Leading, Managing, and Following



Leading, Managing, and Following


Michael R. Bleich




Objectives



• Relate leadership and other organizational theories to behaviors that serve as important functions of professional nursing.


• Link self-knowledge and emotional intelligence to the constructive use of power, influence, and authority needed for professional practice.


• Develop strength in optimizing one’s personal attributes to effectively lead, manage, and follow.


• Apply organizational strategies to improve interprofessional collaboration and care delivery in complex clinical settings.


• Improve decision making as a leader, manager, or follower by enlarging the view of the patient to include the social network and organizational outcomes.



Terms to Know
















The Challenge



In accepting a formal leadership position as an emergency department (ED) director, I was the fourth “formal” director in 3 years in a unionized 32-bed inner-city ED. The attitude of “management” versus “staff” was evident within the informal leadership structure in which power and authority rested with a group of senior nurses with over 10 years of service. I noted that formal policies and procedures did not reflect actual practices; specifically, the patient flow process depended entirely on the senior “charge” nurse’s style and preferences; no one challenged his or her “authority,” including the physicians. Instead, staff adapted to whoever was in charge, causing daily variability in patient flow. The time between the patient arriving in the ED and being evaluated and treated by an ED physician was controlled by the charge nurse—one assigned patients chronologically, another by chart review, and another by acuity. On my first day, one of the most senior members of the staff informed me, “We were here before you, and we will be here long after you are gone.” The implication was that my formal authority was something they neither respected nor accepted.


What do you think you would do if you were this nurse?




Introduction


The nursing profession constitutes the backbone of the healthcare system both in numbers and in its span of influence across the clinical spectrum. Bearing the responsibility of keeping patients safe requires vigilance, acute observation, knowledge of care delivery processes, and a willingness to act—to engage with patients, families, and other nurses, health disciplines, and agencies. This willingness and the way one engages in these actions constitute leading, managing, and following (Meyer & Lavin, 2005).


As important as it is to ensure that patients have safe passage through the health system maze, nursing functions performed beyond the bedside also incorporate nursing knowledge and values. For instance, nurses develop evidence-driven clinical protocols, design care delivery systems through initiatives such as Transforming Care at the Bedside (TCAB) (Chaboyer et al., 2009), and adapt to ever-changing shifts in human resources. Nurses influence policy leading to health reform and lead social change movements. These activities expand the depth and breadth of nursing work, demanding even more sophisticated knowledge of ways to lead, manage, and follow.


At the heart of patient safety, care delivery design, policy development, and point-of-care clinical performance is a central tenet: the nurse must bridge critical thinking with critical action in complex healthcare settings to achieve positive patient and organizational outcomes. This decision making is not isolated but, instead, is done with others to collectively influence constructive change. Decision making and the corresponding actions taken are core work performed in engagement with others. This core work demands that nurses be leaders, managers, and followers at the point-of-care, unit, institutional, and even societal levels.


Too often, nurses new to the profession believe their ability to perform clinical procedures is what makes them appear professional to those receiving care, to their peers, or to the public. They may believe that leadership is left to those holding management positions or that following means blindly adhering to the direction of others. These nurses fail to realize that their professional nursing image and success depend equally on the poise and influence they demonstrate in decision making and in engaging with others, which requires effective leading, managing, and following behaviors. These behaviors are the first lens through which patients, families, supervisors, and other professionals view them and gain confidence in their abilities.


