Chapter 17
Nursing Leadership and Management
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Chapter Overview


Professional nursing within the health care
organization has as much to do with leading
and managing the delivery of care as it does
with actually providing that care
This chapter presents key leadership and
management concepts that will guide the nurse
to grow and develop in this important aspect of
the professional practice role
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2
Leadership and Management
Defined and Distinguished
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3
Leaders



Attempt to influence the beliefs, opinions, or
behaviors of a person or group
Guide people and groups to accomplish
common goals
May not have formal authority but are still able to
influence others
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4
Managers


Coordinate people, time, and supplies to
achieve desired outcomes in a defined area of
responsibility
Have an appointed management position and a
formal line of authority and accountability
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Leadership versus Management


Leadership: ability to guide or influence others
Management: coordination of resources (time,
people, supplies) to achieve outcomes
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Power and Authority


Authority: legitimate right to direct others through
an authorized position in an organization
Power: ability to motivate people to get things
done with or without the formal right granted by
the organization
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Types of Power
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Reward power
Coercive power
Legitimate power
Referent power
Expert power
Informational power
Connection power
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Formal Leadership

Practiced by the nurse who is appointed to an
approved position and is given authority by the
organization to act
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Informal Leadership

Exercised by the person who has no official
authority to act but is able to influence others in
the work group
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Informal Leadership (Cont.)

Strategies for working with informal leaders
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Understand their source of power
Involve them in decision making and change
implementation processes
Clearly communicate goals and work expectations
Do not ignore attempts to undermine teamwork and
change processes
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11
Leadership and Management Theory
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Leadership Trait Theory


Based on the assumption that leaders are born
with certain leadership characteristics
Traits associated with leadership include
intelligence, alertness, dependability, energy,
drive, enthusiasm, ambition, decisiveness, selfconfidence, cooperativeness, and technical
mastery
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Transformational Leadership

Suggests two types of leaders


Transactional
Transformational
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Transformational Leadership (Cont.)

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Transactional leader is concerned with the dayto-day operations of the facility/unit
Transformational leaders
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Committed to organizational goals and clearly
communicate vision and direction
Empower the work group to accomplish goals
Impart meaning and challenge to work
Are admired and emulated
Provide mentoring to individual staff members on the
basis of need
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Transformational Leadership (Cont.)

Nurse executives who demonstrate
transformational leadership characteristics
achieve higher levels of staff satisfaction and
greater work group effectiveness
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Leadership and Management Skills

Three major areas required for effective leadership
(Hersey P, Blanchard K: Management of organizational
behavior: utilizing human resources, ed 4, Englewood
Cliffs, NJ, 1988, Prentice-Hall.)
1. Technical skills: clinical expertise and nursing knowledge
2. Human skills: ability and judgment to work with people in an
effective leadership role
3. Conceptual skills: ability to understand the complexities of the
overall organization and to recognize how one’s own area of
management fits into the overall organization
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Leadership and Management
Skills (Cont.)


At the staff nurse level of management, a
considerable amount of technical skill and
clinical expertise is needed
As one advances from lower levels to higher
levels in the organization, more advanced
conceptual skills are needed
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Management Theory
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Authoritarian: makes all decisions with no staff input and
uses the position to accomplish goals
Democratic: encourages staff involvement in goal
setting, problem solving, and decision making
Laissez-faire: provides little direction or guidance and will
forgo decision making
Today’s health care system requires democratic (or
participative) management
Depending on the situation, the nurse manager may
need to use different types of management styles
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Organizational Theory

Provides a framework for understanding
complex organizations


Systems theory
Chaos theory
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Organizational Theory (Cont.)

Systems theory

Views organization as a set of interdependent parts
that together form a whole
 Anything that affects one aspect of the organization
will affect the other parts
 Open systems suggest that the organization is
affected by not only internal changes but also external
environmental forces
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Organizational Theory (Cont.)

