time for planning and establish priorities. (b) complete the highest priority task, and whenever possible, finish one task before beginning another; and (c) reprioritize based on remaining tasks and new information that may have been received.
Setting aside time at the beginning of each day to plan the day allows the manager
to spend appropriate time on high-priority tasks.
Many individuals fall prey to planning fallacies, where they
are overly optimistic about the time it will take to complete a task.
Making lists is an appropriate tool to manage daily tasks.
This list should not be any longer than what can realistically be accomplished in a day and must include adequate time to accomplish each item on the list and time for the unexpected.
A common cause of procrastination is
failure to break large tasks down into smaller ones so that the manager can set short-term, intermediate, and long-term goals.
Lower-level managers have more interruptions in their work than do higher-level managers.
This results in situational stress and lowered job satisfaction.
Managers must learn strategies to cope with
interruptions from socializing.
Because so much paperwork is redundant or unnecessary
the manger needs to develop expertise in prioritizing it, and eliminating unnecessary clutter at the work site.
An efficient filing system
is invaluable to handling paper overload.
Personal time management refers to “the knowing of self.” Managing time is difficult if
a person is unsure of his or her priorities, including personal short-term, intermediate, and long-term goals.
Being punctual implies that you value other people’s time and creates
an imperative for them to value your time as well.
Effective time management is an essential part of finding
that balance between work life and personal life.
Using a time inventory is one way to gain insight into how and when a person is most productive.
It also assists in identifying internal time wasters.
Chapter 10
Fiscal Planning
Fiscal planning, as in all types of planning
is a learned skill that improves with practice.
Historically, nursing management played a limited role in
determining resource allocation in health-care institutions.
The personnel-workforce budget often accounts for
the majority of health-care organization’s expenses because health-care is labor intensive.
Personnel budgets include actual worked time (productive time or salary expense) and
time that the organization pays the employee for not working (nonproductive time or benefit time)…pto
A budget is at best a forecast or prediction; it is a plan and not a rule.
Therefore, a budget must be flexible and open to ongoing evaluation and revision.
A budget that is predicted too far in advance is open to greater error. If the budget is shortsighted,
compensating for unexpected major expenses or capital equipment purchases may be difficult.
The desired outcome of budgeting is maximal use of resources to meet organizational short- and long-term needs.
Its value to the institution is directly related to its accuracy.
The operating budget reflects expenses that
flex up or down in a predetermined manner to reflect variation in volume of service provided.
Capital budgets plan for the purchase of buildings or major equipment.
This includes equipment that has a long life (usually greater than 5 years), is not used daily, and is more expensive than operating supplies.
Managers must justify their program or needs every budgeting cycle in zero-based budgeting.
Using a decision package to set funding priorities is a key feature of zero-based budgeting.
With the advent of state and federal reimbursement for healthcare in the 1960’s, providers were forced to submit
budgets and costs to payers that more accurately reflected their actual cost to provide these services.
With DRGs, hospitals join the PPS, whereby they receive a specified amount for each Medicare patient’s admission, regardless of the actual cost of care.
Exceptions occur when the provider can demonstrate that a patient’s case is an outlier, meaning that the cost of providing care for the patient justifies extra payment.
Key principles of managed care include the use of
primary care providers as gatekeepers, a focus on prevention, a decreased emphasis on inpatient hospital care, the use of clinical practice guidelines for providers, selective contracting, capitation, utilization review, the use of formularies to manage pharmacy care, and continuous quality monitoring and improvement.
The types of plans available within HMOs typically vary according to
the degree of provider choice available to enrollees.
Managed care has altered the relationships among insurers, physicians, nurses, and patients, with providers today often having to
assume a role as an agent for the patient as well as an agent of resource allocation for an insurance carrier, hospital, or particular practice plan.
Provision of service no longer guarantees reimbursement.
Clear and comprehensive documentation of the need for services and actual services provided is needed for reimbursement.
The 2010 PPACA (often shortened to the Affordable Care Act) put in place
comprehensive insurance reforms, which were to be phased in over a 4-year period.
With bundled payments, providers agree to accept a discounted payment either retrospectively or prospectively
which represents a coordinated plan of care for patients over the course of a single episode of illness.
