Leading and Managing in Nursing

Leading and Managing in Nursing

SEVENTH EDITION

Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN Professor and Dean Emerita, Texas Tech University Health Sciences Center, Lubbock, Texas

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Table of Contents

Cover image

Title page

Copyright

Dedication

Contributors

Reviewers

Acknowledgments

Preface

Concept and practice combined

Diversity of perspectives

Audience

Organization

Design

Learning strategies

Complete teaching and learning package

Chapter overview Part 1: Overview

1: Leading, Managing, and Following

Introduction

Theory development in leading, managing, and following

Leading, managing, and following—different but related

Traditional and emerging leadership and management roles

Leading, managing, and following in a diverse organization

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Conclusion

Reflections

The evidence

Tips for leading, managing, and following

2: Clinical Safety: The Core of Leading, Managing, and Following

Introduction

The classic reports and emerging supports

Other key agencies and endeavors

Meaning for leading and managing in nursing

Conclusion

Reflections

The evidence

Tips for clinical safety

3: Legal and Ethical Issues

Introduction

Professional nursing practice: nurse practice acts

Negligence and malpractice

Informed consent

Privacy and confidentiality

Policies and procedures

Employment laws

Professional nursing practice: ethics

Conclusion

Reflections

The evidence

Tips for incorporating legal and ethical issues in practice settings

4: Cultural Diversity and Inclusion in Health Care

Introduction

Concepts and principles

Theory

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National and global directives

Special issues

Language

Meaning of diversity in the organization

Cultural relevance in the workplace

Individual and societal factors

Dealing effectively with cultural diversity

Implications in the workplace

Conclusion

Reflections

The evidence

Tips for incorporating cultural diversity in health care

Part 2: Know Yourself

5: Gaining Personal Insight: The Beginning of Being a Leader

Introduction

Informal and formal leadership

The core of learning to be a leader

Gaining insight into self

Becoming an authentic leader

Conclusion

Reflections

The evidence

Tips for Gaining Personal Insight

6: Being an Effective Follower

Introduction

Research on followership

Followership theories

Differences between leading and following

Leader–follower relationship

Conclusion

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Reflections

The evidence

Tips on how to be an effective follower

7: Managing Self: Stress and Time

Introduction

Emotional intelligence

Understanding stress

Definition of stress

Sources of job stress

Dynamics of stress

Management of stress

Burnout

Resolution of stress

Management of time

Conclusion

Reflections

The evidence

Tips for self-management

8: Communication and Conflict

Introduction

Effective communication within healthcare settings

Types of conflict

Stages of conflict

Categories of conflict

Modes of conflict resolution

Differences of conflict-handling styles among nurses

The role of the leader

Managing incivility, lateral violence, and bullying

Conclusion

Reflections

The evidence

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Tips for effective communication and addressing conflict

9: Power, Politics, and Influence

Introduction

History

Power

Empowerment

Sharing Power

Personal power strategies

Exercising Power and Influence in the Workplace and Other Organizations

Conclusion

Reflections

The evidence

Tips for using influence

Part 3: Know the Organization

10: Healthcare Organizations

Introduction

Characteristics and types of organizations

Integration

Acquisitions and mergers

Forces that influence healthcare organizations

Theoretical Perspectives

Nursing role and function changes

Conclusion

Reflections

The evidence

Tips for healthcare organizations

11: Organizational Structures

Introduction

Mission

Vision

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Philosophy

Organizational culture

Factors influencing organizational development

Characteristics of organizational structures

Bureaucracy

Types of organizational structures

Emerging fluid relationships

Conclusion

Reflections

The evidence

Tips for understanding organizational structures

12: Care Delivery Strategies

Introduction

Historical methods of organizing nursing care

Leadership during implementation of a model of care

Organizational strategies influencing care delivery

Positive care delivery systems

Transitional care

Interprofessional education and collaboration

Conclusion

Reflections

The evidence

Tips for selecting a care delivery model

13: Staffing and Scheduling

Introduction

The staffing process

Evaluation of effective staffing

Factors in staffing that influence patient outcomes

Supplemental (agency or contract) staff and float pools

Organizational factors that affect staffing plans

Developing a staffing budget

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Scheduling

Evaluating unit staffing and productivity

Conclusion

Reflections

The evidence

Tips for staffing and scheduling

14: Workforce Engagement Through Collective Action and Governance

Introduction

Nurses as knowledge workers

Professional practice responsibility

Workplace advocacy, engagement, and empowerment

Shared governance

Collective action, collective bargaining, and unionization in nursing

Healthy work environments

Conclusion

Reflections

The evidence

Tips for workforce engagement and collective action

Part 4: Use Your Skills

15: Making Decisions and Solving Problems

Introduction

Differentiation of decision making and problem solving

Decision making

Problem solving

Conclusion

Reflections

The evidence

Tips for decision making and problem solving

16: The Impact of Technology

Introduction

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Types of technologies

Knowledge technology

Information systems

Informatics

Patient safety

Impact of clinical information systems

Safely implementing health information technology

Future trends and professional issues

Professional, ethical nursing practice and new technologies

Conclusion

Reflections

The evidence

Tips for managing information and technology

17: Delegating: Authority, Accountability, and Responsibility in Delegation Decisions

Introduction

Historical perspective

Definitions

Assignment versus delegation

NCSBN model: an organizational framework for delegation

Effective communication: an essential competency for successful delegation

Delegation and the decision-making process in nursing

Organizational and individual accountability

Legal authority to delegate

Learning how to delegate: different strategies for success

Conclusion

Reflections

The evidence

Implications for practice

Tips for delegating

18: Leading Change

Introduction

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The nature of change

The change process

People and change

Context and change

Leadership and change

Conclusion

Reflections

The evidence

Tips for leading change

19: Building Effective Teams

Introduction

Groups and teams

Creating effective teams

Key concepts of teams

Issues that affect team functioning

Interprofessional teams

The value of team-building

The role of leadership

Conclusion

Reflections

The evidence

Tips for team building

20: Managing Costs and Budgets

Introduction

What escalates healthcare costs

How health care is financed

Healthcare reimbursement

The changing healthcare economic environment

Why profit is necessary

Cost-conscious nursing practices

Budgets

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Conclusion

Reflections

The evidence

Tips for managing costs and budgets

21: Selecting, Developing, and Evaluating Staff

Introduction

Roles in an organization

Selection of staff

Developing staff

Performance appraisals

Coaching

Conclusion

Reflections

The evidence

Tips for selecting, developing, and evaluating staff

22: Person-Centered Care

Introduction

Person-centered care—why now?

Initiatives to deliver person-centered care

Challenges in the delivery of person-centered care

Patient engagement

Nurses in the delivery of person-centered care

Synthesis and application

Conclusion

Reflections

The evidence

Tips for competent person-centered care

23: Managing Quality and Risk

Introduction

Quality management in health care

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Benefits of quality management

Planning for quality management

Evolution of quality management

Quality management principles

Customers

The quality improvement process

Quality assurance

Risk management

Conclusion

Reflections

The evidence

Tips for quality management

24: Translating Research Into Practice

Introduction

From using research to evidence-based practice

Development of evidence-based practice

Comparative effectiveness research

Practice-based evidence

Participatory action research

Quality improvement

Evaluating evidence

Organizational strategies to embed evidence-based practice into organizations

Issues for nurse leaders and managers

Conclusion

Reflections

The evidence

Tips for developing skill in using evidence and translating research into practice

25: Managing Personal and Personnel Problems

Introduction

Personal/personnel problems

Documentation

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Progressive discipline

Termination

Conclusion

Reflections

The evidence

Tips in the documentation of problems

Part 5: Prepare for the Future

26: Role Transition

Introduction

Types of roles

Roles: The ABCs of understanding roles

Role transition process

Strategies to promote role transition

Conclusion

Reflections

The evidence

Tips for role transition

27: Managing Your Career

Introduction

A career framework

Career theory

Professional development

Contributing through scholarly activities and research

Career marketing strategies

Conclusion

Reflections

The evidence

Tips for a successful career

28: Developing the Role of Leader

Introduction

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What is a leader?