Chaos theory
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
Attempts to account for complexity and randomness
in organizations
Views complicated behaviors, situations, and
variations as predictable; reflects cultural diversity,
constantly fluctuating patient census, and staffing
shortages
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Critical Thinking Question
1.
The hospital’s nursing administration wants to implement a policy
that all wound care be implemented and monitored by the
hospital’s certified enterostomal nurse because of a high rate of
hospital-acquired wound infections. The nursing administrator
refuses to hire an outside consultant suggested by the nurse
managers, stating, “We can do this ourselves; no one needs to
know our problems.” The nursing administrator is adhering to
which management theory?
A.
B.
C.
D.
Open systems
Closed systems
Chaos theory
Participative theory
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23
Management Functions
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Overview

Five management functions are interrelated:
1.
2.
3.
4.
5.

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Planning
Organizing
Staffing
Directing
Controlling
Different phases of the process occur simultaneously
Processes should be circular, with the manager always
working toward improving the quality of health care,
patient safety, and staff and customer satisfaction
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Planning
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Decide in advance what to do; how, when, and
where it is to be done; and who is to do it
All management functions based on planning
Important components of planning
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Mission and philosophy
Strategic planning: long-range; extends 3-5 years into
the future
Goals and objectives: state actions necessary to
achieve the strategic plan
Operational planning: encompasses the day-to-day
activities of the organization
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Organizing
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Establish formal structure to define the lines of
authority, communication, and decision making
Define roles and responsibilities for each level of
management and staff
Coordinate activities with other departments
Communicate to ensure a smooth workflow
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Organizing (Cont.)

Components of organizing
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Organizational chart
Policies and procedures
Job descriptions
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Staffing
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Determine the number and type of staff needed
Recruit, interview, select, and assign personnel
Orient, train, socialize, and develop staff
members
Implement ongoing staff development programs
Implement creative and flexible scheduling
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Staffing (Cont.)

RN work satisfaction factors
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Leaders who inspire vision and excitement
Collaborative decision making
Fairness of the workload and salary
Thanks and positive recognition
Open communication and being informed
Mentorship and professional development opportunities
Challenging work and control over nursing practice
Support for good nurse-physician relationships
Adequate staffing
Agreeable work hours, flexible scheduling, and paid time off
Strong group cohesion and respectful relationships
Ongoing feedback about performance
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Directing
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Clearly communicate performance expectations
Create a motivating climate and team spirit
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Positive reinforcement in the form of a sincere thank you is a
powerful motivational resource
For positive reinforcement to be effective, it must:
•
•
•
•


be specific, with praise given for a particular task
occur as close as possible to the time of the achievement
be spontaneous and unpredictable
be given for a genuine accomplishment
Role model expected behaviors
Manage conflict and facilitate collaboration
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Controlling

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
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Ensure that employees accomplish goals while
maintaining high-quality performance
Establish performance or outcome standards
Measure and evaluate performance against
established standards
Determine an action plan to improve
performance
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Controlling (Cont.)
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Resources for establishing performance
standards
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Written organizational policies and procedures
Standards for the practice of professional nursing
developed by the ANA
Standards for professional nursing specialty practices
Evidence-based practice guidelines
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Controlling (Cont.)

Evaluating employee performance
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Occurs through formal annual evaluation process and
frequent feedback and coaching
Consistent daily feedback and coaching clarify
expectations, improve work quality, allow manager to
correct problems before they become serious
Result of routine performance evaluations should be
mutual goal setting designed to meet the employees’
training, educational, and work improvement needs
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Critical Thinking Question
2. Which of the following would have the greatest
influence on the success of a health care
organization?
A.
B.
C.
D.
Effective protocols
Clear goals and objectives
A transactional nurse manager
Human skills
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Roles of the Nurse as Manager
and Leader
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Patient Satisfaction and Customer
Service Provider
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

Competitive marketplace in which health care
facilities compete for patients
Patient satisfaction is tied directly to financial
rewards for hospitals
Medicare reimbursement rewards (or penalizes)
inpatient hospitals based on the hospital’s
scores on the Hospital Consumer Assessment of
Healthcare Providers and Systems (HSAHPS), a
standardized patient satisfaction survey that
addresses seven core dimensions
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Patient Satisfaction and Customer
Service Provider

Seven core dimensions of the Hospital Consumer
Assessment of Healthcare Providers and Systems
(HSAHPS) standardized patient satisfaction survey
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Communication with nurses
Communication with doctors
Responsiveness of hospital staff
Pain management
Communication about medicines
Cleanliness and quietness of hospital environment
Discharge information
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Team Builder


Team is a group of people organized to
accomplish work
Teams bring together a range of people with
different knowledge, skills, and experiences to
meet customer needs, accomplish tasks, and
solve problems
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Team Builder (Cont.)