Accountable Care Organizations (ACOs) are groups of providers and suppliers of service who work together to better coordinate care for Medicare patients (does not include Medicare Advantage) across care setting with the expectation that
efficiency as well as quality of care will result in shared savings.
In VBP, providers are held accountable for the quality and cost of the health-care services they provide by
a system of rewards and consequences, conditional upon achieving pre-specified performance measures.
The medical home, or PCMH, relies on a team of providers to integrate all aspects of health care
through well-developed health information technology, including electronic health records.
Health insurance marketplaces, also called exchanges, are online insurance supermalls, created for
individuals without access to health insurance through a job or for small businesses who wish to buy affordable and qualified health benefit plans in a competitive insurance marketplace.
Chapter 11
Career Development: From New Graduate to Retirement
There are many outcomes of a career development program
that justify its implementation.
Career job sequencing should
assist the manger in career management.
Career development programs consist of
a set of personal responsibilities called career planning and a set of management responsibilities called career management.
Employees often need to be encouraged to
make more formalized long-term career plans.
Career planning should, at minimum,
a commitment to the use of evidence-based practice, learning new kills or bettering practice though the use of role models and mentors, staying aware of and being involved in professional issues, and furthering one’s education.
Designing career paths is an important part of
organizational career management.
Mangers should plan specific interventions
that promote growth and development in each of their subordinates.
Most individuals progress through
normal and predictable career stages.
Career coaching involves helping others to identify professional goals and career options and
designing a career plan to achieve those goals. This coaching should be both short and long term.
Competency assessment and goal setting in career planning should help the employees identify
how to exceed the minimum levels of competency required by federal, state, or organizational standards.
Professional specialty certification
is one way that an employee can demonstrate advanced achievement of competencies.
To be successful, management development must be planned and supported by top-level management.
This type of planed program is called succession management.
If appropriate management attitudes and insight are goals of a management development program,
social learning techniques need to be part of the teaching strategies used.
Multiple types of transition-to-practice programs exist,
but all are focused on helping nursing students bridge from school into employment.
Maintaining a current, professional resume is
a career planning necessity for the health-care professional and should not be undertaken lightly.
Cover letters (whether by mail or e-mail) should always be used when submitting a resume. Their purpose is to
introduce the applicant, briefly highlight key points of the resume, and make a positive first impression.
All nurses should maintain a professional portfolio
(a collection of materials that document a nurse’s competencies and illustrate the expertise of the nurse) to reflect their professional growth over their career.
Chapter 12 – Organizational Structure
Many modern health-care organizations continue to be organized around a line or a line-and-staff design and have many attributes of a bureaucracy; however, there is a movement toward less bureaucratic designs, such as
ad hoc, matrix, and care-centered systems.
A bureaucracy, as proposed by Max Weber, is characterized by
a clear chain of command, rules and regulations, specialization of work, division of labor, and impersonality of relationships.
An organization chart depicts
formal relationships, channels of communication, and authority through line-and-staff positions, scalar chains, and span of control.
Unity of command means that
each person should have only one boss so that there is less confusion and greater productivity.
Centrality refers to the degree of
communication of a particular management position.
In centralized decision-making, decisions are made by a few managers at the top of the hierarchy. In decentralized decision-making,
decision-making is diffused throughout the organization, and problems are solved at the lowest practical managerial level.
Organizational structure affects how
people perceive their roles and the status given to them by other people in the organization.
Organizational structure is effective when the
design is clearly communicated, there are as few managers as possible to accomplish goals, communication is facilitated, decisions are made at the lowest possible level, informal groups are encouraged, and future leaders are developed.
The entities in an organization’s environment that play a role in the organization’s health and performance, or which are affected by the organization, are called
Authority, responsibility, and accountability differ in terms of
official sanctions, self-directedness, and moral integration.
Organizational culture is
the total of an organization’s beliefs, history, taboos, formal and informal relationships, and communication patterns.
Subunits of large organizations also have a culture.
These subcultures may support or be in conflict with other cultures in the organization.
Informal groups are present in every organization.
They are often powerful, although they have no formal authority. Informal groups determine norms and assist members in the socialization process.
Shared governance refers to an
organizational design that empowers staff nurses by making them an integral part of patient care decision making and providing accountability and responsibility in nursing practice.