The practice of leadership

Leadership development

Leadership development model

Surviving and thriving as a leader

The nurse as leader

Conclusion

Reflections

The evidence

Tips for becoming a leader

29: Developing the Role of Manager

Introduction

The definition of management

Nurse manager as change leader

Nurse manager role and the intergenerational workforce

The nurse manager and interprofessional collaboration

Building a positive work environment

Consuming research

Organizational culture

Mentoring

Day-to-day management challenges

Managing resources

Technology and informatics

Dashboards and decision support tools

Budgets and finance

Quality indicators

Professionalism

Conclusion

Reflections

The evidence

Tips for implementing the role of nurse manager

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30: The Strategic Planning Process

Introduction

Strategic planning

Reasons for strategic planning

Phases of the strategic planning process

Conclusion

Reflections

The evidence

Tips for developing and executing a strategic plan for nursing

31: Thriving for the Future

Introduction

Leadership demands for the future

Leadership strengths for the future

Visioning, forecasting, and innovation

The wise forecast model©

Shared vision

Projections for the future

Conclusion

Reflections

Tips for the Thriving in the future

The evidence

Index

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Copyright

3251 Riverport Lane St. Louis, Missouri 63043

LEADING AND MANAGING IN NURSING, SEVENTH EDITION ISBN: 978-0-323-44913-7

Copyright © 2019 by Elsevier Inc. All rights reserved.

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Dedication

This book is dedicated to the families and friends who supported all of us who created it, to the faculty who use this book to develop tomorrow’s emerging leaders and managers, and to the

learners who have the vision and insight to grasp today’s reality and mold it into the future of dynamic nursing leadership.

Lead on! ¡Adelante!

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Contributors

Joan Benson, BSN, RN, CPN Manager, Clinical Informatics and Practice, Children’s Mercy— Kansas City, Kansas City, Missouri

Kristin K. Benton, BS, BSN, MSN, DNP Director of Nursing, Nursing, Texas Board of Nursing, Austin, Texas

Amy Boothe, DNP, RN Instructor, Traditional Undergraduate Program, Texas Tech University Health Sciences Center, Lubbock, Texas

Elizabeth H. Boyd, MSN, BS Instructor/Site Coordinator, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas

Myra A. Broadway, JD, MS, BSN Formerly, Executive Director, Maine State Board of Nursing, Past President, National Council of State Boards of Nursing, Maine Medical Professionals Health Program Advisory Committee USAFR Nurse Corps (Retired Colonel), Gardiner, Maine

M. Margaret Calacci, MS Director, Simulation and Learning Resources, Arizona State University College of Nursing and Health Innovation, Phoenix, Arizona

Mary Ellen Clyne, PhD President and Chief Executive Officer, Administration, Clara Maass Medical Center, Belleville, New Jersey

Jeannette T. Crenshaw, DNP, RN, LCCE, IBCLC, NEA-BC, FACCE, FAAN Associate Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas

Mary Ann T. Donohue-Ryan, PhD, RN, APN, APRN-MH, NEA-BC Vice President for Patient Care Services and Chief Nursing Officer, Administration, Englewood Hospital and Medical Center, Englewood, New Jersey

Michael L. Evans, PhD, MSN, BSN, BA Dean and Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas

Victoria N. Folse, PhD, APN, PMHCNS-BC, LCPC Director and Professor; Caroline F. Rupert Endowed Chair of Nursing, School of Nursing, Illinois Wesleyan University, Bloomington, Illinois

Jacqueline Gonzalez, DNP, MBA, MSN Senior Vice President/Chief Nursing Officer, Nicklaus Children’s Hospital, Miami, Florida

Debra Hagler, PhD, RN, ACNS-BC, CNE, CHSE, ANEF, FAAN Clinical Professor, College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona

Shari Kist, PhD, RN Missouri Quality Initiative (MOQI) Project Supervisor, Sinclair School of Nursing, University of Missouri—Columbia, Columbia, Missouri

Karren Kowalski, BSN, MSN, PhD President & CEO, Colorado Center for Nursing Excellence, Denver, Colorado Professor, Graduate Program, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas

Mary E. Mancini, RN, MSN, PhD Senior Associate Dean for Education Innovation, Undergraduate Nursing, University of Texas at Arlington, Arlington, Texas

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Maureen Murphy-Ruocco, APN-C, CSN, MSN, EdM, EdD, DPNAP Senior Fellow, National Academies of Practice, Nurse Consultant/Nurse Practitioner New York, New York Professor and Dean Emerita Felician University, Lodi and Rutherford, New Jersey

Karen A. Quintana, PhD, APRN, CPNP-PC Director of Pediatric Nurse Practitioner Studies, Graduate Program, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas

Elaine S. Scott, BSN, MSN, PhD Chair, Nursing Science, East Carolina University, Greenville, North Carolina

Ashley Sediqzad, RN, BSN Manager, Clinical Informatics and Practice, Children’s Mercy Kansas City, Kansas City, Missouri

Janis Bloedel Smith, DNP, MSN, BSN Senior Director, Clinical Informatics & Professional Practice, Patient Care Services, Children’s Mercy Kansas City, Kansas City, Missouri

Susan Sportsman, PhD Nurse Consultant, Collaborative Momentum Consulting, LLC, St. Louis, Missouri

Sylvain Trepanier, DNP, MSN, BSN, RN, CENP Chief Clinical Executive, Administration, Providence St. Joseph Health, Torrance, California

Diane M. Twedell, DNP, MS Chief Nursing Officer, Mayo Clinic Health System, Southeast Minnesota Region, Austin, Minnesota

Jeffery Watson, DNP, RN-BC, NEA-BC, NE-BC, CRRN Assistant Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas

Jana Wheeler, MSN, RN-BC, CPN Manager, Clinical Informatics & Practice, Children’s Mercy Kansas City, Kansas City, Missouri

Crystal J. Wilkinson, DNP, RN, CNS-CH, CPHQ Associate Professor, School of Nursing, Texas Tech University Health Sciences Center, Austin, Texas

Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN Professor and Dean Emerita, Texas Tech University Health Sciences Center, Lubbock, Texas

Margarete Lieb Zalon, PhD, RN, ACNS-BC, FAAN Professor, Nursing, University of Scranton, Scranton, Pennsylvania

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Reviewers

Karen E. Alexander, PhD, RN, CNOR Program Director RN-BSN, Assistant Professor, Clinical Heath and Applied Science—Nursing, University of Houston—Clear Lake, Houston, Texas

Vicki Bingham, PhD, RN, CPE Dean/Associate Professor of Nursing, Robert E. Smith School of Nursing, Delta State University, Cleveland, Mississippi

Deborah Birk, PhD, RN, MHA, NEA-BC Assistant Professor, Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, Missouri