Teams should create synergy through:
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
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defined goals and objectives
commitment to work together
good communication
willingness to cooperate
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Team Builder (Cont.)
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Nurse as a role model for teams
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Respect all members of the team; value their input
Clearly define team goals
Define the team’s decision-making authority
Encourage members to develop stewardship
Exhibit a personal commitment to team goals
Encourage team members to help each other
Provide resources necessary to accomplish goals
Teach members to exchange constructive feedback to achieve
team goals
Provide relevant and timely feedback to the team
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Resource Manager
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Resources include personnel, time, and supplies needed
to accomplish goals
Plan for the necessary resources (primarily staff and
supplies) to manage the unit
Organize resources to meet identified goals
Staff appropriately, as determined by patient needs and
the budget plan
Maintain resource allocations within budgetary
guidelines
Control by analyzing financial reports and making
adjustments where necessary
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Decision Maker and
Problem Solver

Decision making
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
Not always related to a problem situation
Required throughout all aspects of management
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Decision Maker and
Problem Solver (Cont.)

Problem solving
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
Focused on solving an immediate problem
Includes a decision-making step
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Decision Maker and
Problem Solver (Cont.)

Nursing process as a guide for decision making and
problem solving
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Assessment: gather all information about the issue
Analysis and diagnosis: use information/data from the
assessment phase to identify the specific problem
Planning: identify and weigh options for risks, consequences,
positive and negative outcomes
Implementation: implement the plan
Evaluation: ensure problem was resolved effectively
More important to understand the process to solve
problems rather than knowing all the answers
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Change Agent
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Responsible for guiding people through the
change process
Rules to follow when change is necessary
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Should be implemented only for good reason
Should always be planned and implemented
gradually
Should never be unexpected or abrupt
Everyone who may be affected by the change should
be involved in planning for the change
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Change Agent (Cont.)

Lewin’s stages of change
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Unfreezing stage: change agent promotes problem
identification and encourages awareness of the need
for change
Moving stage: change agent clarifies the need to
change, explores alternatives, defines goals and
objectives, plans the change, and implements the
change plan
Refreezing stage: change agent integrates the
change into the organization
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Roles of the Nurse as Leader and
Manager

Important components of change


Involvement
Education and training
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Other Roles

Clinical consultant
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Resource for clinical advice
Role model for excellence in nursing care and
evidence-based practice
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Other Roles (Cont.)

Staff developer
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
Offers learning and training opportunities to enhance
professional and personal growth for all employees
Accesses resources and plans staff development
activities that meet the needs of individual staff
members
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Other Roles (Cont.)

Mentor
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
Accepts responsibility to act as a mentor to new
nurses
Recognizes that mentoring is key to developing future
nursing leaders and managers
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Other Roles (Cont.)

Corporate supporter


Committed to the mission, goals, and objectives of
the employing organization
Professional representative for the organization
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Creating a Caring and
Respectful Environment
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Overview


Caring for staff members as well as for patients
and families
Nurses who feel that their leaders, managers
and peers sincerely care about them and the
work they do are able to pass that feeling of
caring on to their patients and other customers
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Caring Actions
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Offer sincere positive recognition
Praise and give thanks for a job well done
Spend time with staff members to reinforce
positive work behaviors
Meet staff’s personal needs whenever possible
Provide guidance and support for professional
and personal growth
Maintain a positive, confident attitude, and a
pleasant work environments
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Addressing and Preventing Bullying



Bullying: “repeated, unreasonable actions of individuals directed towards an
employee (or employees) which are intended to intimidate, degrade,
humiliate or undermine; or which create a risk to the health or safety of the
employees” (Washington State Department of Labor and Industries.
Workplace bullying and disruptive behavior: What everyone needs to know,
2011. Available online at
http://www.lni.wa.gov/safety/research/files/bullying.pdf.)
Also known as lateral violence or disruptive behaviors
Examples of bullying

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Invalid criticism or unjustified blame
Profane or disrespectful language
Being gossiped about or being the target of rumors
Being yelled or shouted at in a hostile way
Being sworn at or verbally abused
Being assigned undesirable work differently from the rest of your colleagues
Being “put down” or humiliated in front of others
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Addressing and Preventing
Bullying (Cont.)