Magnet designation is conferred by the ANCC to health-care organizations exemplifying
well-qualified nurse executives in a decentralized environment, with organizational structures that emphasize open, participatory management.
Magnet – designated organizations demonstrate
improved patient outcomes and higher staff nurse satisfaction than organizations that do not have a magnet status.
The Pathway to Excellence designation, also conferred by the ANCC, recognizes health-care organizations
with foundational quality initiatives in creating a positive work environment, as defined by nurses and supported by research.
Too many committees in an organization is a sign of
a poorly designed organizational structure.
Committees should have
an appropriate number of members, prepared agendas, clearly outlined tasks, and effective leadership if they are to be productive.
Groupthink occurs when
there is too much conformity to group norms.
Chapter 13
Organizational, Political, and Personal Power
Power and authority are
necessary components of leadership and management.
A person’s response to authority is
conditioned early through authority figures, experiences in the family unit, and gender role identification.
The gap that sometimes exists between a position of authority and subordinate response is called
the authority- power gap.
The empowerment of staff
is a hallmark of transformational leadership. Empowerment means to enable, develop, or allow.
Power has both a positive
and negative face.
Traditionally, women have been socialized to view power differently than men do.
However, recent studies show that gender differences regarding power are slowly changing.
Reward power
is obtained by the ability to grant rewards to others.
Legitimate power
is the power inherent in one’s position.
Expert power
is gained through knowledge or skill.
Referent power
is obtained through association with others.
Charismatic power
results from a dynamic and powerful persona.
Information power
is gained when someone has information that another needs.
Female – dominated professions such as nursing often exemplify the queen bee syndrome.
The queen bee is a woman who has struggled to become successful, but once successful, refuses to help other women achieve the same success.
Even a novice manager or newly graduated nurse
can begin to build a power base by using appropriate power- building tactics.
Power gained
may be lost because one is politically naïve or fails to use appropriate political strategies.
Politics exist in every organization,
and leader-managers must learn the art and skills of politics.
The nursing profession has not been the political force it could be since historically,
it has been more reactive then proactive in addressing needed policy decisions and legislation.
Numerous driving forces are in place to increase the nursing profession’s power base, including
timing, the size of the profession, nursing’s referent power, the increasing educational levels of nurses, nursing’s unique perspective, and the desire of consumers and providers for change.
Chapter 14
Organizing Patient Care
Total patient care, utilizing the case method of assignment
is the oldest form of patient care organization and is still widely used today.
Functional nursing organization
requires the completion of specific tasks by different nursing personnel.
Team nursing typically
uses a nurse-leader who coordinates team members of varying educational preparation and skill sets in the care of a group of patients.
The use of multidisciplinary teams
increases the likelihood that care will be comprehensive and holistic, although the responsibility for team leadership still typically falls to the nurse.
Modular nursing uses mini-teams,
typically an RN and unlicensed health-care worker(s), to provide care to a small group of patients, usually centralized geographically.
Primary care nursing is organized so that the patient is at the center of the structure.
One health-care provider (typically the RN) has 24-hour responsibility for care planning and coordination.
Interprofessional teams now also provide primary care in the form of PHCTs.
These teams typically include, but are not limited to, physicians, nurse practitioners, nurses, physical therapists, occupational therapist, and social workers collaboratively to deliver coordinated patient care.
Case management is a collaborative process that
assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality and cost-effective outcomes.
Although the focus historically for case management has been the individual patient the case manager employed in a DM program plans
the care for populations or groups of patients with the same chronic illness.
The care MAP is a combination of a critical path and a nursing care plan,
except that it shows times when nursing interventions should occur as well as variances.
Delivery systems
may have elements of the various designs present in the system in use in any organization.
Each unit’s care delivery structure should
facilitate meeting the goals of the organization, be cost-effective, satisfy the patient, provide role satisfaction to nurses, allow implementation of the nursing process, and provide for adequate communication among health-care providers.
When work is redesigned it frequently has personal consequences for employees that must be considered.
Social interactions, the degree of autonomy, the abilities and skills necessary, employee evaluation, and communication patterns are often affected by work redesign.
The nurse navigator assists
patients and families to navigate the complex health-care system by providing information and support as they traverse their illness.
The CNL, is an experienced, nurse possessing a graduate degree
who provides clinical leadership in all health-care settings, implements outcomes-based practice and quality improvement strategies, engages in clinical practice, and creates and manages microsystems of care that are responsive to the health-care needs of the individuals and families.