The way nurses lead, manage, and follow has changed over time. Formerly, nurses took direction from physicians or senior nurses, such as “head” or “charge” nurses. These roles still exist today, but the expectation has shifted from top-down order giving with an expectation of unquestioning following to a model in which shared decision making with collaborative action is the norm. Knowledge expansion and the array of treatment interventions available to patients have grown beyond what a command and control model can accommodate in traditional hierarchically led organizations. This is because patient acuity requires immediate and autonomous responses separate from those that can be pre-assigned. Health care is now delivered in a collaborative and, most often, an intraprofessional manner, with select roles (e.g., charge nurses) serving as an information and care coordination conduit. New roles have been introduced in some organizations, such as the clinical nurse leader (CNL) (Drenkard & Cohen, 2004). The CNL is a systems navigator and bedside-focused care coordinator educated to deliver care and intercede with care delivery processes to ensure clinical and organizational outcomes. And, as technology is increasingly available in all clinical settings, knowledge management, decision-support, and social networking tools can be used to expand beyond tradition-bound organizations, linking professionals to solve complex care and health systems problems (Cross & Parker, 2004). Social networking, as used here, relates to webs of relationships supported by technology to rapidly transmit and receive information.


The study of leadership and organizational behavior has never been more important to patients who face making complex health decisions or to the nursing discipline in an era of major health reform. Each nurse—from point-of-care nurses to those in expanded roles—is held accountable to make the best use of scarce nursing resources. Professional nurses are expected to meet the organizational mission and goals, avert medical errors, achieve patient satisfaction, and ensure positive patient outcomes. In addition, organizations expect nurses to contain costs when delivering patient care, contribute to quality improvement and change initiatives, and interact with other healthcare team members to resolve clinical and organizational problems. These expectations mean that each nurse must be effective in leading, managing, and following.


In this chapter and in Chapters 3 and 4, various perspectives of the concepts of leading (leadership), managing (management), and following (followership) are presented. These concepts are integrated, meaning that nurses can lead, manage, and follow concurrently. Leading, managing, and following are not role-bound concepts—the nurse leads, manages, and follows within any nursing role. This chapter highlights the distinctiveness of each concept separately for ease of understanding the differences, beginning with operational definitions.


Leadership is the process of engaged decision making linked with actions taken in the face of complex, unchartered, or perilous circumstances present in clinical situations for which no standardized solution exists. In exercising leadership, the leader assesses the context surrounding the situation, creates and adapts strategies based on scientific evidence and tacit knowledge, and guides others to broad-based outcomes that, at a minimum, alleviate risk and harm. Effective nurse leaders approach decision making and action setting by communicating direction, using principles to guide the process, and projecting an air of self-assuredness. These traits evoke security in those associated with the task at hand, which, in turn, fosters reasonable risk taking.


Nurse leaders can be found at all levels, from practitioners who are novice to expert, in all personality types, and without regard to gender, ethnicity, or age. In fact, leadership is enacted by a willingness to identify and act on complex problems in an ethical manner. Ethical leadership is not coercive or manipulative of others; the leader informs others of the goal to be attained so solutions can be co-created in the best manner to serve clinical and organizational needs. Leadership can be misused when coercive relationships form, information is withheld, and the true goals are withheld.


Management is an engaged process of guiding others through a set of derived practices and procedures that are evidence-based and known to satisfy pre-established outcomes based on repeated clinical situations. In this chapter, management does not refer to persons holding top positions of authority (e.g., nurse director, chief nursing officer). Management-based decisions and actions may be routine in frequency and low in complexity; however, they increasingly are highly complex and require sophisticated skills and abilities. For example, pain management requires knowledge of the derivative causes of the pain and knowledge of a set of interventional choices applied to the situation at hand and can require simple to complex actions. The challenge of management is to maintain enthusiasm for followers who can fatigue or become bored with tasks that require vigilance but are sustained and repeated and yet are essential for clinical care.


Management differs from leadership in that the behaviors and activities required occur in clinical situations that are less ambiguous; the outcomes are known and a sequence of actions is prescribed, either in writing or through historical practices that are embedded in the organization’s culture.


Followership is engaging with others who are leading or managing by contributing to problem identification, completing tasks, and providing feedback for evaluation. Followers provide a complementary set of healthy and assertive actions to support the leader (who is forging into unknown, complex problem solving) or the manager (who is directing and coordinating predetermined actions to achieve outcomes). Dynamic interplay exists between and among individuals when leading, managing, and following—and this interplay defines, in part, a culture that contributes to patient, family, and healthcare team achievement. The nurse as follower promotes clinical and organizational outcomes by practicing acquiescence to individuals leading or managing the team over certain tasks, such as direction setting, politicking, pacesetting, or planning. Followership is not passive direction taking but, rather, behaviors that model collaboration, influence, and action with the leader or manager.


