Nursing Leadership and Management



Nursing Leadership and Management


Barbara Cherry, DNSc, MBA, RN, NEA-BC




Key Terms



Authority


The legitimate right to direct others given to a person by the employer through an authorized position, such as manager or administrator.


External customers


People in need of services from an organization who are not employed by the organization, including patients, family members, physicians, students, payers, discharge planners, and other groups that are a source of patient referrals.


Health care organization


Any business, company, institution, or facility (e.g., hospital, home health agency, ambulatory care clinic, health insurance company, nursing home) engaged in providing health care services or products.


Internal customers


People who are employed by the organization to provide services to various groups and individuals across the organization (e.g., nurses and other patient care staff, administrators, social workers, dietitians, therapists, housekeeping staff, and clerical support staff).


Leadership


The act of guiding or influencing people to achieve desired outcomes; occurs any time a person attempts to influence the beliefs, opinions, or behaviors of an individual or group (Hersey and Blanchard, 1988).


Management


Coordination of resources, such as time, people, and supplies, to achieve outcomes; involves problem-solving and decision-making processes.


Organizational chart


A visual picture of the organization that identifies lines of communication and authority.


Productivity


The amount of output or work produced (e.g., home visits made) by a specific amount of input or resources (e.g., nursing hours worked).


Resources


Personnel, time, and supplies needed to accomplish the goals of the organization.





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http://evolve.elsevier.com/Cherry/


VIGNETTE


Nancy Brown, a new registered nurse (RN), has accepted a position in a busy outpatient dialysis unit. During nursing school, Nancy worked in the facility as a patient care technician, and she is confident in her clinical skills because of this experience. Mary, the nurse manager of the dialysis unit, has scheduled Nancy to attend the new-nurse orientation. Although Nancy thinks to herself, “I know what the RNs do around here; I’d like to jump right in without attending orientation,” she readily accepts the assignment.


The nurse manager begins the orientation program with a discussion about the mission of the organization and the RN’s responsibility to ensure that quality patient care is provided in a safe and cost-effective manner. As Nancy progresses through the orientation program, her confidence quickly fades. She becomes overwhelmed as she listens to a description of her new responsibilities as an RN. The RN’s duties involve much more than the expected physical assessment, identifying nursing diagnoses, and developing and implementing care plans. Some of Nancy’s many new responsibilities as a staff RN are to do the following:



As Nancy is trying to assimilate the information being presented, she almost fails to hear Mary say that within 6 months of employment, all staff RNs are expected to begin orientation for the charge nurse position to provide backup coverage. At the end of the orientation, Nancy has a new perspective about professional nursing practice—it seems to be more about managing the delivery of patient care than actually giving the care!




Chapter Overview


During nursing school, students are often more concerned with developing clinical knowledge and skills and are less concerned with management and leadership skills. However, immediately after graduation the new nurse is placed in many situations that require leadership and management skills—managing a group of assigned patients, serving on a task force or committee, acting as team leader or charge nurse, or supervising unlicensed assistive personnel and licensed vocational or practical nurses. In addition to providing safe, evidence-based, high-quality clinical care, the challenges for RNs today are to manage nursing units that are constantly admitting and discharging higher-acuity patients, motivate and coordinate a variety of diverse health professionals and nonprofessionals, embrace change to develop work environments that are safer and more conducive to professional nursing practice, and manage limited resources and shrinking budgets.


Regardless of in which position or area the nurse is employed, the health care organization will expect the professional nurse to have leadership and management skills, including the following:



As the reader can easily visualize, leadership and management activities are a primary responsibility for the RN. In fact, professional nursing within the health care organization has as much to do with managing the delivery of care as it does with actually providing that care. This chapter presents key leadership and management concepts that will guide the nurse to grow and develop in this important aspect of the professional practice role.


Throughout this chapter, the term organization is used to refer to the hospital, home health agency, post–acute care facility, long-term care facility, ambulatory clinic, managed care company, or any other area in which a nurse might be employed to practice professional nursing. Legal and ethical issues are a critical component of nursing management, although it is not within the scope of this chapter to discuss these issues. The reader is encouraged to review Chapter 8 regarding legal issues and Chapter 9 regarding ethical issues.