The philosophy of patient-and family-centered care is based on
the premise that care should be organized first and foremost around the needs of patients and family members.
Chapter 15
Employee Recruitment, Selection, Placement, and Indoctrination
The first step in the staffing process is
to determine the type and number of personnel needed.
A number of factors are contributing to a projected, severe nursing shortage, including
the aging of the nursing workforce, accelerating demand for professional nurses, inadequate enrollment in nursing programs of study, and the aging of nursing faculty.
Successfully recruiting an adequate workforce depends on many variables, including
financial resources, an adequate nursing pool, competitive salaries, the organization’s reputation, the location’s desirability, and the status of the national and local economy.
Effective recruiting methods include
advertisements, career days, literature, and the informal use of members of the organization as examples of satisfied employees.
Despite their limitations in terms of reliability and validity
interviews continue to be widely used as a method of selecting employees for hire.
The limitations of interviews are reduced when
a structured approach is used in asking questions of the applicants.
The interview should
meet the goals of both the applicant and the manager.
Mangers must be skilled in
planning, conducting, and controlling interviews.
Because of numerous federal acts that protect the rights of job seekers,
interviewers must be cognizant of the legal constraints on interviews.
Selections should be based on the requirements necessary for the job;
these criteria should be developed before beginning the selection process.
Leaders should seek to proactively recruit and hire staff with
age, gender, cultural, ethnic, and language diversity to better mirror the rapidly increasing diversity of the communities they serve.
New employees should be placed
on units, departments, and shifts where they have the best chance of succeeding.
Indoctrination consists of
induction, orientation, and socialization of employees.
A well-prepared and executed orientation program
educates the new employee about the desired behaviors and expected goals of the organization and actively involves the new employee’s immediate supervisor.
Chapter 16
Socializing and Educating Staff for Team Building in a Learning Organization
The philosophy of Los is the concept that
collective learning goes beyond the boundaries of individual learning and releases gains for both the individual and the organization.
The leader
is a role model of the lifelong learning.
Training and education
are important parts of staff development.
All staff development activities should
be evaluated for quality control and fiscal accountability.
There is a shared responsibility for the promotion of
evidence-based nursing practice.
Mangers and education department staff have a shared responsibility for the promotion of
evidence-based nursing practice.
Theories of learning and principles of teaching
must be considered if staff development activities are to be successful.
Social learning theory suggests
that people learn most behavior by direct experience and observation.
The socialization of people into roles
occurs with all professions and is a normal sociological process.
Socialization and resocialization are often neglected areas of the
indoctrination process.
New graduates, international nurses, new managers, and experienced nurses in new roles
have unique socialization needs.
Difficulties with re-socialization usually centers on
unclear role expectations (role ambiguity), an inability to meet job demands, or deficiencies in motivation. Role strain and role overload contribute to the problem.
The terms role model, preceptor, and mentor are not synonymous,
and all play an important role in assisting with the socialization of employees.
People from different cultures and age groups
may have different socialization and learning needs.
Chapter 17
Staffing Needs and Scheduling Policies
The manager has both a fiscal and an ethical duty
to plan for adequate staffing to meet patient care needs.
Innovative and creative methods of staffing and scheduling should be explored
to avoid understaffing and overstaffing as patient census and acuity fluctuate.
Staffing and scheduling policies must
not violate labor laws, state or national laws, or union contracts.
Workload measurement tools include NCH/PPD, PCS, and workload measurement systems.
All workload measurement tools should be periodically reviewed to determine if they are a valid and reliable tool for measuring staffing needs in a given organization.
Mandatory overtime should be a last resort
not a standard operating procedure because an institution does not have enough staff.
Research clearly shows that as
professional nursing representation in a skill mix increases, patient outcomes generally improve and adverse incidents decline.
Those with staffing responsibility
must remain cognizant of mandatory staffing ratios and comply with such mandates.
Mangers should attempt to have a diverse staff that will
meet the cultural and language needs of the patient population.
Fair and uniform staffing and scheduling policies and procedures
must be written and communicated to all staff.
Existing staffing policies
must be examined periodically to determine if they still meet the needs of the staff and the organization.