Barbara B. Blozen, EdD, MA, RN BC, CNL Associate Professor, New Jersey City University, Jersey City, New Jersey

Joseph Boney, MSN, RN, NEA-BC Director of Undergraduate Faculty Development/Instructor, Rutgers School of Nursing, Accelerated BS in Nursing Program, Newark, New Jersey

Mary T. Boylston, RN, MSN, EdD, AHN-BC Professor of Nursing, Nursing, Eastern University, St. Davids, Pennsylvania

Jane Campbell, DNP, RN, NE-BC Professor, School of Nursing, Northern Michigan University, Marquette, Michigan

Holly Johanna Diesel, RN, PhD Associate Professor, Academic Chair for Accelerated and RN to BSN Programs, Department of Nursing, Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri

Jennifer B. Drexler, RN, MSN, PhDc, CCRN Clinical Faculty Educator, College of Nursing, University of New Mexico, Albuquerque, New Mexico

Lynn Renee Dykstra, MS, BSN, HPCN, RN Instructor, Adjunct Faculty, Northern Illinois University, College of Health and Human Sciences, Nursing, DeKalb, Illinois Oakton Community College, Division of Science and Health Careers, Nursing Des Plaines, Illinois

Julie A. Fitzgerald, PhD, RN, CNE Assistant Professor of Nursing, Ramapo College of New Jersey, Mahwah, New Jersey

Kay E. Gaehle, PhD, RN Associate Professor of Nursing, Department of Primary Care and Health Systems, Southern Illinois University—Edwardsville, Edwardsville, Illinois

Maria Gillespie, EdD, MSN, BSN, BS, CNE, RN Assistant Professor, Nursing, University of the Incarnate Word, San Antonio, Texas

Julia Henderson Gist, PhD, RN, CNE Dean, School of Health Sciences, Arkansas State University Mountain Home, Mountain Home, Arkansas

Stephanie A. Gustman, DNP, MSN, BSN, RN Assistant Professor, School of Nursing, Ferris State University, Big Rapids, Michigan

Cam A. Hamilton, PhD, MSN, RN, CNE Assistant Professor, School of Nursing, Auburn University at Montgomery, Montgomery, Alabama

Pamela Gibler Harrison, EdD, RN, CNE Professor of Nursing, Chair, Pre-Licensure Nursing,

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Indiana Wesleyan University, Marion, Indiana

Karen L. Hoblet, PhD, MSN, RN, CNL Licensed RN, Clinical Nurse Leader, Interim Department Chairperson and Associate Professor, Interim Director Nurse Educator and Clinical Nurse Leader Programs, Advanced Population Care, The University of Toledo College of Nursing, Toledo, Ohio

Janine Dailey Johnson, MSN, RN Assistant Professor, Nursing, Clarkson College, Omaha, Nebraska

Leo-Felix M. Jurado, PhD, RN, APN, NE-BC, CNE, FAAN Associate Professor, College of Science and Health, William Paterson University of New Jersey, Wayne, New Jersey

Barbara J. Keith, RN, MSN, CNE Clinical Lecturer, Vera Z. Dwyer College of Health Sciences, Indiana University School of Nursing, South Bend, Indiana

Donnamarie Lovestrand, RN, MSN, CPAN Faculty, Nursing Programs, Nursing Department, Pennsylvania College of Technology, Williamsport, Pennsylvania

Anne Boulter Lucero, RN, MSN Assistant Director, Instructor Nursing, Nursing Department, Cabrillo College, Aptos, California

Richard C. Meeks, DNP, RN, COI Assistant Professor, Graduate Program Coordinator, School of Nursing, Middle Tennessee State University, Murfreesboro, Tennessee

Kereen Forster Mullenbach, MBA, PhD, RN Associate Professor, Nursing, Radford University School of Nursing, Radford, Virginia

Sue S. Myers, RPN, BSW, MSCTE Faculty, Psychiatric Nursing and Bachelor of Psychiatric Nursing Programs, School of Nursing, Saskatchewan Polytechnic, Parkway Campus, Regina, Saskatchewan

Barbara Pinekenstein, DNP, RN- BC, CPHIMS Clinical Professor, Richard E. Sinaiko Professor in Health Care Leadership, School of Nursing, University of Wisconsin—Madison, Madison, Wisconsin

Dawn M. Pope, MS, RN Assistant Clinical Professor (retired), College of Nursing, University of Wisconsin—Oshkosh, Oshkosh, Wisconsin

Cara L. Rigby, DNP, RN, CMSRN Associate Professor, BSN Program Director, Nursing, The Christ College of Nursing and Health Sciences, Cincinnati, Ohio

Dulce Anne Santacroce, DNP, RN, CCM Nurse Educator, Nursing, Touro University—Nevada, Henderson, Nevada

Ruth Schumacher, DNP, RN, CNL, CPN Assistant Professor, Department of Nursing and Health Sciences, Elmhurst College, Elmhurst, Illinois

Kathy S. Sweeney, MSN, RN Assistant Professor of Nursing, Nursing Education, Kansas Wesleyan University, Salina, Kansas

Denise Robin Zabriskie, DNP, RN, CWOCN, WCC Assistant Professor, School of Nursing, Touro University Nevada, Henderson, Nevada

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Acknowledgments

Patricia S. Yoder-Wise, RN, EdD, NEA-BC,ANEF, FAAN, Professor and Dean Emerita, Texas Tech University Health Sciences Center, Lubbock, Texas

As with any publication endeavor, many people other than those whose names appear on the cover make the actual publication possible, including the contributors and the Challenge/Solution authors. These behind-the-scenes people also include the reviewers and the publishing team at Elsevier.

We thank each of the contributors who worked diligently to meet deadlines and content expectations. Their names are listed with the chapters they produced. Without them, this book would be a lot thinner! The nurses who told their fabulous stories related to the various chapters always illustrate the real-world meaning of the importance of the chapter content; their names appear with their stories. Without all of them, this book would be much less interesting! What a fabulous group to work with.

We are indebted to our reviewers, who provided valuable feedback that helped refine the book. Receiving peer review is critical to any successful publication. Now that the book is completed, we know who they are and we thank them!

Jeff Watson took on coordinating the ancillaries, and Shelley Burson coordinated and managed an enormous number of details. Both gently nudged all of us to complete our required tasks in a timely manner.

Special thanks go to our publishing team: Senior Content Strategist Yvonne Alexopoulos, Senior Content Development Specialist Tina Kaemmerer, and Senior Production Manager Jodi Willard.

Even more special thanks go to my husband and best friend, Robert Thomas Wise, who vowed to be minimally disruptive as I sat in my office reading, writing, typing, and talking. He is a man of his word!

This book is designed to stimulate thinking and to encourage continued professional development in the area of leading and managing. When the Institute of Medicine released the report, The Future of Nursing, the idea of leadership was clearly a concern for the profession. This book continues its tradition of providing the information that nurses need to assume greater leadership practices and even new management roles. All contributors attempted to provide their best thinking on a given topic so that learners could integrate concepts to form the basis for their contribution to health care. Both the thinking and the complexities will continue to change…and so, hopefully, will you! The passion of nursing and leadership await!