Leadership and Management Defined and Distinguished


Leadership Defined


Leadership occurs any time a person attempts to influence the beliefs, opinions, or behaviors of a person or group (Hersey and Blanchard, 1988). Leadership is a combination of intrinsic personality traits, learned leadership skills, and characteristics of the situation. The function of a leader is to guide people and groups to accomplish common goals. For example, an effective nurse leader is able to inspire others on the health care team to make patient-centered care an important aspect of all care activities.


It is important to note that leaders may not have formal authority granted by the organization but are still able to influence others. The job title such as “nurse manager” will not make a nurse a leader. Today’s complex health care environment requires that every nurse—regardless of his or her role or setting—provide leadership to advance excellence in nursing practice and patient care.



Management Defined


Management refers to the activities involved in coordinating people, time, and supplies to achieve desired outcomes and involves problem-solving and decision-making processes. Managers maintain control of the day-to-day operations of a defined area of responsibility to achieve established goals and objectives. Managers plan and organize what is to be done, who is to do it, and how it is to be done. A manager will have the following:




Leadership versus Management


Although leadership and management are intertwined and it is difficult to discuss one without the other, these concepts are different. Leadership is the ability to guide or influence others, whereas management is the coordination of resources (time, people, supplies) to achieve outcomes. People are led, whereas activities and things are managed. Leaders are able to motivate and inspire others, whereas managers have assigned responsibility for accomplishing the goals of an organization. A good manager should also be a good leader, but this may not always be the case. A person with good management skills may not have leadership ability. Similarly, a person with leadership abilities may not have good management skills. Leadership and management skills are complementary; both can be learned and developed through experience, and improving skills in one area will enhance abilities in the other.



Power and Authority


Leadership and management require power and authority to motivate people to act in a certain way. Authority is the legitimate right to direct others and is given to a person by the organization through an authorized position, such as nurse manager. For example, a nurse manager has the authority to direct staff nurses to work a specific schedule. Whereas authority is the legitimate right to direct others granted by the organization, power is the ability to motivate people to get things done with or without the legitimate right granted by the organization. The primary sources of power are as follows (Hersey et al, 1979):



• Reward power comes from the ability to reward others for complying and may include such rewards as money, desired assignments, or acknowledgment of accomplishments.


• Coercive power, the opposite of reward power, is based on fear of punishment for failure to comply. Sources of coercive power include withheld pay increases, undesired assignments, verbal and written warnings, and termination.


• Legitimate power is based on an official position in the organization. Through legitimate power, the manager has the right to influence staff members, and staff members have an obligation to accept that influence.


• Referent power comes from the followers’ identification with the leader. The admired and respected nurse is able to influence other nurses because of their desire to emulate her.


• Expert power is based on knowledge, skills, and information. For example, nurses who have expertise in areas such as physical assessment or technical skills, or who keep up with current information on important topics will gain respect from others.


• Information power is based on a person’s possession of information that is needed by others.


• Connection power is based on a person’s relationship or affiliation with other people who are perceived as being powerful.


An individual may also have informal power resulting from personal relationships, being in the right place at the right time, or unique personal characteristics, such as attractiveness, education, experience, drive, or decisiveness. By understanding the authority of an assigned position and the sources of formal and informal power, the nurse manager will be better able to influence others to accomplish goals.



Formal and Informal Leadership


Both formal and informal leadership can exist in every organization. Formal leadership is practiced by the nurse who is appointed to an approved position (e.g., nurse manager, supervisor, director) and given the authority to act by the organization. Informal leadership is exercised by the person who has no official or appointed authority to act, but is able to persuade and influence others. The informal leader, who may or may not be a professional nurse, may have considerable power in the work group and can influence the group’s attitude and significantly affect the efficiency and effectiveness of workflow, goal setting, and problem solving.