Chapter 18
just trucking along
Because human beings have constant needs and wants
they are always motivated to some extent. However, what motivates each human being varies significantly.
Managers cannot intrinsically motivate people
because motivation comes from within the person. The humanistic manager can, however, create an environment in which the development of human potential can be maximized.
Maslow stated that
people are motivated to satisfy certain needs, ranging from basic survival to complex physiological needs, and that people seek a higher need only when the lower needs have been predominately met.
Skinners research on operant conditioning and behavior modification demonstrates
that people can be conditioned to behave in a certain way based on a consistent reward or punishment system.
Herzberg maintained that motivators, or job satisfiers
are present in the work itself and encourage people to want to work and to do that work well. Hygiene or maintenance factors keep the worker from being dissatisfied or demotivated but do not act as true motivators for the worker.
Vroom’s expectancy model says that
people’s expectations about their environment or a certain event will influence their behavior.
McClelland’s studies state that all people are motivated by three basic needs:
achievement, affiliation, and power.
Gellerman states that most managers in organizations over manage,
making their responsibilities too narrow and failing to give employees any decision-making power or to stretch them often enough.
McGregor points out the importance of a manager’s assumptions about workers on the intrinsic motivation of the worker.
There appears to be a perceived threshold beyond which increasing reward incentives results in no additional meaning or weight in terms of productivity.
Offering rewards in defined categories, even when the categories are meaningless, can increase motivation
the very act of segmenting these rewards appears to motivate people to perform better and longer.
Positive reinforcement is one of the most powerful motivators the manager can use and is frequently overlooked or underused.
The supervisor or manager’s personal motivation is an important factor affecting staff’s commitment to duties and morale.
The success of a motivational strategy is measured by
the increased productivity and benefit to the organization, by the growth in the person , which motivates him or her to accomplish again.
Because of the importance that American society places on promotions, certain guidelines must accompany promotion selection to ensure that the process is
fair, equitable, and motivating.
Policies regarding promotion should be
in writing and communicated to all employees.
Recruitment from within has shown to have a positive effect on employee motivation
whereas recruitment from outside the organization allows for new ideas and prevents stagnation.
It is possible to promote individuals beyond their level of capability. The Peter Principle,
suggests that individuals may rise “to the level of their incompetence.”
Managers must show their own positive attitude
to demonstrate to employees that there is joy in work.
Chapter 19
seems like chapter 91
Communication forms the core of management activities
it cuts across all phases of the management process. It is the core of the Nurse-Patient, Nurse-Nurse, and Nurse-Physician relationship.
Depending on the manager’s position in the hierarchy, the overwhelming majority of managerial time is often directed at some type of organizational communication
thus, organizational communication is a high-level management function.
Because most managerial communication time is spent speaking and listening
managers must have excellent interpersonal communication skills.
Communication in large organizations is particularly difficult
due to their complexity and size.
Managers must understand the structure of the organization and recognize whom their decisions will affect.
Both formal and informal communication networks need to be considered.
The clarity of the message is significantly affected by the mode of communication used.
In general, the more direct the communication, the greater the probability of clear communication. The more people involved in filtering the communication, the greater the chance of distortion.
Written communication is
used most often in large corporations.
A manager’s written communication reflects greatly on both the manager and the organization.
Thus, managers must be able to write clearly and professionally and use understandable language.
The incongruence between verbal and nonverbal messages
is the most significant barrier to effective interpersonal communication.
Effective leaders are congruent in their verbal and nonverbal communication
so that followers are clear about the message they receive.
Leaders are sensitive to verbal and nonverbal messages from followers and look for inconsistencies
that may indicate unresolved problems or needs.
To be successful in the directing phase of management
the leader must have well-developed skills in assertive communication.
SBAR and ISBAR provide
structured, orderly approaches to provide accurate, relevant information, in emergent patient situations as well as routine handoffs.
Most people hear or retain only a small amount of information given to them.
about (1/3)
Active listening
is an interpersonal communication skill that improves with practice.
Using a listening model such as GRRRR (Greeting, Respectful listening, Review, Recommend or Request more information, and Reward)
is especially helpful in organizations where disruptive behavior, toxic environments, and power struggles interfere with listening.
Adding new members to an established group
disrupts productivity and group development.
Group members perform
certain important tasks that facilitate work.