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Preface

The first edition of Leading and Managing in Nursing began in a hotel room in New Orleans, Louisiana in January of 1990. Darlene Como, the founding publisher of Leading and Managing, and I conceptualized a new way of presenting content about leadership and management: one that might engage learners in valuing the importance of roles that support clinical practice. This new approach included personal stories (The Challenge and The Solution), Literature Perspectives, Research Perspectives, synopses, exercises, and boxes of key information. If you saw that first edition and compared the number of words then compared with the number of words in this edition, you would know the field has grown and become far more complex. Nursing has also grown the field of leadership and management research, and so we have many more citations we can share to make this content both theoretical and practical.

We continue to include everything today’s nurses need to know about the basics of leading and managing. The changes with each revision of Leading and Managing reflect the intensity with which we know how leading and managing influence nurses in direct and indirect caregiving roles, as well as in other aspects of being a professional nurse in a complex, ever-changing, dynamic healthcare environment.

Nurses throughout the profession serve in various leadership roles. Leading and managing are two essential expectations of all professional nurses and become increasingly important throughout one’s career. To lead, manage, and follow successfully, nurses must possess not only knowledge and skills but also a caring and compassionate attitude.

This book results from our continued strong belief in the need for a text that focuses in a distinctive way on the nursing leadership and management issues— both today and in the future. We continue to find that we are not alone in this belief. This edition incorporates reviewers from both service and education to ensure that the text conveys important and timely information to users as they focus on the critical roles of leading, managing, and following. In addition, we took seriously the various comments offered by both educators and learners as I met them in person or heard from them by e-mail.

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Concept and practice combined Innovative in both content and presentation, Leading and Managing in Nursing merges theory, research, and practical application in key leadership and management areas. Our overriding concern in this edition remains to create a text that, while well-grounded in theory and concept, presents the content in a way that is real. Wherever possible, we use real-world examples from the continuum of today’s healthcare settings to illustrate the concepts. Because each chapter contributor synthesizes the designated focus, you will find no lengthy quotations in these chapters. We have made every effort to make the content as engaging, inviting, and interesting as possible. Reflecting our view of the real world of nursing leadership and management today, the following themes pervade the text:

• Every role within nursing has the basic concern for safe, effective care for the people for whom we exist—our clients and patients.

• The focus of health care continues to shift from the hospital to the community at a rapid rate.

• Healthcare consumers and the healthcare workforce are increasingly culturally diverse.

• Today virtually every professional nurse leads, manages, and follows, regardless of title or position.

• Consumer relationships play a central role in the delivery of nursing and health care.

• Communication, collaboration, team-building, and other interpersonal skills form the foundation of effective nursing leadership and management.

• Change continues at a rapid pace in health care and society in general. • Change must derive from evidence-based practices wherever possible and from

thoughtful innovation when no or limited evidence exists. • Healthcare delivery is highly dependent on the effectiveness of nurses across roles

and settings.

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Diversity of perspectives Contributors are recruited from diverse settings, roles, and geographic areas, enabling us to offer a broad perspective on the critical elements of nursing leadership and management roles. To help bridge the gap often found between nursing education and nursing practice, some contributors were recruited from academia, and others were recruited from practice settings. This blend not only contributes to the richness of this text but also conveys a sense of oneness in nursing. The historical “gap” between education and service must become a sense of a continuum, not a chasm.

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Audience This book is designed for undergraduate learners in nursing leadership and management courses, including those in BSN-completion courses and second-degree programs. In addition, we know that practicing nurses—who had not anticipated formal leadership and management roles in their careers—use this text to capitalize on their own real-life experiences as a way to develop greater understanding about leading and managing and the important role of following. Numerous examples and The Challenge/The Solution in each chapter provide relevance to the real world of nursing.

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Organization We have organized this text around issues that are key to the success of professional nurses in today’s constantly changing healthcare environment. The content flows from the core concepts (leading, managing, and following; clinical safety; legal considerations; and culture), to knowing yourself (being an effective follower, self-management, conflicts, and power), to knowing the organization (care delivery strategies, staffing), to using your personal and professional skills (technology, delegation, change, and quality), to preparing for the future (personal role transition, self and career management and strategic planning).

Because repetition plays a crucial role in how well learners learn and retain new content, some topics appear in more than one chapter and in more than one section. For example, because problem behavior is so disruptive, it is addressed in several chapters that focus on conflict, personal/personnel problems, incivility, and self-management. Rather than referring learners to another portion of the text, the key information is provided within the specific chapter.

We also made an effort to express a variety of different views on some topics, as is true in the real world of nursing. This diversity of views in the real world presents a constant challenge to leaders, managers, and followers, who address the critical tasks of creating positive workplaces so that those who provide direct care thrive and continuously improve the patient experience.

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Design The functional full-color design, still distinctive to this text, is used to emphasize and identify the text’s many learning strategies, which are featured to enhance learning. Full-color photographs not only add visual interest but also provide visual reinforcement of concepts, such as body language and the changes occurring in contemporary healthcare settings. Figures expand and clarify concepts and activities described in the text graphically.

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Learning strategies The numerous strategies featured in this text are designed both to stimulate learners’ interest and to provide constant reinforcement throughout the learning process. Color is used consistently throughout the text to help the reader identify the various chapter elements described in the following sections.

Chapter Opener Elements

• Objectives articulate the chapter’s learning intent, typically at the application level or higher.

• Terms to know are listed and appear in color type in each chapter. • The Challenge presents a contemporary nurse’s real-world concern related to the chapter’s

focus. It is designed to allow us to “hear” a real-life situation. The Challenge ends with a question about what you might do in such a situation.

Elements Within the Chapters

• Exercises stimulate learners to reason critically about how to apply concepts to the workplace and other real-world situations. They provide experiential reinforcement of key leading, managing, and following skills. Exercises are highlighted within a full-color box and are numbered sequentially within each chapter to facilitate their use as assignments or activities. Each chapter is numbered separately so that learners can focus on the concepts inherent in a specific area and educators can readily use chapters to fit their own sequence of presenting information.

• Research Perspectives and Literature Perspectives illustrate the relevance and applicability of current scholarship to practice. Theory Boxes provide a brief description of relevant theory and key concepts.

• Numbered boxes contain lists, tools such as forms and worksheets, and other information relevant to the chapter.

• The vivid full-color chapter opener photographs and other photographs throughout the text help convey each chapter’s key message. Figures and tables also expand concepts presented to facilitate a greater grasp of important materials.

End-of-Chapter Elements

• The Solution provides an effective method to handle the real-life situations set forth in The Challenge. It reflects the response of The Challenge author and ends with a question about how that solution would fit for you.

• The Evidence contains either one example of evidence related to the chapter’s content or contains a summary of what the literature shows to be evidence related to the topic.

• Reflections provide the learner with the opportunity to reflect on something they’ve encountered in practice.

• Tips offer practical guidelines for learners to follow in applying some aspect of the information presented in each chapter.

• References provide the learner with a list of key sources for further reading on topics found in the chapter.

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Complete teaching and learning package In addition to the text Leading and Managing in Nursing, educator resources are provided online through Evolve (http://evolve.elsevier.com/Yoder-Wise/). These resources are designed to help educators present the material in this text and include the following assets:

• Updated PowerPoint Slides, with lecture notes where applicable, are provided for each chapter.

• An updated ExamView Test Bank includes answers and a rationale. • An updated TEACH for Nurses ties together the chapter resources for the most

effective class presentations, with sections dedicated to objectives, instructor and student chapter resources, teaching strategies, application activities and answers, an in-class case study discussion, and answers to the text Exercise boxes.