The nurse manager must learn to recognize and effectively work with informal leaders. Informal leadership may be positive if the informal leader’s purpose is congruent with that of the nursing unit and organizational goals. For example, the informal leader of a patient care group may be highly supportive of a new nursing care delivery model being implemented on the unit, and as a result, the other team members will be more willing to accept the change. However, an informal leader who is not supportive of the nursing unit’s goals can create an uncomfortable work environment for the nurse manager and the entire team. Following are some strategies the nurse manager can use to work with informal leaders:




Leadership Theory


Understanding the development and progression of leadership theory is a necessary building block for developing leadership and management skills. Researchers began to study leadership in the early 1900s in an attempt to describe and understand the nature of leadership. The following sections provide a brief description of key leadership theories. Readers are encouraged to learn more about these theories, especially as they advance in their nursing career.



Leadership Trait Theory


Early leadership theory centered on describing the qualities or traits of leaders and has been commonly referred to as trait theory (Stogdill, 1974). Leadership trait theory was based on the assumption that leaders were born with certain leadership characteristics. Traits found to be associated with leadership include intelligence, alertness, dependability, energy, drive, enthusiasm, ambition, decisiveness, self-confidence, cooperativeness, and technical mastery (Stogdill, 1974). Although trait theories have been important in identifying qualities that distinguish today’s leaders, these theories have neglected the interaction between other elements of the leadership situation. Trait theories also have failed to recognize the possibility that leadership traits can be learned and developed through experience. However, by keeping in mind these traits associated with effective leadership, the new nurse can identify areas in which he or she should improve and develop.




Transformational Leadership


In a contemporary concept of leadership, Burns (1978) identified and defined transformational leadership. Burns contends that there are two types of leaders: (1) the transactional leader, who is concerned with the day-to-day operations of the facility and (2) the transformational leader, who is committed to organizational goals, has a vision, and is able to empower others with that vision. The transformational leader is able to guide employees to feel pride in the work of the organization and to inspire them to be actively engaged to achieve the mission and goals of the organization. Transformational leaders spend time teaching and coaching, seek differing perspectives when faced with problems to solve, and seek new ways to improve the work environment. Box 16-1 compares characteristics of Burns’ (1978) transformational and transactional leadership styles.



Studies have reported that nurse managers who demonstrate more transformational leadership characteristics achieve higher levels of staff satisfaction and work group effectiveness (Casida and Parker, 2011; Failla and Stichler, 2008; Raup, 2008). The implication for nurse managers is that transformational leadership is very effective in increasing staff satisfaction and work effectiveness. The student is encouraged to read more about transformational leadership and to seek out transformational leaders as mentors. However, it is important to note that even the most effective transformational leader will fail without possessing the day-to-day management skills of transactional leaders (Bass et al, 1987).



Leadership Skills


Three major types of skills are required for effective leadership (Hersey and Blanchard, 1988):



At the staff nurse level of management, a considerable amount of technical skill and clinical expertise is needed because the nurse generally is involved in direct supervision of patient care and may be required to help train and mentor nurses and other health care providers. As one advances from lower levels to higher levels in the organization, more conceptual skills are needed. Box 16-2 provides examples of technical, human, and conceptual practices required for nurse leaders.




Management Theory


Behavioral theories emerged to explain aspects of management based on behaviors of managers, leaders, and followers. Three prevalent management behavior styles were identified by Lewin (1951) and White and Lippit (1960): authoritarian, democratic, and laissez-faire. Box 16-3 presents characteristics of these management styles, which vary in the amount of control exhibited by the manager and the amount of involvement that the staff has in decision making. At one extreme, the autocratic manager makes all decisions with no staff input and uses the authority of the position to accomplish goals. At the opposite extreme is the laissez-faire manager, who provides little direction or guidance and will forgo decision making. Democratic management is also often referred to as participative management because of its basic premise of encouraging staff members to participate in decision making.



Depending on the situation, the nurse manager may need to use different types of management styles. This concept of situational leadership requires consideration of staff members’ needs and experiences, the manager’s abilities, and the goals and tasks to be accomplished. For example, autocratic management might be appropriate in a life-threatening situation, such as treating a patient in cardiac arrest. However, in structuring the weekend call schedule for a home health agency, a participative style of management would be more effective.