The collective behaviors that reflect leading, managing, and following enhance each other. All interdisciplinary healthcare providers, including professional nurses, experience situations each day in which they must lead, manage, and follow. Some formal positions, such as charge nurse or nurse manager, require an advanced set of leading and managing know-how to establish organizational goals and objectives, oversee human resources, provide staff with performance feedback, facilitate change, and manage conflict to meet patient care and organizational requirements. In other positions, the nursing role itself demands shifting between leading, managing, and following, almost on a moment-by-moment basis. For instance, nurses lead, manage, and follow in daily clinical practice through assignment making, patient and family problem solving, discharge planning, patient education, and coaching and mentoring staff.



Exercise 1-1


Using the definitions of leadership, management, and followership, imagine that you are faced with a critically ill patient whose family members are spread throughout the country. Some family members are holding vigil at the patient’s side, whereas others are calling the patient care unit incessantly, taking time away from other patient care responsibilities. You recognize the family’s care and concern, yet you want to move from a reactive stance to a proactive position. How would you engage in solving this problem in a leader role? A manager role? A follower role? In which role would you be most comfortable? Least comfortable? Which role would lead to the best outcomes?


image
Being empathetic and showing sensitivity to the experiences of others helps nurse leaders develop their emotional intelligence.


Personal Attributes Needed to Lead, Manage, and Follow


Leading, managing, and following require different skills from those associated with the technical skills-based aspects of nursing. Goleman (2000) and others refer to emotional intelligence—possessing social skills, interpersonal competence, psychological maturity, and emotional awareness that help people harmonize to increase their value in the workplace. Nurses have countless interactions within the course of a workday. In each interaction, nurses can hone their ability to lead, manage, or follow as an emotionally intelligent practitioner within five domains. The domains address:



• Deepening self-awareness (stepping outside oneself to envision the context of what is happening while recognizing and owning feelings associated with an event)


• Managing emotions (owning feelings such as fear, anxiety, anger, and sadness and acting on these feelings in a healthy manner; avoiding passive-aggressive and victim responses)


• Motivating oneself (focusing on a goal, often with delayed gratification, such that emotional self-control is achieved and impulses are stifled)


• Being empathetic (valuing differences in perspective and showing sensitivity to the experiences of others in ways that demonstrate an ability to reveal another’s perspective on a situation)


• Handling relationships (exhibiting social appropriateness, expanding social networks, and using social skills to help others manage emotions)


Emotionally intelligent nurses are credible as leaders, managers, and followers because they possess awareness of patient, family, and organizational needs, have the ability to collaborate, show insight into others, and commit to self-growth. When coupled with performing clinical tasks and critical thinking, the emotionally intelligent nurse demonstrates expanded capabilities. The synergy associated with credibility and capability fuse to become markers of professional nursing. Without self-reflective skills, growth in emotional intelligence is stymied, work becomes routinized, and a nurse can experience a lack of synchrony with others. Box 1-1 is a composite of the attributes that add to the credibility and capability of nurses to lead, manage, and follow.



BOX 1-1   Attributes of Leaders and Managers





Exercise 1-2


Referring back to Exercise 1-1, how would a nurse with highly developed emotional intelligence lead, manage, or follow in reference to problem solving? What kind of social networking skills would be needed for goal attainment? Emotional intelligence is developed through insight into one’s self. Develop a journal or create a feedback circle with other emotionally intelligent colleagues to promote self-awareness about biases, framing complex problems and promoting contextual awareness—seeing a problem through the lens of others. Prepare a sociogram—a list of key relationships to determine balance, perspective, and opportunities for social network expansion. Using these tools, create a personal recipe for enhancing your own emotional intelligence.