Student Resources Learning Resources can also be found online through Evolve (http://evolve.elsevier.com/Yoder- Wise/). These resources provide learners with additional tools for learning and include the following assets:

• NCLEX Review Questions • Sample Resumes

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http://evolve.elsevier.com/Yoder-Wise/
http://evolve.elsevier.com/Yoder-Wise/
Chapter overview

1 Leading, Managing, and Following, 1 The changing landscape of health care provides opportunities for nurses to be actively involved in leading at many levels, from direct patient care to national policy development. Skills related to leading, managing, and following can serve nurses, our patients, and health care well. Nurses must use these skills while incorporating numerous other skills, especially emotional intelligence, to deliver high-quality care to individuals, families, and communities. This chapter provides an overview of theories related to leading and managing as well as complexity science, which can be useful in understanding our evolving healthcare system and profession.

2 Clinical Safety: The Core of Leading, Managing, and Following, 20 Every registered nurse has a legal obligation as a leader—someone who has the opportunity and authority to make changes for his or her patients or for the staff who provide direct care. Despite years of focusing on improving safety, patient safety issues have risen to become the third leading cause of death in the United States. Functioning safely in the clinical area is the complex work of the healthcare team, and the greatest numbers of providers are derived from nursing. This chapter provides an overview of some major patient safety efforts as the basis for nursing’s leadership work. In addition, this chapter addresses staff safety, which is another obligation of nurses to improve the workplace so that safe care can be rendered without harm to providers.

3 Legal and Ethical Issues, 32 This chapter highlights and explains key legal and ethical issues pertinent to managing and leading. Nurse practice acts, negligence and malpractice, informed consent, types of liability, selected federal and state employment laws, ethical principles, and related concepts are discussed. This chapter provides specific guidelines for preventing legal liability and guides the reader in applying ethical decision-making models in everyday practice settings.

4 Cultural Diversity and Inclusion in Health Care, 62 This chapter focuses on the importance of cultural considerations for patients and staff. Although it does not address comprehensive details about any specific culture, it does provide guidelines for actively incorporating cultural aspects into the roles of leading and managing. Diverse workforces are discussed, as well as how to capitalize on their diverse traits and how to support differences to work more effectively. The chapter presents concepts and principles of transculturalism, describes techniques for managing a culturally diverse workforce, emphasizes the importance of respecting different lifestyles, and discusses the effects of diversity on staff performance.

5 Gaining Personal Insight: The Beginning of Being a Leader, 77 Being clinically competent is the goal of every registered nurse, and competence is the foundation of who we are as nurses. In addition, every registered nurse has a legal obligation as a leader. The opportunity to execute this role begins with developing a personal insight about one’s values, strengths, resources, and connections and continues throughout life. Those insights are developed over time and capitalize on past knowledge and experiences and how others react to the demonstration of knowledge, skills, and attitudes in various situations. This chapter provides an overview of some initial strategies to strengthen the skill of leading. These strategies often build on prior experiences and now take on a different perspective of nurse as leader.

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6 Being an Effective Follower, 89 Almost every formal organization has a multilayered hierarchy. The role of the leader has been explicated in the literature for decades. Less well understood, and certainly less well documented, is the role of the follower. This chapter is designed to discuss the role and responsibilities of the follower in the team.

7 Managing Self: Stress and Time, 99 This chapter recalls our understanding of stress and applies it to nursing. Almost every point made about what nurses experience could be applied or modified for other groups of professionals. This is important to remember, because any group has the tendency to think of itself as different from others. This chapter also examines the concept of self-management—developing behaviors that enhance rather than duplicate organizational cultures, social contexts, and occupational expectations as a professional nurse. Positive outcomes of effective self-management include better organization of your day, a higher degree of engagement and positivity, and respect for one’s needs for daily renewal. Three components of self-management are explored: emotional intelligence, time management, and overall stress management. Methods for managing stress and organizing your time are included. Practical exercises and suggestions for stress management and day-to-day time management are presented so they may be applied to personal and professional situations. Personal and professional growth is a life-long journey, and developing healthy habits can serve you well over your entire career.

8 Communication and Conflict, 123 Effective communication and appropriate conflict-handling strategies are essential in professional nursing practice to ensure positive patient outcomes. This chapter focuses on maximizing the ability of nurse leaders to promote a practice environment characterized by effective interprofessional communication and strategies for conflict resolution.

9 Power, Politics, and Influence, 141 The focus of this chapter is the impact of power and politics on the roles of leaders, managers, and followers and the ways in which leaders and managers use power and politics to be influential. Contemporary concepts of power, empowerment, and types of power exercised by nurses are considered. Key factors important to develop a powerful image and personal and organizational strategies for exercising power are recommended. Finally, the power of nurses to shape health policy by taking action in the arena of legislative politics is explored. Each of these concepts will help the nurse manager effectively engage in the politics of the workplace and, ultimately, use these skills in the broader healthcare environment.

10 Healthcare Organizations, 159 This chapter presents an overview of healthcare organizations, their characteristics, and their designs. Economic, social, and demographic factors that influence organizational development are discussed. An emphasis is placed on management and leadership responses that professional nurses must consider in planning the delivery of nursing care in the changing environment. Leaders, managers, and followers must be engaged and aware of the changing dynamics if they are to be effective healthcare professionals and advocate for patients, families, and community.

11 Organizational Structures, 176 The key concepts related to organizational structures and information on designing effective structures that reflect the organization’s mission, vision, philosophy, and values are the focus of this chapter. This information can be used to help nurse managers and others function in an organization and to design structures that support work processes. An underlying theme is designing organizational structures that will respond to continuous changes in the healthcare environment.

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12 Care Delivery Strategies, 193 Nursing care delivery models used to organize care in a variety of healthcare organizations are explored in this chapter. Several historical methods of organizing nursing care—functional nursing, team nursing, and primary nursing (including hybrid forms of these approaches)—are presented. The chapter summarizes an overview of key concepts associated with each care delivery model, including the benefits and disadvantages, with an explanation of the nurse manager’s and direct care nurse’s role. Also discussed are strategies that influence care delivery, such as differentiated practice, the use of rapid cycle change at the bedside, and transitions models to help patients move through various levels of care. Approaches to case management by nurses are also considered.

13 Staffing and Scheduling, 215 This chapter explores research regarding the relationship between nurse staffing and various nurse and patient outcomes and discusses the interrelationship between the personnel budget and the staffing plan. Measures for evaluating unit productivity and the impact of various staffing and scheduling strategies on overall nursing satisfaction and continuity of patient care are discussed. These key points are critical to nurse managers’ ability to deliver safe and effective care in their areas of responsibility while maintaining a high degree of employee satisfaction on the units. Understanding the impact of nurse-sensitive indicators on patient outcomes helps nurse managers control the unit’s labor expenses while ensuring safe and effective care. The nurse manager’s ability to use this information and communicate about staffing to employees is critical to effectively managing productive services and being a valuable member of the leadership team.

14 Workforce Engagement Through Collective Action and Governance, 237 In the healthcare industry today, organizations must empower and retain highly qualified, knowledgeable nurses to provide their services. The ongoing and projected shortage of qualified nurses provides incentives for healthcare organizations to create work environments that attract and engage the most qualified nursing workforce. Work environments that empower and engage nurses promote nurses having a voice in decisions that impact their professional practice, impact patient outcomes, and increase job satisfaction. Empowerment through shared decision making can also provide leverage for nurses to negotiate pay commensurate with their education and expertise and helps create a healthy work environment. This chapter provides information on how to assess work environments through assessing organizational and governance characteristics, nurse empowerment/engagement strategies, and a variety of collective action and bargaining strategies that can shape nurses’ practice.