Group members also perform
roles that assist with group-building activities.
Some group members will perform
roles to meet their individual needs.
Rapidly flourishing communication technologies have great potential to
increase the efficiency and effectiveness of organizational communication. They also pose increasing challenges to patient confidentiality.
Chapter 20
keep going
Professional nursing organizations and regulatory bodies are actively engaged in
clarifying the scope of practice for unlicensed workers and delegation parameters for RNs.
Delegation is not an option for the manager
it is a necessity.
Delegation should be used for
assigning routine tasks and tasks for which the manager does not have time. It is also appropriate as a tool for problem solving, changes in the manager’s own job emphasis, and building capability in subordinates.
In delegation, managers must clearly communicate
what they want to be done, including the purpose for doing so, Limitations or qualifications that have been imposed should be delineated.
Although the manager should specify the end product desired, it is important
that the subordinate has an appropriate degree of autonomy in deciding how the work is to be accomplished.
Managers must delegate
the authority and the responsibility necessary to complete the task.
RNs who are asked to assume the role of supervisor and delegator
need preparation to assume these leadership tasks.
Assuming the role of delegator and supervisor to the NAP
increases the scope of liability for the RN.
Although he Omnibus Budget Reconciliation Act of 1987 est. regulations for the education and certification of “nurse’s aides” (minimum of 75 hours of theory and practice and successful completion of an examination in both areas)
no federal or community standards have been est. for training the more broadly defined NAP.
The RN always bears the ultimate responsibility
for ensuring that the nursing care provided by his or her own team members meets or exceeds minimum safety standards.
When subordinates resist delegation
the delegator must ascertain why the delegated task was not accomplished and take appropriate action to remove these restraining forces.
Transcultural sensitivity in delegation
is needed to create a productive multicultural work team.
Chapter 21
nearing the end
Conflict can be defined as
the internal discord that results from differences in ideas, values, or feelings of two or more people.
Because managers have a variety of interpersonal relationships with people with different values, beliefs, backgrounds, and goals
conflict is an expected outcome.
The most common sources of organizational conflict are
communication problems, organizational structure, and individual behavior within the organization.
Conflict theory has changed dramatically during the last 100 years. Currently, conflict is viewed as
neither good nor bad because it can product growth or be destructive, depending on how it is managed
Too little conflict results in organizational stasis, whereas too much conflict
reduces the organization’s effectiveness and eventually immobilizes its employees.
Conflict also has a qualitative component, and the impact of a conflict on any individual
varies significantly in terms of how it is perceived and handled.
The three categories of conflict are
intrapersonal, interpersonal, and intergroup.
The first stage in the conflict process is called latent conflict
implies the existence of antecedent conditions. Latent conflict may progress to perceived conflict or to felt conflict. Manifest conflict may also ensue. The last stage in the process is conflict aftermath.
The optimal goal in conflict resolution is creating
a win-win solution for everyone involved.
Common conflict resolution strategies include
compromise, competing, accommodating, smoothing, avoiding, and collaboration.
As a negotiator, it is important to
win as much as possible, lose as little as possible, and make the other party feel satisfied with the outcome of the negotiation.
Because knowledge is power
the more informed the negotiator has, the greater is his or her bargaining power.
The leader, while able to recognize and counter negotiation tactics
always strives to achieve an honest, collaborative approach to negotiation.
The manager must know
his or her bottom line but try to never use it.
Closure and follow-up
are important parts of the negotiation process.
ADR usually involves at least one of the elements of mediation
fact finding, arbitration, and the use of ombudspersons.
Seeking consensus (concord of opinion) although time consuming
is an effective conflict resolution and negotiation strategy.
Chapter 22
still sucks keep going
Historically, union activity increases
during times of labor shortages and economic upswings.
Although nurses are still roughly twice as likely to be in a union as other occupations
the percentage of nurses as well as the total number of nurses in unions nationwide is decreasing.
Union alliances are becoming increasing commonplace in health care
since increased negotiating power comes with greater membership.
The ANA acts as a professional associate for RNs and as a
collective bargaining agent. This dual purpose poses a conflict in loyalty for some nurses.
People are motivated to join or reject unions
as a result of their numerous needs and values.