Theory Development in Leading, Managing, and Following


Theory has several important functions for the nursing profession. First, theory can help address important questions for which answers are needed. Second, theory (and the expanding array of research methods available to researchers) adds to evidence-based care and management practices (Goode, 2004). Third, theory directs and sharpens the ability to predict or guide clinical and organizational problem solving and outcomes. Nurses often have less exposure to organizational theories than to clinical theories. Leadership, management, and organizational theories are still evolving as the complexity of healthcare organizations grow and the variables that influence care delivery increase and become more apparent. Unfortunately, a single universal theory to guide all organizational and human interactions does not exist. Theory development plays an important role in health care today, in which constant interplay exists among workforce supply, consumer/patient demand, healthcare economics, workforce planning, work environment, research and data support, technology, workforce development, and leadership (Bleich, Hewlett, Santos, Rice, Cox, & Richmeier, 2003).


Theory development associated with leading, managing, and following concepts has been a process of testing, discarding, expanding, creating, and applying. These theories overlap. Terms such as leadership theory, transformational leadership, servant leadership, management theory, and motivational theory and even attempts at followership theories are interrelated and cannot be categorized in any mutually exclusive manner. Developing theories for leading, managing, and following is a complicated task. Furthermore, the theories that leaders, managers, and followers use are drawn from yet another set of theories, many addressed in this book. These include change theory, conflict theory, economic theory, clinical theories, individual and group interaction theories, communication and social networking theories, and many more.


The Theory Box in this chapter is organized as an overview to highlight two sets of theoretical work that are commonly referenced: leadership theories (including management and followership concepts) and motivational theories (because of the magnitude of research that explored human behavior and reward structures). As more disciplines embraced leadership and management theory development, other theories have grown increasingly rich and multidimensional. The complex factors associated with clinical care and organizational functioning explain why no single theory fully addresses the totality of leading, managing, and following. (See the Literature Perspective at right and the Theory Box on pp. 9-11.)



imageLiterature Perspective


Resource: Kerfoot, K.M. (2009). Leadership: Social identity and guiding from within. Dermatology Nursing, 21(1), 45-47.


Kerfoot presents a concise and concentrated history of leadership as a concept, shifting from command-and-control modes in which inheritance played a role (as in Royalty) to military power–based leadership; the next era notes the leader as celebrity, reflected through hierarchical structures and endowed with information.


Generational differences have formed new models of leadership as a construct. Contingency theory shifts to a relationship-oriented view of what is needed to effect change. Today, Kerfoot suggests, an important consideration is the social identity of the group in relationship to its leaders. New research from organizational psychology suggests that the best leaders come from within a group—and that groups are best led from within. She reflects on the body of science that suggests that leaders who are separate from the group or hold different social identities lead from the outside rather than from the inside. Identifying the many types of social identities within healthcare organizations, she explains why nurse leaders reflect the differing expectations of the groups they lead—and so appear different.




Theory Box


Leadership Theories










































THEORY/CONTRIBUTOR KEY IDEA APPLICATION TO PRACTICE

Leaders have a certain set of physical and emotional characteristics that are crucial for inspiring others toward a common goal. Some theorists believe that traits are innate and cannot be learned; others believe that leadership traits can be developed in each individual. Self-awareness of traits is useful in self-development (e.g., developing assertiveness) and in seeking employment that matches traits (drive, motivation, integrity, confidence, cognitive ability, and task knowledge).

 Style theories focus on what leaders do in relational and contextual terms. The achievement of satisfactory performance measures requires supervisors to pursue effective relationships with their subordinates while comprehending the factors in the work environment that influence outcomes. To understand “style,” leaders need to obtain feedback from followers, superiors, and peers, such as through the Managerial Grid Instrument developed by Blake and Mouton (1985). Employee-centered leaders tend to be the leaders most able to achieve effective work environments and productivity.