15 Making Decisions and Solving Problems, 257 This chapter explores the stages of the decision-making and problem-solving processes and describes the analytical tools used in the application of these processes. Strategies for both individual and group (intraprofessional) decision making are addressed.

16 The Impact of Technology, 274 This chapter describes recent technology that allows nurses to effectively and efficiently use data gathered at the point of care. It discusses nurses as knowledge workers who use biomedical and information technology to care for patients. It includes sections on biomedical, information, and knowledge technology with subsections that discuss informatics competencies, information systems hardware, the science of informatics, and patient care safety and quality. Nurses build knowledge for practice by comparing and contrasting not only current patient data with previous data for the same patient but also data across patients with the same diagnosis. Information tools and skills are essential for these decision-making processes now and in the future.

17 Delegating: Authority, Accountability, and Responsibility in

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Delegation Decisions, 298 Delegation, a multifaceted decision-making process, is a learned nursing leadership behavior achieved by understanding the art of delegation, developing critical thinking and diagnostic reasoning skills, and applying critical judgment to effectively delegate to others in clinical practice. The overall purpose of delegation is to achieve nursing goals and improve person-centered care. This chapter discusses different aspects of delegation including the five rights of delegation, organizational and individual accountability, challenges and barriers to delegation, implementation of effective delegation strategies, and the legal parameters of delegation in professional nursing practice. The emphasis is on the role of registered nurses as delegators.

18 Leading Change, 320 This chapter highlights the increasing changes in health care and describes how all nurses must be change agents. The nature of change and the elements of the change process are reviewed. The theories, conceptual frameworks, and human responses to change are considered in an effort to understand the magnitude of managing the change experience. The roles of both the direct care nurse and the nurse manager in navigating change in the healthcare system are explored. Direct care nurses support change by remaining open to and engaging in new models of care, evidence- based practices, and requirements for ensuring safe and effective patient care. Nurse leaders must anticipate, prepare for, facilitate, oversee, and sustain change to achieve improved outcomes and professional and organizational goals. Avenues for promoting staff empowerment and engagement are examined as proactive change management strategies leaders can use to facilitate rapid, efficient, and almost continuous change.

19 Building Effective Teams, 336 This chapter explains major concepts and presents tools with which to create and maintain a smoothly functioning team. Many important group and team efforts occur in the work setting. Effective teamwork requires that we work together in a smooth and efficient manner, communicate clearly, and develop relationships that produce partnerships. Great team members use behaviors such as establishing a clear purpose, active listening, honesty, compassion, and flexibility. Each individual member of the team commits to participate in conflict resolution and cooperates in order to meet the agreed-upon goals. Leaders who understand the value of building an effective team use skills such as debriefing, acknowledgment, and group agreements to manage issues that can impact team functioning. They support the collaboration of interprofessional team members to provide safe and high-quality care.

20 Managing Costs and Budgets, 358 This chapter focuses on methods of financing health care and specific strategies for managing costs and budgets in healthcare settings—something that has become increasingly important as healthcare delivery evolves. Factors that escalate healthcare costs; sources of healthcare financing; reimbursement methods; cost-containment; promotion of growth, access, and revenues; value- based purchasing (as part of The Patient Protection and Affordable Care Act); and implications for nursing practice are discussed. Various budgets and the budgeting process are explained. In addition to clinical competency and caring practices, understanding the cost and revenue in healthcare delivery and the ethical implications of financial decisions is essential for nurses to contribute fully to the health of patients and populations.

21 Selecting, Developing, and Evaluating Staff, 377 One of the most important roles of a nurse leader is that of interviewing, hiring, and developing employees for an organization. Hiring the right employees is an important part of building a highly functioning team that provides safe and high-quality patient care and staff and patient satisfaction. The role of the nurse leader as a coach who empowers employees to grow as followers and develop their leadership skills in a learning environment is explored. Nursing staff in a patient care area are followers who play an important role in interviewing potential candidates and need to be clear

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about various role expectations. The nurse leader also plays an important role in staff development and ongoing feedback of an individuals’ performance.

22 Person-Centered Care, 385 This chapter provides an overview of concepts related to person-centered care and strategies for its effective delivery. Specifically, the role of nurses in the delivery of person-centered care, factors in the healthcare delivery system driving the development of person-centered care approaches, and strategies that can be used by nurse leaders and followers to enhance the delivery of person- centered care are examined.

23 Managing Quality and Risk, 407 The key concepts and strategies related to quality and risk management are explained in this chapter. All healthcare professionals, including nurses, must be actively involved in the continuous improvement of patient care.

24 Translating Research Into Practice, 428 The importance of research in the development of the scientific basis for nursing practice is described in this chapter. The role of the nurse as a follower, manager, and leader of a healthcare organization in applying research to practice is delineated in the context of demands for the provision of health care based on the best available scientific evidence. This chapter also describes the practical aspects of appraising research, the development of evidence-based practice and practice-based evidence, and the use of large data sets to develop evidence in nursing. Strategies for translating research into practice that can be used by the individual nurse as a follower, leader, and manager in the context of the organization are outlined.

25 Managing Personal and Personnel Problems, 451 The purpose of this chapter is to discuss various personal and personnel problems that a leader must face in all nursing settings. Some specific tips and tools are provided as ways to intervene, coach, correct, and document problem behaviors such as absenteeism, uncooperative employees, emotional problems, or substance abuse. Supportive communication applications are also discussed. The problems and issues discussed are not only the responsibility of nursing leadership but also the responsibility of the entire team, including newly licensed registered nurses. Working on these issues from the perspective of newly licensed registered nurses provides a significant learning experience as these nurses transition into the workplace.

26 Role Transition, 465 As individuals progress through life, they transition through many roles at home, at work, and in relation to other individuals. This chapter focuses on role transition—the process of moving from one role to another. An example of this could be a nurse whose primary role is providing direct patient care (direct care nurse) transitioning to a nurse leader role. Role expectations need to be clearly articulated and determined for successful role transition to occur. The process of role transition and the different phases of this are reviewed.

27 Managing Your Career, 476 Successful people actively manage their careers rather than wait for “lucky breaks.” Although trusted others may guide or influence career development, individuals manage their own reputations and careers. Continuous lifelong learning and the ability to demonstrate and document competence are critical elements in effective career management. This chapter provides guidance for creating a successful career in nursing through academic progression, continuing education, certification, and service in professional organizations. In addition, this chapter includes the process of documenting qualifications and accomplishments for use in employment and career transitions.

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28 Developing the Role of Leader, 495 The role of leader is vitally important in all healthcare settings. Nurses are present in virtually all settings, and developing the role of leader is very important to quality, safety, and staff productivity. This chapter focuses on leadership and its value in advancing the profession of nursing. Leadership development is explained with examples of how to survive and thrive in a leadership position. The differences between emerging and entrenched workforce generations are explored, and the desired characteristics of a leader for the emerging workforce are described. Leadership in a variety of situations, such as clinical settings, community venues, organizations, and political situations, is described. In addition, this chapter provides an introduction to the opportunities, challenges, and satisfaction of leadership.