Nurses with less than 10-15% (equal to about one shift per pay period) of their time as charge nurse are considered to be staff nurses, while nurses working more than
15% of their professional time as charge nurse are considered supervisors, and therefore, are ineligible for protection under the NLRA.
Although all mangers play an important role in establishing and maintaining effective management -labor relationships
the middle-level manager has the greatest influence on preventing unionization in a nonunion organization.
Creating a climate in which labor and management work together to accomplish mutual goals is
Labor relation laws concern
the rights and duties of unions and employers in their relationship with each other.
Labor standards are regulations
dealing with the conditions of the employees work, including physical conditions, financial aspects, and the number of hours worked.
State and federal employment legislation often overlap; as a general rule
the employer must abide by the stricter of the two regulations.
Much of the human rights legislation concerning employment practices came about because of
documented discrimination in the workplace.
Sexual harassment and other types of nonphysical violence are worldwide problems for nurses, with English-speaking countries exhibiting the highest rates of
both physical violence and sexual harassment in nursing.
Although some legislation makes the job of managing people more difficult for managers, it has resulted in
increased job fairness and opportunities for women, minorities, the elderly, and the disabled.
Chapter 23
suck it up
Controlling is implemented throughout
all phases of management.
Quality control refers to activities that are used to
evaluate, monitor, or regulate services rendered to consumers.
A standard is a predetermined baseline condition or level of excellence that constitutes
a model to be followed and practiced.
Because there is no one set of standards, each organization and profession must set standards and objectives to guide
individual practitioners in performing safe and effective care.
CPGs provide diagnosis-based, step-by-step interventions for nurses to follow in an effort to promote
evidence-based, high-quality care and yet control resource utilization and costs.
Benchmarking is the process of
measuring products, practices, and services against those of best-performing organizations.
The difference in performance between top-performing health-care organizations and the national average is called
the quality gap.
While the quality gap is typically small in industries such as manufacturing, aviation, and banking
wide variation in is the norm in healthcare.
CEA and Root Cause Analysis help to identify not only what and how an event happened but why it happened, with the end goal being
to ensure that a preventable negative outcome does not occur.
Outcome audits determine
what results, if any, followed from specific nursing interventions for patients.
Process audits
are used to measure the process of care or how the care was carried out.
Structure audits
monitor the structure or setting in which patient care occurs (such as the finances, nursing service structure, medical records, and environmental structure).
There is a growing recognition that it is possible to separate the contribution of nursing to the patient’s outcome; this recognition of outcomes that are nurse-sensitive
creates accountability for nurses as professionals and is important in developing nursing as a profession.
Standardized nursing languages
provide consistent terminology for nurses to describe and document their assessments, interventions, and the outcomes of their actions
Quality Assurance models
seek to ensure that quality currently exists, whereas
Quality Improvement models
assume that the process is ongoing and that quality can always be improved.
Quality control in health-care organizations
has evolved primarily from external forces and not as a voluntary effort to monitor the quality of services provided.
Critics of the PPS argue that although DRGs may have helped to contain rising health-care costs,
the associated rapid declines in length of hospital stay and services provided have resulted in declines in quality of care.
The JACO is the major accrediting body for health-care organizations and programs in the united states.
It also administers the ORYX initiative and collects data on core measures in an effort to better standardize data collection across acute-care hospitals.
The CMS plays an active role in setting standards for and measuring
quality in health care including the HQI and P4P.
The 27-item HCAHPS survey is the first
national, standardized, publically reported survey of patients’ perspectives of hospital care. It measures recently discharged patients’ perceptions of their hospital experience.
The NCQA, a private organization that accredits managed care organizations
also developed the HEDIS to compare quality of care in managed care organizations.
Ideally, everyone in an organization
should participate in quality control activities.
In response to the demand for objective measures of quality
a number of health-plans, health-care-providers, employer purchasing groups, consumer information organizations, and state governments have begun to formulate health-care quality report cards.
A plethora of studies across the past 2 decades suggest that
medical errors continue to be rampant in the health-care system.
The patient safety and quality improvement act, signed into law in 2005, protects medical error information that is voluntarily submitted to new private organizations (patient safety organizations)
from being subpoenaed or used in legal discovery and generally requires that the information is treated as confidential.
The Leapfrog Group identified four evidence-based standards that they believe will provide the greatest impact on reducing medical errors:
CPOE, EHR, IPS, and the use of leapfrog safe practices scores.