 Three factors are critical: (1) the degree of trust and respect between leaders and followers, (2) the task structure denoting the clarity of goals and the complexity of problems faced, and (3) the position power in terms of where the leader was able to reward followers and exert influence. Consequently, leaders were viewed as able to adapt their style according to the presenting situation. The Vroom-Yetton model was a problem-solving approach to leadership. Path-Goal theory recognized two contingent variables: (1) the personal characteristics of followers and (2) environmental demands. On the basis of these factors, the leader sets forth clear expectations, eliminates obstacles to goal achievements, motivates and rewards staff, and increases opportunities for follower satisfaction based on effective job performance. The most important implications for leaders are that these theories consider the challenge of a situation and encourage an adaptive leadership style to complement the issue being faced. In other words, nurses must assess each situation and determine appropriate action based on the people involved.

 Transformational leadership refers to a process whereby the leader attends to the needs and motives of followers so that the interaction raises each to high levels of motivation and morality. The leader is a role model who inspires followers through displayed optimism, provides intellectual stimulation, and encourages follower creativity. Transformed organizations are responsive to customer needs, are morally and ethically intact, promote employee development, and encourage self-management. Nurse leaders with transformational characteristics experiment with systems redesign, empower staff, create enthusiasm for practice, and promote scholarship of practice at the patient-side.


Hierarchy of Needs


Maslow is credited with developing a theory of motivation, first published in 1943.

 People are motivated by a hierarchy of human needs, beginning with physiologic needs and then progressing to safety, social, esteem, and self-actualizing needs. In this theory, when the need for food, water, air, and other life-sustaining elements is met, the human spirit reaches out to achieve affiliation with others, which promotes the development of self-esteem, competence, achievement, and creativity. Lower-level needs will always drive behavior before higher-level needs will be addressed. When this theory is applied to staff, leaders must be aware that the need for safety and security will override the opportunity to be creative and inventive, such as in promoting job change.


Two-Factor Theory


Herzberg (1991) is credited with developing a two-factor theory of motivation, first published in 1968.

 Hygiene factors, such as working conditions, salary, status, and security, motivate workers by meeting safety and security needs and avoiding job dissatisfaction. Motivator factors, such as achievement, recognition, and the satisfaction of the work itself, promote job enrichment by creating job satisfaction. Organizations need both hygiene and motivator factors to recruit and retain staff. Hygiene factors do not create job satisfaction; they simply must be in place for work to be accomplished. If not, these factors will only serve to dissatisfy staff. Transformational leaders use motivator factors liberally to inspire work performance.


Expectancy Theory


Vroom (1994) is credited with developing the expectancy theory of motivation.

 Individuals’ perceived needs influence their behavior. In the work setting, this motivated behavior is increased if a person perceives a positive relationship between effort and performance. Motivated behavior is further increased if a positive relationship exists between good performance and outcomes or rewards, particularly when these are valued. Expectancy is the perceived probability of satisfying a particular need based on experience. Therefore nurses in leadership roles need to provide specific feedback about positive performance.


OB Modification


Luthans (2008) is credited with establishing the foundation for Organizational Behavior Modification (OB Mod), based on Skinner’s work on operant conditioning.

 OB Mod is an operant approach to organizational behavior. OB Mod Performance Analysis follows a three-step ABC Model: A, antecedent analysis of clear expectations and baseline data collection; B, behavioral analysis and determination; and C, consequence analysis, including reinforcement strategies. The leader uses positive reinforcement to motivate followers to repeat constructive behaviors in the workplace. Negative events that de-motivate staff are negatively reinforced, and the staff is motivated to avoid certain situations that cause discomfort. Extinction is the purposeful non-reinforcement (ignoring) of negative behaviors. Punishment is used sparingly because the results are unpredictable in supporting the desired behavioral outcome.

Related posts:

  1. Context
  2. Patient Safety
  3. Developing the Role of Manager
  4. Care Delivery Strategies

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Aug 7, 2016 | Posted by in NURSING | Comments Off on Leading, Managing, and Following

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