29 Developing the Role of Manager, 510 The nurse manager serves as the catalyst for change by exhibiting a multitude of critical skills. Finding a mentor(s) is key in building and learning new skills as a nurse manager. Mentors serve as guides and coaches and share the lessons they have learned, including acute observation, proactivity, and risk-tasking. This chapter provides an overview of important elements that can assist in optimizing the knowledge and competency of the nurse manager. In addition, this chapter addresses items such as the evolution of management theories, managing the complexities of an intergenerational workforce, ensuring a positive workplace culture, mentoring, and the manager’s role in handling resources. The importance of the nurse manager’s use of dashboards and key performance indicators is demonstrated to ensure positive patient outcomes.

30 The Strategic Planning Process, 530 Today’s healthcare landscape is in a state of evolution with a concentrated focus on quality outcomes, patient safety, improved operational efficiencies, new reimbursement models, and demonstrated cost savings. Healthcare organizations must be resilient while navigating this new paradigm. The strategic planning process is one way in which a healthcare organization can chart its course for future success, and nurses are poised to be an integral part of the strategic planning process. The strategic planning process incorporates the same scientific process as the nursing process by: (1) assessing the current state of the organization; (2) conducting a gap analysis to establish a baseline of where the organization needs to be; (3) examining the organization’s mission, vision, and values; (4) implementing a plan with benchmark data; and (5) evaluating and continuing to monitor the outcomes of the plan and to revise the plan as needed. Nursing has the ability to create its own strategic plan that aligns with the mission, vision, values, and goals of the organization and that can serve as the basis for a division-, service-, or unit-level strategic plan. Unless all elements in an organization can envision how they fit within the overall strategic plan, it is likely it will not be achieved. This chapter provides an overview of strategic planning and the strategic planning process. Specifically, this chapter will demonstrate how nursing is integral in this strategic journey.

31 Thriving for the Future, 540 As everyone in health care knows, health care is changing so rapidly that keeping up-to-date is an increasing challenge. To be current, we really need to think about the future and what the nature of various changes will do to and for our practice. How we think about the future and the actions we take now shape what health care will be like and what our practice might be. This chapter explores the potential for the future and how the changes we face can be maximized to our benefit— organizationally and personally. The key leadership skills of visioning, forecasting, and innovating are presented. Projections for the future and their implication for nursing are included.

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PA R T 1 Overview

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Leading, Managing, and Following Shari Kist

LEARNING OUTCOMES

• Describe the evolution of the theoretical basis for leadership and management. • Evaluate leadership and management theories for appropriateness in health care today. • Apply concepts of complexity science to healthcare delivery and the evolution of nursing. • Compare and contrast the actions associated with leading, managing, and following.

KEY TERMS advanced practice registered nurse (APRN) clinical process complexity science emotional intelligence followership leadership

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leadership theory managing management theory motivation process of care quadruple aim social networking values vision

T h e C h a l l e n g e JoAnn Franklin, DNP, RN, GNP-BC, FNP-BC, MHNP, FAANP Missouri Quality Initiative (MOQI), University of Missouri-Columbia, Columbia, MO APRN at National Health Care Desloge, Desloge, MO

Angelita Pritchett, MSW, LMSW MOQI Care Transitions Coach, University of Missouri-Columbia, Columbia, MO

The acuity of residents in long-term care [LTC] facilities has increased over time. Today’s nursing home residents are similar to hospitalized medical-surgical patients of the past. However, the processes of care in these facilities have not changed to meet the demand. The minimum requirement for physician visits is a 10- to 30-minute visit every other month. A change in the resident’s condition generally results in either an emergency department visit or hospitalization— thus the mantra, “when in doubt, send them out.” However, hospitalization puts an older person at risk for further decline unrelated to the primary admission diagnoses.

At a particular LTC facility, no systems were in place to prevent transfers. It was not uncommon for multiple residents to be sent to the hospital every week. The solution to any symptom was to add more medications to the resident’s drug regimen, often resulting in polypharmacy. Clinical skills of nursing staff were limited, and management was accustomed to “putting out fires” as opposed to being proactive in having preventive care/conversations with residents and their families. Communication among staff was limited and no active staff education program, beyond new employee education and mandatory in-service classes, was in place. Those in management positions did not make rounds on the nursing units. Additionally, residents and their family members were not having open, honest conversations about the residents’ goals for care. In many instances, transfers occurred because goals of care, particularly for end-of-life care, had not been addressed.

What would you do if you were this nurse?

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Introduction The nursing profession constitutes the backbone of the healthcare system, both in numbers and in span of influence. All too often nurses, especially new graduates, desire to focus on direct patient care, with limited attention to the the healthcare spectrum. However, our complex work environments should stimulate us to look more broadly at the systems affecting how we practice. The skills of leading, managing, and following can be used whether the nurse is providing direct patient care or collaborating with stakeholders of a large healthcare system.

Beyond the expectation to lead, manage, and follow, nurses are also expected to help fulfill health care’s quadruple aim. Initially known as the triple aim by the Institute for Healthcare Improvement (IHI), the quadruple aim relates to improving access to care, quality of care, cost of care, and work life of the healthcare team (Bodenheimer & Sinsky, 2014) (Fig. 1.1). Nurses who practice in expanded roles, such as advanced practice registered nurses, help improve healthcare access beyond traditional hospitals and ambulatory centers.

FIG. 1.1 Quadruple aim.

Nurses must be vigilant in delivering care that is scientific, state of the art, and sensitive to patients’ needs, collectively creating an accessible and cost-effective experience that leaves care

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providers satisfied with their contributions. Patients want their values and beliefs respected as they partner with the care team. Patients also demand a safe clinical experience, free from medical error and catastrophic events, up to and including death.

Access to care and cost of care must be considered by patients, providers, and payers. Technology, institutional care, supplies, and human resource requirements carry a staggering cost burden. How to provide quality care at a reasonable cost is an ongoing discussion at many levels, ranging from the family dinner table to board rooms and Congress.

Providing access to quality, reasonably priced care creates a new level of stress for all members of the healthcare team. Healthcare team members must learn to identify professional burnout and implement strategies that will achieve work–life balance. The expectations of the quadruple aim require that all members of the team function at the highest level possible both as a team member and as an individual. As a discipline, we are called upon to develop expanded roles congruent with societal needs; we influence policy development, and we design and carry out clinical processes to provide safe and high-quality patient- and family-centered experiences in a wide range of settings.

The practice of nursing can be both physically and emotionally demanding. Consistent with the quadruple aim, nurses should actively care for their own physical and emotional well-being and lead initiatives that promote health. Self-care actions for balanced lives with early recognition of burnout can lead to a healthier personal and professional life.

This chapter starts to frame your professional journey, and the chapters that follow add to your professional formation. In this chapter and in subsequent chapters, various perspectives on the concepts of leading (leadership), managing (management), and following (followership) are presented. Leading, managing, and following are not institutionally role-bound concepts—the nurse must lead, manage, and follow within any nursing role, from direct care nurse to chief executive nurse, and do so with fluidity among those roles. In the end, nurses with leadership, management, and followership abilities will make better clinical decisions, consider the organizational and societal context of decisions, act as advocates for individuals receiving care, and influence the impact of these decisions on families, the organization, and the society.

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Theory development in leading, managing, and following Theory has several important functions for the nursing profession. First, theory can be used to guide how the nurse approaches a particular situation. Second, theory can be used to frame a research question and guide a research study. Third, theory directs and sharpens the ability to predict or guide clinical and organizational problem solving and outcomes. Because nursing is a practice discipline, it is possible to focus more effort on the doing rather than the theoretical perspective. However, having a theory-based approach can enhance performance and strengthen the value of the theory.