The FDA has suggested that a drug bar code system coupled with a computerized order entry system
would greatly decrease the risk of medication errors.
Historically, the health-care industry has been comfortable with striving for three sigma processes (all data points fall within 3 standard deviations) in terms of health-care quality
instead of six (that are adopted by the highest-performing organizations in terms of quality).
As direct caregivers, staff nurses are in excellent position to monitor nursing practice by
identifying problems and implementing corrective actions that have the greatest impact on patient care.
Chapter 24
Nearing the end
The employee performance appraisal
is a sensitive and important part of the management process, requiring much skill.
When accurate and appropriate appraisal assessments are performed
outcomes can be very positive.
Performance appraisals are used to determine how well employees are performing their job.
Therefore, appraisals measure actual behavior and not intent.
Job descriptions often produce objective criteria
for use in the performance appraisal.
There are many different types of appraisal tools and methods
the most appropriate one to use varies with the type of appraisal to be done and the criteria to be measured.
The employee must be involved in the appraisal process
and view the appraisal as accurate and fair.
Management By Observation has been shown to increase
productivity and commitment in employees.
Peer review has great potential
for developing professional accountability but it is often difficult to implement.
Unless the appraisal interview is carried out in an appropriate and effective manner
the appraisal data will be useless.
Because of past experience, performance appraisal interviews are
highly charged, emotional events to most employees.
Showing a genuine interest in the employee’s growth and seeking his or her input at the interview
will increase the likelihood of a positive outcome from the appraisal process.
Performance appraisals should be signed
to show that feedback was given to the employee.
Informal work performance appraisals
are an important management function.
Leaders should routinely
use day to day coaching to empower subordinates and improve work performance.
In performance management appraisals are eliminated.
Instead, the manager places his or her efforts into ongoing coaching, mutual goal setting, and the leadership training of subordinates. ((as per class- performance appraisals are not eliminated b/c of $$ reasons))
Chapter 25
last one
It is essential that managers are able to distinguish between
employees who need progressive discipline, those who are chemically impaired, psychologically impaired, or marginal employees, so that the employee can be managed in the most appropriate manner.
Discipline is a necessary
and positive tool in promoting subordinate growth.
The optimal goal in constructive discipline is
assisting employees to behave in a manner that allows them to be self-directed in meeting organizational goals.
To ensure fairness, rules should include McGregor’s “Hot Stove” components of
forewarning, immediate application, consistency, and impartiality.
If a rule or regulation is worth having, it should be enforced.
When rule-breaking is allowed to go unpunished, groups generally adjust to and replicate the low-level performance of the rule-breaker.
As few rules and regulations as possible should exist in the organization,
all rules, regulations, and policies should be regularly reviewed to see if they should be deleted or modified in some way.
Except for the most serious infractions, discipline should be administered in progressive steps, which include
verbal admonishment, written admonishment, suspension, and dismissal.
In performance deficiency coaching, the manager actively brings areas of unacceptable behavior or performance to the attention of the employee and
works with him or her to establish a short-term plan to correct deficiencies.
The grievance procedure is essentially a statement of wrongdoing or a procedure to follow when one believes that a wrong has been committed.
All employees should have the right to file grievances about disciplinary action that they believe has been arbitrary or unfair in some way.
The presence of a union generally entails
more procedural, legalistic safeguards for administering discipline and a well-defined grievance process for employees who believe that they have been disciplined unfairly.
Because chemical and psychological impairment are a disease, traditional progressive discipline is inappropriate because
it cannot result in employee growth.
The profile of the impaired nurse may vary greatly, although typically behavior changes are seen in three areas:
personality/behavior changes, job performance changes, and time and attendance changes.
Nurses and managers traditionally have been slow to recognize and respond to
chemically impaired colleagues.
Confronting an employee who is suspected of chemical impairment should always occur before
the problem escalates and before patient safety is jeopardized.
The manger should not assume the role of counselor or treatment provider or feel the need to diagnose the cause of the chemical addiction.
The manager’s role is to clearly identify performance expectations for the employee and to confront the employee when those expectations are not met.
Strategies for dealing with marginal employees vary with
management level, the nature of the healthcare organization, and the current prevailing attitude toward passive or active intervention.

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