Consequences of bullying are significant

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Nurses who are victims of bullying may have problems with poor
physical health, feelings of self-blame, reduced self-esteem, and
work-withdrawal
Other staff may feed distress and low morale among other staff
Lower productivity and higher costs for the organization
May also lead to patient safety and quality concerns
Nurses must provide the leadership to STOP bullying in
the workplace!!
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Addressing and Preventing
Bullying (Cont.)

Steps to address bullying by individuals

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

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Recognize that bullying is occurring
Realize that the victim is NOT the source of the
problem
Recognize that bullying is about control and has
nothing to do with the victim’s performance
The victim should keep a record of the nature of the
bullying (dates, times places, what was said or done
and who was present)
Obtain documents that contradict the bully’s
accusations against the victim
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Addressing and Preventing
Bullying (Cont.)

Steps to address bullying by employers

Implement and enforce zero-tolerance anti-bullying
policies
 Be sure everyone is aware of what bullying is and
encourage reporting
 Create a Code of Conduct signed by all employees
that defines professional, respectful behaviors

Resources: Book entitled Bullying in the
Workplace: Reversing a Culture published by
the American Nurses Association
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59
Special Leadership Challenges in
the Twenty-First Century
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Overview

Nurses as leaders face daunting challenges




Rapidly rising health care costs
Implementation of health care reform
Ongoing concerns about safety and quality of care
Institute for Healthcare Improvement has established
The Triple Aim to guide all health care professionals to
improve health care



Improve the patient experience of care to include both quality
and satisfaction
Improve the health of populations
Reduce health care costs
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Overview

Three national initiatives provide a framework for making
significant changes



A Proclamation for Change: Transforming the Hospital Patient
Care Environment (Hendrich A, Chow MP, Goshert WS: A
proclamation for change: transforming the hospital patient care
environment, JONA 39(6):266–275, 2009.)
Keeping Patients Safe: Transforming the Work Environment of
Nurses (Institute of Medicine; Page A: Keeping patients safe:
transforming the work environment of nurses, Washington, DC,
2003, National Academies Press.)
The Future of Nursing: Leading Change, Advancing Health
(Institute of Medicine: The future of nursing: leading change,
advancing health, Washington, DC, 2010, National Academies
Press.)
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Proclamation for Change
(Hendrich A, Chow MP, Goshert WS: A proclamation for
change: transforming the hospital patient care environment,
JONA 39(6):266–275, 2009.)


Provides evidence-based recommendations to
address inefficiencies that threaten patient
safety and to improve nurse retention
Basic tenets




Patient-centered design
System-wide, integrated technology
Seamless workplace environments
Vendor partnerships
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63
Patient Safety and the Nurse’s Work
Environment

IOM Report Keeping Patients Safe: Transforming the
Work Environment of Nurses (2003)



Demonstrated a strong connection between the nurse’s work
environment and medical errors
Scientific evidence that nurses are essential to patient safety
continues to grow
Major categories of recommendations from IOM’s Keeping
Patients Safe report:
• Promote transformational leadership and evidence-based
management
• Maximize workforce capability
• Redesign work processes to prevent errors
• Create and sustain a culture of safety
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64
The Future of Nursing

Purpose of the initiative:


Guide advancement of the nursing profession in recognition of
the vital role that nurses play in safe, cost-effective, high-quality
health care
Four key recommendations for nurses:




Practice to the full extent of their education and training
Achieve higher levels of education
Be full partners, with physicians and other health care
professionals, in redesigning health care
Engage in effective workforce planning and policy making with
better data collection and information infrastructure
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Challenges

It will be up to the nurse leader at all levels to
begin this long, yet exciting, process of
redesigning work environments
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