The theoretical basis for understanding leading, managing, and following originates from multiple disciplines. Early researchers in organizational science noted the differences in the ways some organizations operated. The focus was on traits of individual leaders rather than characteristics or functioning of the organization. Studies of individual leaders resulted in awareness that some individuals possessed traits that seemed to produce better organizational outcomes. Trait theory, developed from these studies, is still examined as a leadership factor today, even though it holds less influence than some other theories.

Closely tied to this appreciation of traits as one leadership ingredient were observations that a leader could be successful in one environment yet not necessarily in another. The situation at hand and the work environment itself were variables that mattered. Activities being performed were yet another variable that was studied. When the setting required reproducible and repetitive tasks, a charismatic leader may be less effective than in an unpredictable or unstructured situation where the tasks required on-the-spot innovation. Study of these variables advanced knowledge about leading, managing, and following and promoted the development of other theories. These include situational/contingency theory, which examines variables in the external and internal environment, including the nature of the work itself, worker behaviors (individual or group), the predictability or unpredictability of work, and the risk associated with work. Management theories, which address planning, organizing, directing, and controlling aspects of work design, were also included and sometimes were cited as leadership theories. These theories, originating from the mid-1950s, are still relevant today. They continue to evolve and often are combined with other theories to guide professionals into evidence-based organizational practices.

Terms such as leadership theory, transformational leadership, servant leadership, authentic leadership management theory, motivational theory, and even attempts at followership theories are interrelated and cannot be categorized in a mutually exclusive manner. The theories that leaders, managers, and followers use are drawn from yet another set of theories, some of which are addressed later in this book and include change, conflict, economic, clinical, individual and group interactions, communication, and social networking. The Theory Box on p. 9 is organized as an overview to highlight sets of theoretical works that are commonly referenced for the purpose of demonstrating the variety, approach, and constant evolution of theory development in organizational studies. The complex factors associated with clinical care and organizational functioning explain why no single theory fully addresses the totality of leading, managing, and following.

Using Complex Adaptive Science to Understand Health Care Today Too often, theories are thought to have evolved from circumstances that do not reflect current practices and are too narrow in scope to be useful. Typically, theory development has been based on assumptions that by reducing something into its component parts, its functioning could be better understood. For example, departments of a healthcare organization, such as laboratory, pharmacy, and dietary, all have leaders and managers. Although they have both responsibility and authority within a department, very often a decision made within the department will have a complex ripple effect on the rest of the organization, and most commonly the nursing department is affected by each of those other departments.

Complexity theory is a nontraditional theory that has emerged over time from the works of physical and social sciences. Complex adaptive science can help us understand health care as it is

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delivered to patients and families, as well as healthcare systems in general. Complexity science does not refer to the complexity of the decision to be made or to the work environment, but rather to examining how systems adapt and function—where co-creation of ideas and actions unfold in a nonprescriptive manner. Complexity theory can be used by those in leadership and management roles for understanding an organization as well as in planning and executing changes within an organization.

Complexity science promotes the idea that the world is full of patterns that interact and adapt through relationships. These interactive patterns may be missed when one focuses solely on a single part. Complexity scientists pay keen attention to what naturally occurs as patterns in the universe and how these patterns create adaptive change rather than how people create planned or forced change. Stated in nursing terms, nurses care for individual patients who each present a unique challenge. With experience, nurses recognize that patterns of patient behaviors emerge and learn that certain nursing actions lead to effectively managing pain, engaging family members in end-of- life planning discussions, and addressing a host of other issues. Most healthcare team members are very focused on problems and predictable solutions that appear to be linear in nature, which is described as technical work. However, if we look more deeply at both disease processes and health care, we realize that both are an interconnected web of physiologic processes and services. Thus a linear solution may not be feasible, and solutions require adaptations that account for a multitude of factors. The application of complexity science is reflected in the elements of evidence-based nursing practice, which includes patient preferences, along with assessment data, research findings, and clinical expertise. Although much work in health care has focused on acute care organizations, complexity science is applicable in other settings, including long-term care, as illustrated in the Research Perspective.

R e s e a r c h Pe r s p e c t i ve Resource: Colon-Emeric, C., Toles, M., Cary M. P., Batchelor-Murphy, M., Yap, T., Song, Y., Hall, R., Anderson, A., Burd, A., & Anderson, R. A. (2016). Sustaining complex interventions in long- term-care: A qualitative study of direct care staff and managers. Implementation Science, 11, 94.

The aim of this qualitative study was to understand perspectives related to the sustainability of an intervention being tested in a long-term care facility. Complexity science served as the theoretical basis for the intervention portion of the study and thus guided the qualitative study being described here. Fifteen focus groups with 83 participants were conducted. Participants included both managers and direct care staff to get a wide variety of perspectives.

The findings identified that all participants believed the intervention was useful because it would ultimately improve the care of residents. The intervention tested was complex. Some participants, especially those with less education, struggled to grasp the intent and how it could affect their roles in the long-term care facility. Although participants valued the training they received, they expressed concern that sustaining change would be difficult because of staff turnover, lack of leadership support, and lack of culture change.

Implications for Practice By using the lens of complexity science for this study, nurses can begin to appreciate the numerous factors that come into play when planning, implementing, and evaluating a change in a care process. Being able to sustain a change in behaviors requires that those in administrative roles are supportive, while maintaining a level of accountability for all staff.

In complex adaptive leadership, the goal in responding to patient and organizational problems is to examine a problem through multiple lenses. An adaptive leader understands that systems are ecological—they restore themselves—and that change can happen equally from the bottom up or from the top down. Questioning, observing patterns, and generating new patterns through being involved is how change unfolds. Adaptive leaders appreciate that they have influence and can help shape overall outcomes, with no sense that absolute control is either necessary or possible.

In complexity science, information is not a commodity to be controlled by those in charge. Instead, it is intended to be shared with and interpreted by a wide audience, to provide varying interpretations of the same scenario. Diverse thinking leads to creative problem solving in which

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multiple individuals are actively engaged, using diverse skills to be part of the solution. Relationships and communication are central factors in complex adaptive leadership. Poor team

communication has been directly linked to preventable medical errors, high staff turnover rates, and low morale. On the other hand, team members who communicate effectively with each other and feel that their voices are heard are likely to provide safe high-quality care, be active team members, and stay with the organization for a period of time. In complexity science, every voice counts and every encounter with patients and families merges to co-create a desired outcome. Co- creation, the idea that a change doesn’t belong to one person or group, is critical to moving quality of care and innovation forward.

One of the early references in complexity science and leading and managing identified four concepts:

• Managers must be aware that employees will self-manage themselves into work groups. Rather than exerting control, effective managers stimulate creative problem solving. These groups may start as having a single purpose but may be sustained through achieving positive outcomes.

• Managers must be skillful in providing context. While keeping a clear vision of the objective to be accomplished, employees can be encouraged to explore and develop solutions to complex problems. Concepts of shared governance and adaptive leadership blend well with the overall aim of safe and effective patient care.

• Managers must adapt to the changing environment and use influence where they can have the most impact. Health care is often procedure driven, yet managers must remain cognizant of the communication and relationships necessary to carry out procedures that create positive outcomes.

• Managers must address sources of tension and contradiction. Disagreement and tension may be the result of creative problem solving by the group and are expected when working with diverse groups. Seeking insight and encouraging creativity and communication allow the manager to capitalize on tension for a positive benefit.

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