Today’s health care system requires the use of a democratic or participative management style that involves the staff in patient safety, quality improvement, and patient-centered care. Health care settings are driven to become increasingly cost-effective while continuing to improve quality, customer satisfaction, and positive patient outcomes. Staff directly involved in the challenges presented by patient care often can suggest the most workable, practical solutions.



Organizational Theory


Just as leadership and management theories have evolved to provide a framework for understanding leadership and management, organizational theory has evolved to provide a framework for understanding complex organizations. A brief review of bureaucracy theory, systems theory, and chaos theory can provide the reader with insight into the value of using organizational theory to understand management processes within today’s dynamic, complex health care organizations.



Weber’s Theory of Bureaucracy


Max Weber, known as the father of organizational theory, began his work in the 1920s when he observed the growth of large organizations and predicted that this growth required a formal set of procedures. In his classic work on defining the characteristics of bureaucracy, Weber argued that the great benefit of bureaucracy was in its ability to apply general rules to specific cases, making the actions of management fair and predictable. The basis of Weber’s concepts of bureaucracy revolves around explaining authority within organizations. He postulated that authority—the right to issue commands within an organization—is based on impersonal rules and rights granted by virtue of the management



position rather than related to the person who occupies that position. Weber’s conceptualization of bureaucracy emphasized rules instead of individuals and competency instead of favoritism as important for effective organizations.


Although the structure of bureaucracy described by Weber is still present in most organizations today, his work failed to recognize the complexity of human behavior and the constantly changing work environments. As discussed, current leadership and management theories (i.e., participatory management, transformational leadership) recognize the importance of supportive, respectful relationships between managers and employees, with employees being involved in decision making and problem solving.



Systems Theory


The systems theory views the organization as a set of interdependent parts that together form a whole (Thompson, 1967). The interdependent nature of the parts of the organization suggests that anything that affects the functioning of one aspect of the organization will affect the other parts of the organization. Open systems suggest that the organization is affected not only by internal changes among any of its parts, but also external environmental forces that will have a direct influence on the organization and vice versa—the internal forces will affect the external environment. In contrast to open systems theory, closed systems theory views the system as being totally independent of outside influences, which is an unrealistic view for health care organizations. To be successful, today’s health care organizations must be able to continually adapt to internal and external changes. Consider Case Study 16-1 to help explain systems theory.


This example demonstrates open systems theory. As internal forces in one department (hospital



administration) mandated changes that affected another area (RNs and patient care), internal forces (RNs) pushed for changes from the external environment (state nurses association and state government). The external environment may now force changes to the organization (hospital administration).


Systems theory has provided nurse managers with a framework to view nursing services as a subsystem of the larger organization and to realize the interrelatedness and interdependence of all the parts of the health care organization. The nurse will be wise to consider open systems theory and the effect a change in one area will have in another area, internal as well as external to the organization.



Chaos Theory


The chaos theory is a more recently developed organizational theory that attempts to account for the complexity and randomness in organizations. Despite the implications of the word chaos, the theory actually suggests that a degree of order can be attained by viewing complicated behaviors and situations as predictable. Nurse managers may wish for balanced and steady work environments, but in reality they are dealing with, what seems at best, a chaotic system. Chaos theory says that variation is a normal part of managing health care systems. Based on chaos theory, a nurse manager knows that staff absences as a result of illness, sick children, and family emergencies are a fact of life, requiring the nurse manager to have backup plans in place in the event that staff members “call in” and are unable to report for their assigned shift. Other examples of variation in health care are cultural diversity, a constantly fluctuating patient census, and staffing shortages. Until nurses understand that these variations are a normal, predictable state in the organization and should be planned for, they may continue to experience excessive anxiety with the daily events that occur in health care organizations (McGuire, 1999).



Management Functions


Classic theories of management suggest that the primary functions of managers are planning, organizing, and controlling (Stogdill, 1974). Leaders in nursing management have added two more functions to this list and now recognize five major management functions (Figure 16-1) as necessary for the management of nursing organizations: (1) planning, (2) organizing, (3) staffing, (4) directing, and (5) controlling (Marquis and Huston, 2012).


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Nov 6, 2016 | Posted by in NURSING | Comments Off on Nursing Leadership and Management

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